CORONARY HEART DISEASE IN INDIA

By Dr Ajay GoyalP.G.3rd year

Deptt. Of Community MedicineS.S.M.C. Rewa (M.P.)

Coronary artery disease

• It is impairment of the function of the heart due to inadequate blood flow to the myocardium as a result of obstruction in the coronary circulation

• CAD is manifested in any of the following .Angina pectoris of effort. .myocardial infarction. .Irregularities of the heart. .Cardiac failure. .Sudden death.

• CAD is the leading cause of death in developed countries accounting for 25 to 30 % of total death

• In India increases the incidences of CAD because of changes in the life –style and behavior pattern of the people.

• Incidence is 2-3 times greater in urban areas than rural areas.

• CAD is one and half times more among men then women.

• Incidence is maximum in the age group of 50 to 60 years.

The Prevalence of Coronary Heart Disease (CHD) “ HEART ATTACK” is rapidly increasing in India

It has become an “ EPIDEMIC”.

It is a major contributor for mortality and morbidity.

It is expected that deaths due to HEART ATTACK will double in the next 10 years

The death rate due to heart attack will be 295 per 1,00,000 population in the year 2015.

• CAD is a local manifestation of progressive and generalized disorders of the arteries namely atherosclerosis.

• Disease is produced from the blockage of the lumen of the coronary arteries.

• A plague is formed inside the arteries which gradually grows to form a thrombus that fills up the lumen and causes obstruction to the flow of blood.

Angina

• Angina is a type of chest discomfort caused by poor blood flow through the blood vessels (coronary vessels) of the heart muscle (myocardium).

Predisposing Factors

• Non Modifiable .Age –Incidences of CAD is high above 50 years

and maximum between 50 to 60 years of age . Sex- More among men than women .Family history – CAD has been seen to run in

families .Genetic factors – play a role indirectly by

determining the total cholesterol and LDL levels

Modifiable Risk Factors

• Hypertension – increases the risk of CAD by accelerating the atherosclerotic process

• Serum cholesterol- increase in cholesterol level increases the risk of CAD . Threshold level is 220 mg/dl beyond which the risk increases.

• Cholesterol is associated with the atherosclerosis of peripheral vessels resulting in intermittent claudication rather than CAD

• The ratio of LDL to HDL is more than 5 indicates the risk• The level of plasma apolipoprotein –A1 (a fraction of HDL

protein)and apolipoprotein-B(a fraction of LDL protein )are better predictors of CAD than HDL and LDL cholesterol

Smokingmajor risk factor

• CO(Carbon Mono-Oxide), induces atherogenesis

• Nicotine stimulates the release of adrenaline resulting hypertension

• Nicotine also increases myocardial oxygen demand and decrease HDL level

• Risk is directly proportional to No. of cigarettes smoking per day and duration of exposure.

• Serum homocystine –more than 15.5 mol/litre damages the intima of the arteries thus causes CAD.

• Diabetes mellitus –risk of CAD 2 to 3 times higher than non diabetes.

• Obesity –increases CAD because of its association with LDL cholesterol level HTN, and Diabetes.

• Hormones –hyper-estrogenemia favours development of CAD. Means OC pills may causes CAD.

• Type A personality –Chaterised by competitive drive , restlessness impatience, irritability, short temper ,sence of urgency, overthinking etc are higher risk of CAD than calmer type B personality people.

• Alcohol – CAD iscommon in heavy drinkers • Soft water –incidence is higher than those

consuming hard water

• Noise –chronic exposure to noise over 110 db increases serum cholesterol level thus the risk of CAD.

• Drugs –misuse of fenfluramine and phentermine used for weight reduction can be damaging to the heart.

PATTERN OF CHD IN INDIANS :-

1. Heart attacks occur in Indians 10-15 years earlier than the western population2. Malignant coronary artery disease3. Multivessel disease and left main coronary artery disease4. Smaller Coronary arteries?

Tests• Many tests help diagnose CHD. Usually, your doctor will order more than

one test before making a definite diagnosis.

• Electrocardiogram (ECG) • Exercise stress test • Echocardiogram • Nuclear scan • Electron-beam computed tomography (EBCT) to look for calcium in the

lining of the arteries -- the more calcium, the higher your chance for CHD • CT angiography -- a noninvasive way to perform coronary angiography • Magnetic resonance angiography • Coronary angiography/arteriography -- an invasive procedure designed to

evaluate the heart arteries under x-ray

Prevention• Avoid or reduce stress as best as you can. • Don't smoke. • Eat well-balanced meals that are low in fat and cholesterol and include

several daily servings of fruits and vegetables. • Get regular exercise. If your weight is considered normal, get at least 30

minutes of exercise every day. If you are overweight or obese, experts say you should get 60 - 90 minutes of exercise every day.

• Keep your blood pressure below 130/80 mmHg if you have diabetes or chronic kidney disease, and below 140/90 otherwise

• Keep your cholesterol and blood sugar under control. • Moderate amounts of alcohol (one glass a day for women, two for men)

may reduce your risk of cardiovascular problems. However, drinking larger amounts does more harm than good.

Diatery changes

• Consumption of saturated fats should be less than 10% of total energy intake.

• Average intake of cholesterol should be less than 300mg/day/adult.

• Serum cholesterol level should be less than 200mg/dl• Consumption of carbohydrates must be proportionately

increased.(vegetables, fruits whole grains and legumes)• Avoidance of alcohol consumption ; reduction of salt

intake to 5gm daily or less.

Key ways to help prevent heart disease:

Don’t smoke or use tobacco products◦ Tobacco smoke contains more than 4,800 chemicals; many of which can

damage your heart and blood vessels◦ The goal should be to achieve a smoke free society ◦ By effective information, educational activities ,legislative restrictions,smoking

cessation programmes.

Get active◦ Exercise◦ Gardening◦ Taking the stairs

Eat a heart-healthy diet◦ Research shows that fruits, vegetables, whole grains and low-fat dairy

products that can help protect your heart

Key ways to help prevent heart disease:

• Maintain a healthy weight– excess weight can lead to conditions that

increase your chances of heart

• Get regular health screenings– Blood Pressure– Cholesterol Levels

• Stress-free– Relax– Smile

Ways to Prevent Obesity

• Order off the children’s menu• Limit the amount of time watching TV• Have six small nutrient-dense meals a day. • Changing up your orders at fast food

restaurants• Reduce weight approx 10% from baseline.

Then reduce weight at a rate of about half to one kg per week for 6 months.

HOW MUCH PHYSICAL ACTIVITY IS ENOUGH?

30 to 60 minutes, on most days of the week, at 50-80 percent of your maximum

capacity.

Blood pressure

• Even a small reduction in the BP of the whole population by a mere 2 or 3 mm hg would produce a large reduction in the incidence of cardivascular complications.

It can be controlled by multifactorial approach based on prudent diet (reduced salt intake and avoidance of high alcohol intake ),regular physical activity and weight control.

High risk strategy

• Identifying risk: by measuring BP, serum cholesterol ,and taking ECG of high risk patients

• Specific advice: those who have high BP should be treated ,the patient should be helped to break the smoking permanently –nicotine chewing gum can be tried to wean patients from smoking.

Treatment of CAD

• Aspirin. Taking a small (75 mg) daily dose of aspirin makes your blood less likely to form clots in your coronary arteries and reduces your risk of having a heart attack.

M/A of asprin –inhibits the synthesis of prostaglandins notably thrombaxane A2,a potent vasoconstrictor and platelet activator .

• Statins. These drugs help to lower your cholesterol levels and so slow down the process of atherosclerosis.

• Beta-blockers. These drugs slow your heart rate and reduce the pumping power of the heart. This reduces your heart's demand for oxygen. Beta-blockers also widen blood vessels helping to lower blood pressure.

• ACE inhibitors. These drugs are often used in people with heart failure or after a heart attack. They lower your blood pressure.

Surgery

• Angioplasty (also known as percutaneous coronary intervention or PCI). In this operation a collapsed balloon is threaded through the blood vessels until it reaches the arteries of the heart. The balloon is inflated to widen the narrowed coronary artery. A stent (flexible mesh tube) is sometimes inserted to help keep the artery open afterwards. The stent sometimes releases a drug that helps to keep the blood vessel open. You should be able to go home the day after the operation.

• Coronary artery bypass graft (CABG). In this operation, the surgeon takes a piece of blood vessel from your leg or chest and uses it to bypass the narrowed coronary arteries. The bypass provides the heart with more blood. This is open-heart surgery and requires a longer stay in hospital.

Indications for coronary artery revascularization

1. Pt .with unacceptable symptom despite medical therapy to its tolerable limit.

2.pt. with left main coronary artery stenosis greater then 50% with or without symptom.

3.Pt. with three vessel disease with left ventricle dysfunction (ejection fraction <50% or previous transmural infraction).

4. Pt .with unstable angina who after symptom control by medical therapy continue to exhibit ischemia on exercise testing or monitoring .

5. Post myocardial infraction pt. with continuing angina or sever ischemia on non invasive testing.