...
Review Article
Burden of cardiovascular diseases in Indians:
Estimating trends of coronary artery disease and
using low co...
world population.1,2
World Health Organization (WHO) has
projected 55 million NCD related deaths by 2030.3
Around 80%
of a...
Though the high mortality rates due to CVDs in India may
have major economic repercussions, the analysis on eco-
nomic imp...
4.2. Behavioral risk factors
Ebrahim et al. (2010) observed comparable prevalence of
obesity (37.8% versus 19.0%) and diab...
stroke event over a period of 10 year per 800 to 1000 in-
dividuals in intermediate risk category (Emerging Risk Factor
Co...
have been devised by Mohan et al.89
and Ramachandran et al90
The Indian Diabetes Risk Score (IDSR) developed by Mohan
et a...
r e f e r e n c e s
1. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life
years (DALYs) for 291 diseases and inj...
41. Gupta R. Review Smoking, educational status and health
inequity in India. Indian J Med Res. 2006;124:15e22.
42. Stamle...
79. Emerging Risk Factors Collaboration, Wormser D, Kaptoge S,
Di Angelantonio E, et al. Separate and combined association...
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Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools

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The global trends in disease specific mortalities indicate that ischemic heart disease (IHD) is the leading cause of death in age group ≥60 years. It is also being recognized that cardiovascular diseases (CVDs) and their risk factors are emerging as primary health problems in India with all socioeconomic groups being equally vulnerable. Though the high mortality rates due to CVDs in India may have major economic repercussions, the analysis on economic impact of CVDs remains incomplete, because of inadequate coverage of these diseases in India's vital event registration and absence of surveillance systems for disease specific mortality data. The per capita expenditure on health by public sector is very low making the poor to go for costly private healthcare facilities. We discuss here the burden of CAD and its risk factors in India and need for using population and individual based prevention strategies to halt and reverse the CVD epidemic. The country will need to create data for technical and operational factors for making prevention and control of CVDs feasible. National and international multidisciplinary collaborations will be needed to address the challenge posed by CVDs.

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Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools

  1. 1.                                                                                                                                             Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools 
  2. 2. Review Article Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools Meenakshi Sharma a,* , N.K. Ganguly b,c,d a Indian Council of Medical Research, New Delhi 110029, India b President, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India c Distinguished Biotechnology Research Professor, Dept. of Biotechnology, New Delhi, India d Adviser, Sir Ganga Ram Hospital, New Delhi, India a r t i c l e i n f o Article history: Received 8 July 2014 Accepted 18 July 2014 Available online xxx Keywords: Cardiovascular diseases (CVD) Ischemic heart disease (IHD) Food and Agriculture Organization (FAOSTAT) a b s t r a c t The global trends in disease specific mortalities indicate that ischemic heart disease (IHD) is the leading cause of death in age group !60 years. It is also being recognized that car- diovascular diseases (CVDs) and their risk factors are emerging as primary health problems in India with all socioeconomic groups being equally vulnerable. Though the high mortality rates due to CVDs in India may have major economic repercussions, the analysis on eco- nomic impact of CVDs remains incomplete, because of inadequate coverage of these dis- eases in India's vital event registration and absence of surveillance systems for disease specific mortality data. The per capita expenditure on health by public sector is very low making the poor to go for costly private healthcare facilities. We discuss here the burden of CAD and its risk factors in India and need for using population and individual based pre- vention strategies to halt and reverse the CVD epidemic. The country will need to create data for technical and operational factors for making prevention and control of CVDs feasible. National and international multidisciplinary collaborations will be needed to address the challenge posed by CVDs. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction There is now compelling evidence suggesting that non communicable diseases (NCDs) are affecting population of both developed and developing countries. Of the 52.8 million deaths reported globally in 2010 NCDs were responsible for 34.5 million annual deaths surpassing 13.2 million deaths related to communicable, maternal, neonatal and nutrition.1 However, a decline of 32.1% in age and gender specific NCD death rates was observed in the last two decades. The key drivers behind this global epidemiological shift from communicable diseases to NCDs are growth and ageing of * Corresponding author. E-mail address: smeenakshi@hotmail.com (M. Sharma). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e9 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002 http://dx.doi.org/10.1016/j.apme.2014.07.002 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. world population.1,2 World Health Organization (WHO) has projected 55 million NCD related deaths by 2030.3 Around 80% of all deaths in 2008 were due to NCDs in developing countries, with 48% of these occurring in individuals below 70 years of age.3 As per World Economic Forum and Harvard School of Public Health's collaborative report, an increase in NCD related years of life lost (YLLs) due to premature mortalities may have financial implications to the tune of US$ 30 trillion on the global economy in the next 20 years.4 Given these concerns, United Nations dedicated its High-Level Meeting to NCDs in 2011 in which heads of states gave their commitment to set up specific measures in a time bound fashion to address NCD burden and World Health Assembly in 2012 embarked on a global target of 25% reduction in NCD caused mortalities by 2025.5 This target will require identification and sealing of gaps in health infrastructure and scaling up of surveillance methods for collection of local reliable data. The global strategy to combat NCDs demands that in resource constrained settings, public resources may first be concentrated against diseases with catastrophic conse- quences. It is with an intention to keep focus of the national agenda in India on CVD that we review in this article the burden of cardiovascular diseases (CVD) in India with partic- ular emphasis on coronary artery disease (CAD), risk factors for CAD and need for shifting the focus of healthcare system to prevention rather than treatment of sick persons alone. 2. Why reduction in cardiovascular diseases (CVD) is the best global buy? With 30% of the deaths worldwide, CVDs and circulatory diseases were the topmost cause of death in 2010.1 Absolute numbers of deaths due to individual CVDs are provided in Table 1. Ischemic heart disease (IHD) and stroke with 7 million and 5.9 million of global deaths respectively, accounted for one quarter of deaths with an increase in premature mortal- ities.1,2 Though the global disability-adjusted life years (DALYs) remained constant from 1990 to 2010, 54% of the 2.5 billion DALYs in 2010 were attributed to NCDs of which 11.8% were due to CVDs and circulatory diseases.2 DALYS from IHD increased by 29.2%, stroke (both hemorrhagic and ischaemic) by 18.9% and hypertensive heart disease by 37.4%. Both gen- ders aged 15e49 years were equally affected.1 In women, with 61.5% of deaths due to NCDs, CVD mortalities surpassed even maternal mortalities.6 It is estimated that with a cost of nearly US $863 billion, strategic public health allocations aimed at reducing exposure to CVD risk factors will provide respite to populations from a vicious ‘health poverty trap’. 3. CVD burden in India and its economic repercussions Mortality data gathered from vital registration system, with medical certification of cause of death or survey with verbal autopsy can help in assessment of health programs targeting reduction in premature mortality from NCDs by 25%, as per the global NCD mortality targets laid down by WHO.5 In India, the vital event registration system under the civil law act of 1969 requires each death to be registered. Despite this, 33.1% of deaths were not registered in 2009 with lowest registration of less than 30% in Bihar and Arunachal Pradesh; 90% and more in only Kerala, Punjab, Goa, Mizoram and Sikkim.7 India will therefore need to undertake concrete steps to improve the vital event registration system. The 2004e2005 ‘Special Survey of Deaths’ by Registrar General of India and Centre for Global Health Research, Toronto, observed 42% of all deaths in India as due to NCDs with 56% in urban and 40% in rural areas.9 Another study by Mahal el al estimated 60% of the 8.1 million deaths from all causes in 2004 due to NCDs.10 CVDs emerged as leading cause of death in both genders, all ages, rural and urban areas.9 The projected rise in YLL due to CAD from 7.1 million in 2004 to 17.9 million in 2030 in India, with largest proportion of deaths being in the age group 25e69 years, requires an immediate action by all stakeholders.9,11 The Southern States appear to have the highest proportions (25%) of deaths due to CVDs and Central region States have the lowest (12%).9 Cross sectional epidemiological studies In India have been carried out to find prevalence rates of coronary artery disease (CAD) in different regions of the country at different times with inadequate sample sizes and often using ‘convenience sampling’. This makes it difficult to make inter-temporal and interregional comparisons. These studies have reported an increase in CAD prevalence in urban parts from 1% to 2% in 1960s to 10e12% in 2012 and from 0.5% to 1% to 4e5% in rural parts.12,13 The projected rise in DALYs lost due to CAD in India from 2000 to 2020 is 14.4 million.14 CREATE registry observed presence of severe form of coronary atherosclerosis in young Indians with a mean age of presentation of Acute Coronary Syndrome (ACS) of 57.5 years.15,16 Another large registry from Kerala, a state with health indicators close to those of devel- oped countries, also observed lower mean age (60 years) at presentation of ACS.17 Sixty percent of ACS patients presented with STEMI and a good proportion of these were from poor families, who also had higher 30 day mortalities.15 Thus In- dians of all socioeconomic strata are facing a hostile cardio- vascular environment and poor suffer the most due to less likely affordability of costly in-hospital treatment or percep- tions of the healthcare personnel.15 Table 1 e Relative mortalities due to cardiovascular and circulatory diseases in 2012.1 Cause All age deaths (million) Percentage Rheumatic heart disease 0.3 1.9% Ischemic heart disease 7.0 44.9% Cerebro vascular diseases (Stroke) 5.9 37.8% Hypertensive heart disease 0.9 5.8% Cardiomyopathy and myocarditis 0.4 2.6% Atrial fibrillation and flutter 0.1 0.6% Aortic aneurysm 0.2 1.3% Peripheral vascular disease 0.05 0.3% Endocarditis 0.05 0.3% Other cardiovascular and circulatory diseases 0.7 4.5% Total 15.6 a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e92 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002
  4. 4. Though the high mortality rates due to CVDs in India may have major economic repercussions, the analysis on eco- nomic impact of CVDs remains incomplete, because of inadequate coverage of these diseases in India's vital event registration and absence of surveillance systems for disease specific mortality data. It has been projected that GDP of India will suffer a 1% loss during the next 10 years due to heart diseases, stroke and diabetes.18 The financial implica- tions of CAD on individuals as measured by ‘out of pocket expenditure’ are substantial. Mahal et al. estimated that US$ 15.52 billion (INR 846 billion) were spent by Indians as out of pocket expenditure on health care in 2004, a 268% increase from US$ 5.8 billion (INR 315 billion) spent in 1995e96.10 This was 3.3% of country's GDP in that year with share of NCDs increasing significantly from 31.6% in 1995e96 to 47.3% in 2004.10 However, such expenditures may also indicate increased paying capacity of individuals due to growth of Indian economy as well as increased awareness among in- dividuals due to higher literacy rates and media coverage.10 But given the high rate of socio-economic inequalities in India, such high out of pocket expenditures are undesirable. Furthermore, the estimated annual income loss from NCDs was US$ 18.34 billion (INR 1 trillion) in 2004.10 This figure may be underestimation of actual losses as it has not taken into account public subsidies on health expenditure (which lower the net national savings/investments), impact of mortalities and morbidities on household work allocation, schooling of children and burden to caregivers and effect on labour market.10 Given this high burden of CVDs and its economic impli- cations, Government of India initiated National Program for Prevention and Control of Cancer, Diabetes, CVDs and Stroke in 2008. This program has recently been integrated with another vertical program, National Rural Health Mission. Though this is a welcome step, but for its effectiveness, complete coverage of the country alone will not be enough. It will also be important to have monitoring and quality control measures in place from the beginning, so that best care practices can be provided to the population. 4. Why Indians are at higher risk of CAD? There are no large prospective studies on CHD risk factors in Indians. The INTERHEART study and INTERSTROKE study involving several countries established that conventional risk factors for MI and stroke (both hemorrhagic and thrombotic), such as smoking, abnormal lipids, hypertension, diabetes, high waist-hip ratio, sedentary lifestyle, psychosocial stress, and a lack of exercise and consumption of fruit and vegetables explained more than 90% of acute CHD events and strokes in South Asians in both sexes and at all ages.19,20 Hypertension emerged out to be significant contributor to stroke occurrence, whereas raised sugar levels and abnormal lipids were related more with ACS and stroke.19,20 Government of India established Integrated Disease Sur- veillance Project (IDSP), a vertical program, in the country with assistance from World Bank in 2004 to carry out NCD risk factor surveillance initially in 7 states.21 The program could not be scaled up. One of the major drawbacks with IDSP is its lack of integration with healthcare system. A well designed, financially viable surveillance program for NCD risk factors using low cost, indigenous electronic technologies through primary health care workers will go a long way in capturing data and making it available to policymakers through a na- tional database repository. The data capturing system inte- grated with a decision support system can decentralize the health system by allowing grass root worker to guide the in- dividual to a comprehensive health promotion, treatment and intervention program. We discuss below the CAD risk factors prevalent in Indian population. 4.1. Socio-demographic factors As compared to USA, western European countries and Japan, there is far more rapid pace of nutritional epidemiological shift marked by shift in occupation structures, urbanization, introduction of processed food, increased prevalence of obesity, mass media and environmental toxins in India.22 Duality of food insecurity in the form of undernutrion and obesity are visible and indicate failure of food systems to provide optimal diets to the population.23 It has been contemplated that through a rapid entry into the markets of developing countries accompanied by mass marketing cam- paigns, global multinational and beverage companies are bringing about a very rapid nutritional transition from a traditionally simple diet to a highly processed diet rich in refined flour, salt, sugar and fat.22e24 Increase in diabetes, childhood obesity and cardiovascular diseases has also been linked to increased consumption of these highly processed fast foods.25e30 However, in India the issue is more complex due to presence of unregulated food vendors at nooks and corners of almost every street in the country. The increased consumption of energy dense foods and decrease in physical activity along with the genetic makeup of the population and other biological factors may have caused a surge in CVDs in the country. Though rural urban migration is an important factor in increasing CAD prevalence in India, no nationally represen- tative study on rural urban migration is available. A large proportion of rural migrants shifted from agricultural sector to less labor intensive industrial and service sectors and contribute to urban slum population (52.4 million as per 2001 Census and 96.9 million in 2013).31,32 Though Government has launched various schemes for the benefit of urban slum population, these are seldom known to get trickled down to end users because of problems with implementation. Evi- dences exist for increased tobacco smoking and physical inactivity among slum dwellers and lower socioeconomic status.11 Studies have reported physical inactivity of the level of 14.7% and 12.2% in urban and rural population.11 In an ICMR's multi-centric study on NCD risk factors undertaken at 6 centres in Haryana, Tamil Nadu, Assam, Delhi, Maharashtra and Kerala among men and women aged 15e64 years, tobacco smoking and alcohol consumption were found to be highest in periurban areas, whereas fruit and vegetable consumption was low in rural and periurban population.33 Rural population was however more active than their urban and periurban counterparts and had lower BMI.33 a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e9 3 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002
  5. 5. 4.2. Behavioral risk factors Ebrahim et al. (2010) observed comparable prevalence of obesity (37.8% versus 19.0%) and diabetes (13.5% vs. 6.2%) in industrial migrants and urban men as compared to rural sib- lings of industrial migrants.34 This is explained by increase in median energy intake, dietary intake of meat, dairy product and sugar in migrant population.35 The food balance sheets of Food and Agriculture Organization (FAOSTAT) of the United Nations also estimate an increase in available energy, protein and fat with largest increase in fat consumption in Indians.36 The diet derived energy (kcal) from fat increased from 13.5% in 1971 to 19.4% in 2009.36 The 2004e05 National Sample Survey Organization (NSSO) also observed a higher fat intake in urban areas (48 g) as compared to rural areas (36 g) but similar energy intake in both areas (2047 kcal in rural and 2020 kcal in urban areas).37 Significantly, the number of meals taken at home has decreased by 1.66% in the urban area and 0.57% in rural areas from 1993 to 94 to 2004e05.37 The survey does not provide data on types of meals taken away from home. Acquiring exact estimates of number and quality of meals taken outside is important as frequent consumption of fast food is known to increase prevalence of obesity.38 In India, estimated smoking associated deaths have increased within a short period - from 930,000 in 2008 to 1 million in 2010.39 Tobacco consumption in India is largely through bidis (sun dried tobacco rolled in leaf) with 8e10 bidis being smoked for every cigarette.39 About 100 million premature deaths in men aged !35 years occurring between 1910 and 2010 in India have been ascribed to tobacco consumption, of which 77 million deaths were due to bidi consumption.39 The Global Adult Tobacco Survey (GATS) estimated that one out of every three Indian adults (around 275 million) use tobacco in one form or the other; 164 million use smokeless tobacco, 69 million only smoke and 43 million smoke as well as use smokeless tobacco.40 Overall prevalence of tobacco use among males is 48% and 20% in females. Regional variations in prevalence of current smoking range from 10% in Maharashtra to 40% in Mizoram and that of smokeless tobacco varied from 5% in Kerala to 50% in Miz- oram.21 Initiation of smoking occurred at a younger age in Indians. Mean age of initiation of smoking varied from 17 to 20 years with lowest among females in Andhra Pradesh (14 years).21 Lower levels of education and income are considered to be associated with higher consumption of tobacco.41 Thus interventions need to target reduction of tobacco consump- tion in younger age groups. 4.2.1. Physiological risk factors Major physiological risk factors for CAD appear to be increasing in Indians. Systolic and diastolic BP have been shown to be strong, independent continuous variables significantly associated with cardiovascular mortality and all- cause mortality.42 As many as 54% of deaths due to stroke and 24% of deaths due to CAD are due to hypertension in India.43 It has been estimated that reduction of blood pressure by 2 mm Hg can prevent 151,000 stroke and 153,000 CAD deaths in India.43 Review of studies conducted between 1994 and 2013 indicates that the prevalence of hypertension is around 20e48% in urban and 7e36% in rural population.12,44e52 Gupta et al. (2013) reported an age-adjusted prevalence of pre hypertension in men and women as 40.2% and 30.1% respec- tively and of hypertension as 32.5% and 30.4%.48 Prevalence of pre hypertension in the IDSP study was higher and ranged from 46% to 62% in urban areas and 41%e54% in rural areas, with an overall prevalence rate of 43%e58%.21 Pre hyperten- sive individuals are known to have at least one more CVD risk factor, suclinical atherosclerosis and significantly higher CVD events as compared to normotensives.53e57 Lifestyle modifi- cations including diet rich in potassium (fruits and vegeta- bles), decrease in sodium intake (<2400 mg/day), moderation in alcohol intake and physical activity (>30 min/day) can reduce systolic blood pressure and incidence of hyperten- sion.58 Screening of population for pre hypertensive stage is vital for undertaking population level prevention measures. The proportion of fat in Indians is high and centrally (abdominal obesity) distributed for any given weight.59 This pattern of central obesity is known to be associated with diabetes, hypertension and insulin resistance. Prevalence of diabetes has increased from <1e3% to 10e15% in urban areas in last 20 years and was 3e5% in rural areas.60 The ICMR multicentric study using WHO steps for surveillance observed that proportion of men and women with glucose levels !126 mg/dl was 11.4% and 10.3% respec- tively among urban, 6.2% and 5.7% among rural and 8.5% and 9.6% among periurban population.33 Hypercholesterolemia (cholesterol ! 200 mg/dl) was present in one third of urban men and women and one quarter of rural and periurban population.33 4.2.2. Challenges to foetal programming e a risk for CAD The risk of CAD is also known to increase if intrauterine life/ early childhood is challenged by nutritional and environ- mental toxin insults or metabolic diseases like diabetes in the mother.61,62 Epigenetic modifications including changes in DNA methylation, histone modifications and non-coding RNA expressions, caused by nutritional imbalance and exposure to environmental toxins during development, may be respon- sible for the early development of CAD and its risk factors such as blood pressure, factor VIII concentration, fibrinogen concentration and glucose intolerance.63e67 The New Delhi Birth Cohort of persons born between 1969 and 1973 observed a correlation between adult metabolic syndrome and impaired glucose tolerance with BMI gain in infancy.68 4.2.3. Emerging risk factors The care model for CAD patients targets conventional risk factors including lowering of cholesterol, management of hypertension and diabetes. Despite the advances in CAD risk factor management, half of the MI and stroke are estimated to be occurring in patients well below the recommended goals.69 Concentration of CRP, an inflammatory marker, has been shown to be associated with a wide variety of disorders including risk of CAD, ischaemic stroke, vascular mortality, cancer, etc.70 Recently, addition of CRP and fibrinogen to risk prediction models using conventional risk factors like age, sex, smoking status, blood pressure, history of diabetes, total cholesterol and HDL cholesterol levels to categorize in- dividuals into predicted 10-year CVD risk factor categories [“low”(<10%), “intermediate” (10% to <20%) and “high” (!20%)] was shown to result in prevention of two additional CAD or a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e94 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002
  6. 6. stroke event over a period of 10 year per 800 to 1000 in- dividuals in intermediate risk category (Emerging Risk Factor Collaboration study).71 Unlike CRP and fibrinogen, Lip- oprotein(a) (Lp[a]) and lipoprotein associated phospholipase A2 (Lp-PLA2) are continuous and independent markers for CAD.72,73 However, Lp(a) is specific marker for vascular out- comes in contrast to Lp-PLA2 which is not exclusive to these events.72,73 Genetic studies indicate a causal relationship of Lp(a) with CAD risk. Higher benefits of cholesterol lowering are suggested in individuals with high levels of Lp(a).72 Addi- tion of values of apolipoprotein B and apolipoprotein A-I, lip- oprotein(a), or lipoprotein-associated phospholipase A2 to total cholesterol and HDL cholesterol slightly improved CVD prediction in individuals without baseline CVD with a median follow up for 10.4 years.74 The À1131T > C (rs662799) promoter polymorphism of the apolipoprotein A5 (APOA5) gene is strongly related to triglyc- eride concentrations and modestly associated with low HDL cholesterol and apolipoprotein AI concentration and high apolipoprotein B levels.75 A 32.6% or 9.2 mg/dl increase in TG levels in individuals homozygous for C alleles as compared to non-carriers was observed in Emerging Risk Factor Collabo- ration study of cohorts of western population. Studies in In- dian population have shown a higher triglyceride levels in individuals with À1131 C risk allele of APOA5 gene.76e78 Be- sides these biological risk factors, addition of measures of adiposity (Body Mass Index (BMI), waist circumference, waist- to-hip ratio) to the risk prediction models has recently been shown not to improve risk prediction in populations of developed countries.79 However, as most of these studies have analyzed results from studies in European population, there- fore more studies in population of developing countries like India are required. 5. Addressing prevention of heart diseases The three pillars of prevention include health promotion activities, early detection and management of existing dis- ease. An effective CVD prevention program will need to be multidisciplinary, multi professional and multi stakeholder so as to focus on social, environmental and policy de- terminants, thereby supporting people to make healthy choices. The three pillars of prevention of CVDs/NCDs can be addressed through surveillance, development of knowledge (what works in a given community) and its dissemination, involving communities, creating health promoting environ- ments, building capacity at different levels of the health system and policy level changes. The surveillance at regular intervals is important for understanding and evaluating the preventive activities. Due to deep embedment of risk factors into the cultures of societies, promotion activities need to focus families and communities. Both population based measures to reduce the risks of developing CVDs/NCDs and targeted interventions in those at highest risk will be required to halt and reverse the CVD epidemic. There are enough evidences of the impact of prevention of CVD risk factors. A reduction of heart attack risk by 50% is observed following one year of quitting smoking.80 Similarly a decrease in risk by 25%e30% on 10e12% reduction in systolic blood pressure and total cholesterol has been documented.80 Given these strong evi- dences, Global Cardiovascular Disease Task Force supports four exposure targets to reduce premature mortality due to CVDs (Box 1).81 Treatment of individuals through a combination pharma- cotherapy approach (fixed dose of aspirin, a statin and one or two blood pressure reducing drugs) has been viewed as a harm reduction strategy similar to nicotine replacement therapy in tobacco smokers with a potential of increasing compliance and to reach the populations of developing countries .82,83 The safety and efficacy of such a combination pharmacotherapy is a subject of research globally.84 UMPIRE study in participants with established CVD from India and Europe observed that polypill can increase adherence to therapy and reduce systolic blood pressure and LDL cholesterol.85 However exercise, a cheap strategy with low adverse effects, is thought to have more benefits than pharmacotherapy.86 In a diabetes pre- vention program study, overweight participants assigned to 30 min walking per day, 5 days a week and decreasing their caloric intake through reduction in fat consumption with a target of reduction of 5e7% in weight, had a higher (58%) reduction/delay in onset of diabetes as compared to controls. The moderate activity group performed better than the one on metformin.87 We argue for stronger advocacy of cheap prevention strategies like regular exercise with dietary modifications for reducing the CVD risk as this is likely to produce overall health benefits to individuals as well as population. Early detection of CVD will be required for prevention of development of disease or slowing down its progress. This needs development and validation of simple cost effective tools. Gaziano et al. compared laboratory based method using age, systolic blood pressure, smoking status, total cholesterol, reported diabetes status, and current treatment for hyper- tension for assessment of CVD risk with non-laboratory-based model, substituting body-mass index for cholesterol and observed that both models were able to predict fatal events with a comparable c statistics.88 The limitation of this study is that this risk score has been tested in US population and will require validation in India. In India, two simple Risk Scores Box 1 Exposure targets to prevent CVDs supported by Global Cardiovascular Disease Task Force.84 1. Physical activity: 10% relative reduction in prevalence of insufficient physical activity 2. Raised blood pressure: 25% relative reduction in prevalence of raised blood pressure 3. Salt/sodium intake: 30% relative reduction in mean population intake of salt, with an aim of achieving recommended level of <5 g/d (2000 mg of sodium) 4. Tobacco: 30% relative reduction in prevalence of cur- rent tobacco smoking a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e9 5 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002
  7. 7. have been devised by Mohan et al.89 and Ramachandran et al90 The Indian Diabetes Risk Score (IDSR) developed by Mohan et al. using two non-modifiable risk factors (age and family history) and two modifiable risk factors (physical activity and waist circumference) was useful as screening tool for finding the prevalence of diabetes and pre-diabetes.89,91,92 A similar simple tool will need to be developed for heart attack and validated in a community setting for its sensitivity and spec- ificity as well as its use by a community worker. This is chal- lenging given the need to correlate with actual outcomes of interest (MI) in a prospective cohort setting. 5.1. Need for global health partnerships Though India shares a large proportion of the CVD burden, the research capacity and financial investments are often inade- quate. These lead to deficiencies in its policies, advocacy, planning strategies and legislations. On the other hand, developed countries further increase their scientific produc- tivity by attracting scientific immigration by providing better opportunities to persons with high standards from developing countries. India needs to create lucrative research opportunities for its brightest, database for technical and operational factors for making prevention and control of CVDs feasible using national and international multidisciplinary collaborations. Box 2 shows the impact of global health part- nerships in combating a disease of public health importance in various parts of the world. 6. Conclusion Though there are evidences of higher burden of CAD in India, disease surveillance nationally representative data for mor- talities and risk factors, generated through both public and private healthcare setups, is essential for careful strategic policy level as well as individual level interventions for pre- vention and control of CAD. India will also require to create database for technical and operational factors for making prevention and control of CVDs feasible using national and international multidisciplinary collaborations to halt the onslaught of these diseases. Conflicts of interest All authors have none to declare. Box 2 Shifting towards global health partnerships (GHP) a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e96 Please cite this article in press as: Sharma M, Ganguly NK, Burden of cardiovascular diseases in Indians: Estimating trends of coronary artery disease and using low cost risk screening tools, Apollo Medicine (2014), http://dx.doi.org/10.1016/ j.apme.2014.07.002
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