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Increased burden of coronary artery disease in South-Asians living in North America: Need for an aggressive management alg...
Introduction <ul><li>Despite significant declines in cardiovascular (CV) mortality, coronary artery disease (CAD) is still...
Objectives <ul><li>Review migration patterns and effects on prevalence of CAD in SAs </li></ul><ul><li>Review the evidence...
Migration patterns of SA Copyright  © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Ba...
Consequences of migration  <ul><li>According to Neel’s thrifty gene hypothesis, subjects conditioned to a low calorie diet...
Adapted from Anand et al. Lancet 2000;356:279-84. Copyright  © 2008 Society for Heart Attack Prevention and Eradication. A...
Excess mortality risk  <ul><li>Population-based studies show that mortality rates are higher in SAs compared to other ethn...
Adapted from Palaniappan et al. Ann Epidemiol 2004;14:499-505  Copyright  © 2008 Society for Heart Attack Prevention and E...
Adapted from Sheth et al. CMAJ 1999;161:132-138. Copyright  © 2008 Society for Heart Attack Prevention and Eradication. Al...
Conventional risk factors  <ul><li>According to the INTERHEART study, conventional risk factors predict myocardial infarct...
Diabetes and SA  <ul><li>Type-2 diabetes is a major global concern and is particularly relevant in SA migrants </li></ul><...
Prevalence of diabetes mellitus in SAs  living in the United States Adapted from Venkataraman et al.  Am J Cardiol  2004;9...
The contribution of  metabolic syndrome <ul><li>The prospective Finnish study showed that middle-aged men with metabolic s...
WHO MS: World Health Organization definition of metabolic syndrome NCEP MS: National Cholesterol Education program definit...
Non-traditional risk factors  <ul><li>Due to the lack of correlation between increased CV risk and conventional risk facto...
Novel Cardiac Biomarkers Copyright  © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Ba...
CV disease continuum in SA Copyright  © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR ...
Revascularization Outcomes  <ul><li>SAs more commonly have extensive diffuse CAD on coronary angiography </li></ul><ul><li...
A Prevention Strategy   for physicians caring for SA patients Copyright  © 2008 Society for Heart Attack Prevention and Er...
Modified C V  risk algorithm Copyright  © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. K...
Key summary points - 1 <ul><li>SAs are at high-risk for developing premature CAD and its adverse consequences, including e...
Key summary points - 2 <ul><li>SAs are more prone to develop accelerated atherosclerosis and its adverse consequences due ...
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  1. 1. Increased burden of coronary artery disease in South-Asians living in North America: Need for an aggressive management algorithm K.R. Bainey, MD B.I. Jugdutt, MD KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved.
  2. 2. Introduction <ul><li>Despite significant declines in cardiovascular (CV) mortality, coronary artery disease (CAD) is still a global concern </li></ul><ul><li>In North America, CV disease is still the leading cause of death </li></ul><ul><li>South Asian (SA) migrants appear to be particularly at risk </li></ul><ul><li>We reviewed the evidence for the increased risk of CAD in SAs and suggestions for its management </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  3. 3. Objectives <ul><li>Review migration patterns and effects on prevalence of CAD in SAs </li></ul><ul><li>Review the evidence for excess mortality risk in SAs </li></ul><ul><li>Review conventional risk factors in SAs </li></ul><ul><li>Review the contribution of type-2 diabetes in SAs </li></ul><ul><li>Review the effects of metabolic syndrome in SAs </li></ul><ul><li>Review non-traditional CV risk factors in SAs </li></ul><ul><li>Review revascularization outcomes in SAs </li></ul><ul><li>Propose a prevention strategy for SAs </li></ul><ul><li>Propose a simple algorithm for CV risk modification in SAs </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  4. 4. Migration patterns of SA Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  5. 5. Consequences of migration <ul><li>According to Neel’s thrifty gene hypothesis, subjects conditioned to a low calorie diet and intense physical activity would be expected to do poorly in an environment characterized by a high calorie diet and inactivity </li></ul><ul><li>SAs appear to be particularly susceptible to these physiologic detrimental effects of migration </li></ul><ul><li>This may partially explain the heightened CV risk in SA migrants </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  6. 6. Adapted from Anand et al. Lancet 2000;356:279-84. Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  7. 7. Excess mortality risk <ul><li>Population-based studies show that mortality rates are higher in SAs compared to other ethnic groups </li></ul><ul><li>In 1992, SA migrants were reported to have 1.5 -3.0-fold higher risk of CV mortality and a 2.5 - 5.0-fold higher risk of myocardial infarction compared to the native population </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  8. 8. Adapted from Palaniappan et al. Ann Epidemiol 2004;14:499-505 Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  9. 9. Adapted from Sheth et al. CMAJ 1999;161:132-138. Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  10. 10. Conventional risk factors <ul><li>According to the INTERHEART study, conventional risk factors predict myocardial infarction across nations irrespective of ethnicity </li></ul><ul><li>The collective evidence suggests that conventional risk factors contribute to the increased risk of CAD in SAs but they do not fully explain the total burden of the disease among SAs </li></ul><ul><li>However, type-2 diabetes / insulin resistance is prevalent among SAs and contributes to their increased risk of CAD </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  11. 11. Diabetes and SA <ul><li>Type-2 diabetes is a major global concern and is particularly relevant in SA migrants </li></ul><ul><li>SA migrants to Europe, Canada and the United States all show higher rates of type-2 diabetes compared to other ethnic groups </li></ul><ul><li>In addition, the impact of diabetes on cardiovascular mortality is more pronounced in SAs, and is likely due to its contribution to the heightened risk of CAD </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  12. 12. Prevalence of diabetes mellitus in SAs living in the United States Adapted from Venkataraman et al. Am J Cardiol 2004;94:977-80. Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier Study Age group Ethnic group Diabetes NHANES III ≥ 20 yrs Hispanics 9.3% NHANES III ≥ 20 yrs Blacks 8.2% NHANES III ≥ 20 yrs Whites 4.8% Venkataraman et al. ≥ 20 yrs South Asians 18.1%
  13. 13. The contribution of metabolic syndrome <ul><li>The prospective Finnish study showed that middle-aged men with metabolic syndrome had a 2-fold greater risk of all-cause mortality and a 3-4-fold increased risk of cardiovascular mortality after 10 years </li></ul><ul><li>SA migrants have higher rates of metabolic syndrome compared to their European counterparts </li></ul><ul><li>Due to the high prevalence of metabolic syndrome and ‘muscle thin/visceral fat’ phenotype among SAs, obesity measurements have been modified to include waist circumference (as opposed to BMI) at lower cut-off points </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  14. 14. WHO MS: World Health Organization definition of metabolic syndrome NCEP MS: National Cholesterol Education program definition of the metabolic syndrome Adapted from Gupta et al. Can J Cardiol 2004;20(suppl D):500. Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  15. 15. Non-traditional risk factors <ul><li>Due to the lack of correlation between increased CV risk and conventional risk factors for CAD, novel cardiac risk markers have been explored in SAs </li></ul><ul><li>Not surprisingly, many of these novel cardiac biomarkers support the heightened CV risk in the SA population </li></ul><ul><li>Collective evidence suggests that CV risk factors (conventional and non-traditional) participated in accelerated progression of atherosclerosis and premature CAD among SAs. The CV disease continuum appears to be supercharged, accentuated and accelerated in migrant SAs </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  16. 16. Novel Cardiac Biomarkers Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier Novel Cardiac Markers in South Asians Elevated prothrombotic markers ↑ Fibrinogen; ↑ t-PA Elevated atherogenic markers ↑ Lipoprotein (a) ↑ Plasminogen-activator-inhibitor-1 ↑ Homocysteine ↑ Small, dense LDL particles ↑ Apolipoprotein-B to AI ratio ↑ Small HDL particle size ↓ Large HDL particle size Elevated inflammation markers ↑ C-reactive protein
  17. 17. CV disease continuum in SA Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  18. 18. Revascularization Outcomes <ul><li>SAs more commonly have extensive diffuse CAD on coronary angiography </li></ul><ul><li>SA Americans have twice as much 3-vessel CAD and a higher burden of atheroma compared to white Americans </li></ul><ul><li>CABG is often the revascularization strategy of choice among SAs, and in-hospital mortality is worse in SAs compared to Caucasians </li></ul><ul><li>The outcome of percutaneous coronary intervention among SAs is largely unknown </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  19. 19. A Prevention Strategy for physicians caring for SA patients Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier Strategy Education Dietary and lifestyle modification Metabolic syndrome screen Cardiovascular risk factor reduction Close follow-up by primary care physician
  20. 20. Modified C V risk algorithm Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  21. 21. Key summary points - 1 <ul><li>SAs are at high-risk for developing premature CAD and its adverse consequences, including extensive myocardial infarction, complications and death </li></ul><ul><li>The metabolic syndrome and diabetes are more prevalent among SAs </li></ul><ul><li>Type-2 diabetes is an especially acute problem among SAs, likely due to a combination of genetic predisposition, metabolic dysfunction and adverse interaction with western high calorie/fat and low vegetable diets, and sedentary lifestyle </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
  22. 22. Key summary points - 2 <ul><li>SAs are more prone to develop accelerated atherosclerosis and its adverse consequences due to several enhanced non-conventional risk factors </li></ul><ul><li>SAs appear to have a supercharged cardiovascular risk continuum that underscores the importance of prevention with an aggressive risk reduction algorithm </li></ul>Copyright © 2008 Society for Heart Attack Prevention and Eradication. All Rights Reserved. KR Bainey, BI Jugdutt. Atherosclerosis ( 2008), doi: 10.1016/j.atherosclerosis. 2008.09.123. With permission from Elsevier
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