Naresh trehan

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Cardiovascular
Disease Trends in
India

Naresh Trehan
Escorts Heart Institute and Research Centre
New Delhi, India

Cardiovascular Disease

According to recent estimates,
! Cases of CVD may increase from about 2.9
crore in 2000 to as many as 6.4 crore in
2015
! Deaths from CVD will also more than double.
! Most of this increase will occur on account of
coronary heart disease —AMI, angina, CHF
and inflammatory heart disease

Source:NCMH Background Papers—Burden of Disease in India (New Delhi,
India), September 2005

1


Cardiovascular Disease
Data also suggest that although the
! Prevalence rates of CVD in rural populations will
remain lower than that of urban populations, they
will continue to increase, reaching around 13.5% of
the rural population in the age group of 60–69 years
by 2015.
! The prevalence rates among younger adults (age
group of 40 years and above) are also likely to
increase
! Prevalence rates among women will keep pace with
those of men across all age groups.


Largest Share in Non-
communicable Diseases
Cancers, 10%

Others, 21% Diabetes, 2%

Oral diseases, 1%
COPD and asthma, Mental health
5% disorders, 26%

Blindness, 4%
Cardiovascular
disease, 31%
Priority non-communicable health conditions in India, by share in
the burden of disease (1998)
Source: Peters et al. 2001

2


Rising Population

Projected trends in population

Source: Report of the Registrar General of India 1996

Rising Prevalence and
Mortality
Forecasting the prevalence rate (%) of coronary heart disease (CHD) in India

Estimated mortality from coronary heart disease (CHD)


3


Estimates and trends of coronary heart disease (CHD) cases in
various age groups

Trends of CAD Prevalence in India

% Prevalence URBAN % Prevalence RURAL
14 Trivandrum 14
12 12
Delhi
10 Jaipur 10
8 Chandigarh 8
6 6 Kerela
Rajasthan
Rohtak Punjab
4 4 Haryana UP
2 Delhi 2
Agra
0 0
1960 1970 1980 1990 2000 1960 1970 1980 1990 2000
Year of Study Year of Study

4


Burden of CVD: 1990-2020
50
India
DALYs (millions)

40 China

SSA
30
Mexico
LAC
20 EME
PSE
QAI
10

0
1990 2000 2010 2020

CORONARY ANATOMY

INDIANS HAVE MORE
COMMON
! Involvement at younger age
! Smaller Coronary Arteries
! Diffuse Distal Disease
! Multi-vessel Disease
! Higher incidence in women

5


Metabolic Syndrome:
Prevalence

Metabolic Syndrome
Prevalence in India: EHIRC Data

6


Metabolic Syndrome

40.0%
33.7%
29.0% 30.0%

19.3% 20.6%
20.0%
7.1%

0.0%
Overall 21-30 31-40 41-50 51-60 61-70

299 consecutive subjects aged 20-65 years, without any
evidence of CVD, undergoing routine health check-up

Metabolic Syndrome

76.3%
80.0%

60.0%

40.0%
16.7%

20.0% 60.0%
40.3%
0.0%
Diabetics Nondiabetics 40.0%
24.4%
p <0.001 for comparison
20.0%

0.0%
Males Females
p <0.001 for comparison

7


EHIRC data contd.
Prevalence of individual metabolic abnormalities

50.0% 46.8%
45.80%

28.5%
28.4%
30.0%

12.70%

10.0% Increased WC Low HDL High TG Increased FBS HT

EHIRC data
Prevalence of Metabolic Syndrome

• 1000 consecutive patients undergoing CABG
included

• Overall prevalence of metabolic syndrome by
modified ATP III criteria-
– 60.0%

Submitted for publication; Accepted for presentation at CSI 2005

8


EHIRC data
1000 CABG patients

• Mean age- 59.73 ± 9.5 years
• 88.4% males; 11.6% females
• Obesity (BMI)-

100.0%
75.2%
80.0%
50.8%
60.0%

40.0%
14.6%
20.0%

0.0%
>30.0 kg/m2 >25.0 kg/m2 >23.0 kg/m2
Obese Overweight Overweight (Asian criteria)

EHIRC data
1000 CABG patients

Diabetes Mellitus

60.0% 55.2%

47.5% 46.5%
Hypertension

40.0% 80.0%
Overall Males Females
70.8% 71.6%
70.9%
p 0.078 for comparison between
males and females

60.0%
Overall Males Females
males and females

9


EHIRC data
1000 CABG patients
100.0% Dyslipidemia
93.9%

85.6% 84.5%

81.4%

80.0% Overall (LDL Males Females Overall (LDL
cut-off cut-off
100mg%) 130mg%)
Lipid abnormalities
males and females 72.5%
80.0%

60.0%

37.0%
40.0%

23.3%

20.0%
High LDL Low HDL High TG

Parameter Year 2000 Year 2005 p value

N 1747 1302

Age (years) 50.0 ± 11.1 43.2 ± 13.1 <0.001

Male gender (79.9%) (78.3%) 0.309

Body-mass index (kg/m2) 24.7±3.9 25.0±3.9 0.034

Hypertension (47.4%) (42.1%) 0.004

Diabetes mellitus (13.0%) (16.5%) 0.012

Dyslipidemia* (76.4%) (62.0%) <0.001

Family h/o CAD (16.8%) (33.5%) <0.001

10


Escorts Heart Institute & Research Centre
New Delhi

1988

Angiographies / Year
11000 10011
9603
8974 8990 9123
8829
9000 7945

6520
7000
5544
4826
5000 4092
3430
2917
2527
3000 2135
1623
1011
1000 117

-1000 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

11


Angioplasties / Year
2800 2565
3000
2600 2370
2400 2185
2200 2035
2000 1815 1818
1800
1600 1376
1400 1206
1200
1000 860
800 651 717
600 365
468
400 192 256
200 94
2
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2005

Cardiac Surgeries / Year
6000

5000
4176 4280
4016 4150
4000 3680
3360
3142
2751
3000 2493
2106
2000 1737 1750 1863
1555
1145 1283
806
1000
86
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2005

12


Total Cardiac Surgeries 1988 – 2005 Dec
(N = 51,599)

8097

MISCELL
4040
CONGENITAL

VALVES CABG
5555
33686

Age group wise Admissions
( Jan. - Aug. 2006)
26238
28000

24000
No. of patients

20000
16000 13387
11580
12000

8000 5838
4488
3241
4000
581
0
< 14 Years 14 - 18 Years 19 - 30 Years 31 - 40 Years 41 - 50 Years 51 - 65 Years Above 65
Years

13


Ejection Fraction of Surgical Patients
(Jan. - Aug. 2006)
1000
Off CPB

On CPB

800 742

620
600

400 336

186
200 155
76 96
61
23 20
0
<= .20 .21 - .30 .31 - .40 .41 - .50 > .50

Growth of OPCABs : 1995 - 2005
3500

3000

2500
423
3022
1411
2000 355
349 3400 3444
204 2907 3011
1500 125

1000 2117
1783
1598
1388 1492 1416
500

225 268 286 352 255
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

OPCAB CCAB

14


Age wise Mortality rate in Isolated
CABG (Jan. - Aug. 2006)
3.0%
(n=287)

2.5% 2.3%
Percentage (%)

2.0%
n=687)
(n=702)
1.5% (n=230)
1.2%
1.0%
0.9%
1.0%

0.5% (n-4) (n=23)

0.0% 0.0%
0.0%
<= 30 Years 31 - 40 Years 41 - 50 Years 51 - 60 Years 61 - 70 Years > 70 Years

15


TECAB using DaVinci Computer Enhanced
Telemanipulation System
EHIRC Data

December 2002 – Dec 2005
• Robotic surgery done - 255
• TECAB 22
– Beating heart TECAB - 20
– Arrested heart TECAB - 2
• EndoACAB 231
– LIMA Skeletonized 152
– ThoraCAB 79
• ASD,Valve Repair 2

Postoperative Data

• Complete Ventilation time (hrs) -4.36
• Chest tube drainage - 164 (55ml-
360ml)
• ICU stay - 1.2 days
• Hospital stay - 4.5 days
• Perioperative MI - Nil
• Reoperation for bleeding - 6
• New onset atrial fibrillation - Nil
• Wound Infection - Nil
• Mortality - Nil

16


Functional Ischemic MR
Myocardial Infarction

LV Remodeling

Mitral Annular Dilatation
+
Papillary Muscle

Mitral Valve Tenting

Functional Ischemic MR

Coapsys Mitral Annuloplasty System

Annular Dilatation Restricted Leaflets
Type I Type IIIb

17


Patient Selection
CABG Patients
Ischemic Functional MR
Baseline MR Grade ! 2
EF>25%
N = 75

Intra-Op TEE:
MR ! 2 Post CABG and Hemodynamic Challenge
MR " 1

Group 1 Group 2
Coapsys Untreated
(Mitral Valve Repair + CABG) (CABG Only)
Intra-op MR = 2.7 Intra-op MR = 1.0
N=35 N=40

Coapsys Effect:
Intraoperative MR Reduction

Pre-tightening Post-tightening

18


Change in MR Grade With
10
Time
Grade 4 Grade 3
Grade 2 Grade 1/0
9
8
7
6
5
4
Untreated
3
2
Group
1
0 Grade 4 Grade 3
Baseline Discharge 3 Months 12 Months 12
Grade 2 Grade 1/0

Coapsys 10

8

Group 6

4

2

0
Baseline Discharge 3 Months 12 Months

LVED and LVED Changes in
Coapsys Patients

19


THE HEART FAILURE CLINIC
AT EHIRC SINCE
SEPTEMBER 99’

HEART FAILURE CLINIC
AT EHIRC
50 2000 2001 47.4
2002 2005
40
35.6
30 28.8

20.6
20

10

0
No. of Patients Per OPD

20


THE HEART FAILURE CLINIC

CLINICAL
EVALUATION

OPTIMIZE MEDICAL REHABILITATION
THERAPY

MONITORING PATIENT
& FOLLOWUP HF CLINIC EDUCATION

IS IT SURGICAL
DISEASE? DATA REGISTRY

RESEARCH TRAINING

REASONS FOR REFERALS
! OPTIMIZING MEDICAL CARE
" PHARMACOLOGICAL
" DIET, EXERCISE
" PATIENT EDUCATION
" PSYCHO-SOCIAL REHABILITATION

! REFRACTORY HEART FAILURE TO CONSIDER FOR
" OPTIMIZATION OF MEDICAL CARE
" ALTERNATIVE MEDICINE, SECP, PACEMAKER, AICD
" INTERMITTENT / DOMICILLIARY INOTROPES
" PLAN SURGICAL INTERVENTION

! RESEARCH TRIALS

21


HEART FAILURE CLINIC

!91% HAD CAD, 85% WERE
OPERATED CASES
!REDUCED HOSPITAL READMISSION
RATE
!SIGNIFICANT IMPROVEMENT IN
EXERCISE CAPACITY

IMPACT OF HEART FAILURE
CLINIC ON 3 MONTHS POST
CABG FOLLOW UP IN
PATIENTS WITH LV
DYSFUNCTION

22


No OF POST CABG PATIENTS
240
224
220

200 188
180 167
160

140

120

100
Oct 1997- Oct 1998- Oct 1999-
Apr 1998 Apr 1999 Apr 2000

Heart Failure Re-Admission Rates:
3 Months Post CABG
7 6.91
12 11.11
5.99
9.76 Oct 1999- 6
10
Apr 2000
5
8
4
6 Oct 1998-
Apr 1999 3
4
2
2.33 1.34
2 1
Oct 1997-
Apr 1998
0 0
LVEF <20% LVEF <30%

23


Myocardial Sudden
Infarct Death
Coronary Arrhythmia &
thrombosis Loss of Muscle

Myocardial
Ischemia ENDSTAGE HEART Remodeling
DISEASE Ventricular
CAD dilatation
- CHAIN OF EVENTS
Atherosclerosis
LVH CHF

Coronary Endstage
Risk Factors Heart Disease
Dzau and Braunwald, 1991

Thank You

24

Naresh trehan

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