This document discusses coronary artery disease (CAD) and its epidemiology in India. It provides three real stories about myocardial infarctions occurring in young individuals to illustrate the severity of the issue. It then presents statistics on the leading causes of death in India, showing that cardiovascular diseases are becoming more common, now accounting for over a third of deaths and occurring at younger ages compared to developed countries. The document discusses the traditional risk factors for CAD, including diabetes, hypertension, smoking, dyslipidemia, obesity, lack of exercise, and family history. It provides data on the prevalence of these risk factors in India. The document emphasizes that risk factor assessment is not prevalent in India's public health system. It concludes by describing clinical features of

1. 1
EPIDEMIOLOGY OF CORONARY
ARTERY DISEASE
DR HARIVANSH CHOPRA
D.C.H.,M.D
PROFESSOR & EX HOD
COMMUNITY MEDICINE
LLRM MEDICAL COLLEGE MEERUT

2. THREE REAL STORIES
Eighteen year old
smart boy son of a
doctor suffered from
myocardial infarction
and could not be
saved despite getting
best available
treatment
2

3. Thirty eight year old a
famous specialist doctor,
son of professor of
Medicine Died at home on
the first floor.
Unfortunately no medical
assistance was possible due
to acuteness of episode
3
THREE REAL STORIES

4. THREE REAL STORIES
Fourty two year old
faculty member of a
medical college had an
episode of impending
infarction and fortunately
was given treatment in
private sector in first
thirty minutes and
survived.
4

5. 5
Facts
50% of Mortality in MI / CHD occurs in
first thirty minutes
CHD is occurring a decade earlier in
india as compared to developed
countries.
Risk factor assessment is not
prevalent in public health system

6. 6
TOP FIVE CAUSES OF MORTALITY
6
Main Causes of Death in India
2005
36.2%
29.0%
16.0%
10.8%
8.0%
Communicable Diseases
Cardiovascular Diseases
Other Chronic Diseases
Injuries
Cancer
Main Causes of death in India
Projected: 2030
21.0%
19.1%
12.1%
11.9%
35.9%
WHO INFOBASE

7. Deaths below 70 Years
• Gupta R. Burden of coronary heart disease in India. Indian Heart J 2005; 57 : 632-8.
• Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 :
807-10.
Western countries India
23%
52%
Deaths due to NCDs
Deaths below 70 Years age
7

8. Non
communicable
diseases
50%
Communicable
diseases
40%
Injuries
10%
Estimated percentage of deaths by cause in India, 2008
Source: Global Health Observatory.World Heath organization 2011 8

9. 0%
10%
20%
30%
40%
50%
60%
70%
80%
Communicable
Disease
Non communicable
disease
Injuries
38%
50%
16%
15%
75%
14%
2004
2030
Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PloS Medicine, 2006, 3(11):e442.
Trends in estimated percentage of deaths by cause of death,
South-East Asia region, 2004 and 2030
9

10. 10
Estimated burden of CHD in India
Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South
Asia. BMJ 2004; 328 : 807-10.
0
0.5
1
1.5
2
2.5
1990
2010
1.17
2.03
CHDs Burden In millions

11. 12%
9%
3%
1%
0%
2%
4%
6%
8%
10%
12%
14%
Ischaemic heart
disease
Cerebrovascular
disesases
Hypertensive heart
disease
Other
cardiovascular
diseases
Percentage of deaths due to CVDs* of subtype CVD,
India, 2008
CVDs: Cardiovascular diseases
Source:Global HealthObservatory.World HeathOrganization 2011.
11

12. CARDIOVASCULAR DISEASE BURDEN
 Cardiovascular diseases (CVDs) are the
number 1 cause of death globally, taking an
estimated 17.9 million lives each year an
estimated 31% of all deaths
 A review of current trends shows that the
number of adults with hypertension increased
from 594 million in 1975 to 1.13 billion in
2015, with the increase seen largely in low-
and middle-income countries.

13. CVDs Burden in India
 In 2016, the estimated prevalence of CVDs in
India was estimated to be 54.5 million. One in
4 deaths in India are now because of CVDs
with ischemic heart disease and stroke
responsible for >80% of this burden.

14. AGE
HYPERTENSION
SMOKING
DIABETES
DYSLIPIDEMIA
OBESITY/
LACK OF EXERCISE
PREMATURE
FAMILY HISTORY OF
CAD
TRADITIONAL RISK FACTORS
14

15. COVID 19

16. Schematic representation of an iceberg for NCDs
16

17. 28%
72%
IDSP DATA
MedicineOPD LLRM MEDICAL COLLEGE,MEERUT 2012-13
NCD CD
17

18. 57%
16%
5%
22%
IDSP DATA OF MEDICINE OPD
(Aug.2012-July 2013)
HT
IHD
DM I
DM II
18

19. 17%
3%
80%
OPD DATA ANALYSIS UHC,COMMUNITY
MEDICINE,LLRM medical college,meerut
2008
HT
HT+DM
OTHERS
19

20. 25%
9%
66%
OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM
medical college,meerut
2009
HT
HT+DM
OTHER
20

21. TRADITIONAL RISK FACTORS
DIABETES DIABETES
DIABETES
21

22. 22
Diabetes mellitus: In India
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and
projections. Diabetes Care 1998; 21 : 1414-31.
1995 2025
19.3
57.2
DM in Millions
22

23. 23
ICMR estimates
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in
India. Lancet 2005; 366 : 1746-51.
Rural area
Urban area
3.80%
11.80%
Prevalence of Diabetes
23

24. 0%
2%
4%
6%
8%
10%
12%
Males
Females
11%
11%
Percentage of adult population with raised
blood glucose level*, India, 2008
* Fasting glucose> 7.0 mmol/L or on medication for diabetes
Source:World HealthOrganization. Global status report on non communicable diseases, 2010. Geneva, 2011
24

25. 25
Diabetes:Top 10 Countries (absolute numbers)

26. INDIAN DIABETES RISK
SCORE
(IDRS)

27. Introduction
 In the year 2005, Madras Diabetes Research
Foundation (MDRF) devised the Indian Diabetes Risk
Score (IDRS) in order to detect the high risk
individuals or the undiagnosed Type 2 Diabetes in the
community
 This score is based on an extremely large population
base study on Diabetes in India “CURES” (Chennai
Urban Rural Epidemiology Study).
 Has a Sensitivity of 72.5% and Specificity of 60.1%.

28. INDIAN DIABETES RISK SCORE
 Effective Screening Strategy to assess Diabetes risk
 4 components are assessed:
2 Modifiable Risk-
Factors
• Abdominal
Obesity (Waist
Circumference)
• Physical Activity
2 Non-Modifiable
Risk-Factors
• Age
• Family History of
Diabetes

29. S.No. Factors Score
Min 0 max 100
1. Age
<35 years 0
35-49 years 20
>50 years 30
2. Abdominal Obesity (WC)
<80cm (F), <90cm (M) 0
80-89cm (F), 90-99cm (M) 10
>90cm (F), >100cm (M) 20
3. Physical Activity
Vigorous exercise or Sternous work 0
Moderate exercise at Work/Home 10
Mild exercise at Work/Home 20
No exercise and Sedentary work 30
4. Family History
No Parent Diabetic 0
Either Parent Diabetic 10

30. Interpretation of IDRS:
 SCORE <30 : LOW RISK OF HAVING DIABETES IN
FUTURE
 SCORE 30-59 : INTERMEDIATE RISK OF HAVING
DIABETES IN FUTURE
 SCORE ≥60 : HIGH RISK OF HAVING DIABETES IN
FUTURE

31. 31
Subjects with High IDRS,
regardless of their Blood Sugar
status
are ideal candidates for Lifestyle
Modification
as these are risk factors for not
only Diabetes But also for
Cardiovascular Diseases.

32. Advantages
 Cost Effective
 Non-invasive
 Simple and Easily applicable on the target
population.
 Effective for Mass screening programmes.
 Can be easily used at a Primary Health Care
Centre

33. 33
PECULARITY OF CHD IN DIABETES
33
DIABETIC SUBJECTS HAVE 2-4
TIMES MORE RISK OF CHD
CHD MAY BE SILENT
OCCURS ATYOUNGER AGE
RESULT IN MICROVASCULAR
ANGINA
WORSE OUTCOME
FOLLOWING
REVASCULARISATION

34. TRADITIONAL RISK FACTORS
HYPERTENSION HYPERTENSION
HYPERTENSION
34

35. 36%
34%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Males Females
Percentage of adult population with high blood pressure*,
India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability
*Systolic BP>140 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP 35

36. 36
Hypertension:
• Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18 : 73-8.
0%
10%
20%
30%
40%
Urban Rural
40%
17%

37. 37
2000 2025
No. of Persons with
HYPERTENSION
118 Million 214 Million
No. of Persons Dying
from TOBACCO
900,000 2 Million +
Rising Chronic Disease Burdens
Source: Jha et al, NEJM, Feb 2008 . WHO infobase

38. TRADITIONAL RISK FACTORS
SMOKING SMOKING
SMOKING
38

39. 39
Cigarette smoking
An alarming
rate of current
tobacco use of
56 % among
Indian men aged
12-60 yr.

40. Survey of sixth and eighth
graders attending school
in an urban setting
revealed that the
prevalence of tobacco use
(any history of use or
current use) was 2-3 times
higher among sixth
graders compared with
eighth graders.
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of
chronic diseases in India. Lancet 2005; 366 : 1746-51.
40

41. Males
Females
0%
10%
20%
30%
40%
50%
60%
70%
No formal
schooling
Less than
Primary
Primary
but less
than
secondary
Secondary
and above
68%
61%
49%
30%
32%
22%
11%
4%
Percentage of adults, who are current users of tobacco
products, by education, India, 2009
Males
Females
Source: India Global Adult Tobacco Survey 2009
41

42. TRADITIONAL RISK FACTORS
NUTRITIONAL
DYSLIPIDEMIA
FAMILIAL
DYSLIPIDEMIA
METABOLIC
DYSLIPIDEMIA 42

43. 0%
5%
10%
15%
20%
25%
30%
Males Females
26%
29%
Percentage of adult population with raised total cholesterol,
India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability
43

44. TRADITIONAL RISK FACTORS
OBESITY
FAMILIAL METABOLIC
44

45. 45
OBESITY RUNS INTHE FAMILY
NO BODY RUNS INTHE FAMILY

46. 0%
2%
4%
6%
8%
10%
12%
14%
Overweight(BMI>=25
kg/m2)
Overweight(BMI>=30
kg/m2)
10%
1.30%
13%
2.50%
11%
1.90%
Percentage of adult population that is overweight and obese,
India, 2008
Male
Female
Both sexes
Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability 46

47.  Childhood obesity is an
emerging issue.
 In a Mysore (India) study
on 43 152 school children,
obesity and overweight
prevalence was 3.4% and
8.5%, respectively.
47

48. 48
NUTRITIONAL STATUS OF CHILDREN (5-15 YRS)
IN URBAN MEERUT
48%
38%
10%
4%
Under weight
Normal weight
Over weight
Obese

49. 49
Physical activity
Daily moderate
intensity physical
activity (e.g., the
equivalent of briskly
walking 35-40 min per
day) is associated with
a 55 percent lower
risk for CHD.
Rastogi T, Vaz M, Spiegelman D, Reddy KS, Bharathi AV, Stampfer MJ, et al. Physical
activity and risk of coronary heart disease in India. Int J Epidemiol 2004; 33 : 759-67.

50. 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Male Female
14%
19%
Percentage of adults with insufficient
physical activity, India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 based for comparability
50

51. 21%
2%
0%
5%
10%
15%
20%
25%
Males Females
Percentage of adults consuming
alcohol*, by sex, India, 2007
Source: National NCD risk-factor surveys in Member countries
*People who have consumed alcohol in the past 30 days.
51

52. 0%
10%
20%
30%
40%
50%
60%
2010 2050
30%
55%
Projected mid-year population, residing
in urban areas,
India, 2010-2050
2010
2050
Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs
Population Division.United Nations New York, 2008.
52

53. Physicians
2000-2010
Nursing and
midwifery personnel
2000-2010
Public health
workers
2000-2010
Community health
workers
2000-2010
Number Density* Number Density* Number Density* Number Density*
660801 6.0 1430555 13 --- --- 507150 0.5
Source:World Health Statistics 2011,World Health Organization
2011
*per 10 000 population
Health workforce in India
56

54. Source: Global Health Observatory.World Heath organization 2011
All India Uttar Pradesh
Medical
Colleges
529 32
M.B.B.S seats 70978 7392
M.D- General
Medicine
3188 186
D.M- Cardiology 406 29
Mch- Cardio-
thorasic surgery
185 7
Annual Intake of medical students in India and Uttar Prades
Source: MedicalCouncil of India

55. CLINICAL FEATURES OF CHD
58
ANGINA
PECTORIS
ANGINA
ON
EFFORT
ANGINA
AT REST M I

56. RAQ possible myocardial
infarction questionnaire
59
RAQ possible myocardial infarction
questionnaire
Q1. Within the last 1 year, have you ever had a
severe pain across the front of your chest lasting
for half an hour or more?
If no go to the angina effort questionnaire
If yes ask the following question
Q2. Did the pain occur for the first time in the last
year?
If yes to both above then diagnose incident case of
MI
Yes/No
Yes/No

57. RAQ angina pectoris questionnaire
60
Q1. Within the last 1 year, have you ever had any pain
or discomfort in your chest? Yes/No
If No, within the last 1 year, have you ever had any
pressure or heaviness in your chest? Yes/No
If No, diagnosed as ‘not an incident case of angina
pectoris’?

58. RAQ angina pectoris questionnaire
61
Q2. Did the pain/discomfort/pressure/heaviness in the chest occur
for the first time in the last year? Yes/No
If No, diagnosed as ‘not an incident case of angina pectoris’
Q3. Did you get it when you walked uphill or hurry?
Yes/No/Never hurries nor walks uphill
Q4. Did you get it when you walked at an ordinary pace on the
level? Yes/No
IfYes to either Q3 or Q4, proceed to the next question

59. RAQ angina pectoris questionnaire
62
Q5.What did you do if you get it while you were walking?
Stops or slow down/Carry on
Q6. If you would stand still, what happened to it?
Relieved/Not relieved
Q7. How soon?
10 min or less/More than 10 min
Q8.Will you show me where it was?
Sternum/Left anterior chest/Left arm/Others

60. RAQ angina pectoris questionnaire
63
IfYes to Q1 and Q2, Q3 or
Q4, ‘stops or slow down’
for Q5, ‘relieved’ for Q6,
‘10 min or less’ for Q7,
‘sternum’ or ‘left anterior
chest and left arm’ for
Q8; diagnosed as
‘incident case of angina
pectoris’

61. DIAGNOSIS OF CHD
64
ECG TMT
THALLIUM
CORONARY
ANGIOGRAP
HY
CT -ANGIO

62. INNOVATIONS IN ECG AND BLOOD SUGAR
MESUREMENT
65

63. TREATMENT OF CHD
66
THROMBOLYSIS
PTCA
CABG

64. PREVENTION OF CHD
PRIMORDIAL
PRIMARY
SECONDARY
67

65. PREVENTION OF CHD
 PRIMORDIAL
 It is the prevention of
emergence of risk factor in a
community where it is absent
68

66. PREVENTION OF CHD
 PRIMARY PREVENTION
 It includes
 Health promotion and healthy
lifestyle and diet
69

67. PREVENTION OF CHD
 Secondary prevention
70
POST INTERVENTION
ANTIPLATELET
ANTIANGINAL YOGA
STATINS
EXERCISE
& DIET

68. PREVENTION OF CHD
DIABETES CONTROL
HYPERTENSION
CONTROL
OBESITY CONTROL
STOP SMOKING &
ALCOHOL
SECONDARY
PREVENTION
71

69. 72
National Programme for Prevention and Control of
Cancer, Diabetes, CVDs and Stroke
(NPCDCS)
Ministry of Health & Family Welfare
GOI c.

70. 73
Objectives of NPCDCS
Prevent and control common NCDs through
behavior and life style changes,
 Provide early diagnosis and management of
common NCDs,
 Build capacity at various levels of health
care for prevention, diagnosis and treatment
of common NCDs,

71. 74
Train human resource within the public health
setup viz doctors, paramedics and nursing staff to
cope with the increasing burden of NCDs, and
 Establish and develop capacity for palliative &
rehabilitative care.
Objectives of NPCDCS

72. 75
India Map showing the States
to implement NPCDCS
36 STATES/UT
298 DISTRICTS

73. 76
As on March 2016, the
programme is under
implementation in all 36
States/UTs. A total of 298
District NCD Cells and 293
District NCD Clinics have been
established in the country.
Also, there are 103 functional
Cardiac Care Units for
emergency cardiac care and 64

74. 77
Packages of services to be
made available at different
levels under NPCDCS
At Sub Center Level:
 Health promotion for behavior change
 ‘Opportunistic’ Screening using B.P
measurement and blood glucose by strip
method
 Referral of suspected cases to CHC

75. 78
At CHC Level:
 Prevention and health
promotion including
counseling
 Early diagnosis through
clinical
and laboratory
investigations (Common
lab investigations:
Blood Sugar, lipid profile,
ECG, Ultrasound, X ray
etc.)

76. 79
At CHC Level:
79
 Management of common
CVD, diabetes and
stroke cases (out patient and
in patients.)
 Home based care for bed
ridden chronic cases
Referral of difficult cases to
District Hospital/
higher health care facility

77. At District Hospital Level:
Early diagnosis of diabetes, CVDs, Stroke
and Cancer
 Investigations: Blood Sugar, lipid profile, Kidney
FunctionTest (KFT),Liver FunctionTest ( LFT), ECG,
Ultrasound, X ray, colposcopy , mammography etc. (if
not available, will be outsourced)
 Medical management of cases (out patient ,
inpatient and intensive Care )
80

78. 81
At District Hospital Level:
 Follow up and care of
bed ridden cases
 Day care facility
 Referral of difficult
cases to higher health
care facility
 Health promotion for
behavior change

79. 82
Cardiac Care Unit (CCU)
 Support of Rs. 1.5 crores
 Functional in 103 districts so far
82
CCU at Pattanamthita, Kerala CCU at Kupwara, J&K
Issues:
Procurement of equipments
 Non availability of specialists
 Lack of space in some district hospitals

80. Tertiary
Level
Dist. Hospital
NCD Clinics, CCU
CHC
NCD Clinic
Diagnosis and Management, Lab.
Investigations, Home Based Care, Referral
Sub Center
Screening Facility
Health Promotion, Opportunistic Screening, Referral
State NCD cell
District NCD cell
Block CHC
( Rogi Kalyan Samiti)
Village Health
Committee
Referral
83

81. 84
MISSING LINK
Stress
Strength
Traffic
control
Redesign
Erase
Share
Surrender
to God
STRESS

82. “Live sensibly -
among a thousand
people, only one
dies a natural
death; the rest
succumb to
irrational modes of
living.”
-
Maimonides
85

83. 86
Avoid alcohol
Be physically active
Cut down on salt and sugar
Don’t use tobacco products
Eat plenty of fruits and vegetables
Being healthy is as easy as ABCDE

84. 87