Cardiovascular diseases (CVDs), particularly ischemic heart disease (IHD), are a leading cause of mortality in India, affecting all socioeconomic groups. The high burden of CVDs presents significant economic challenges, prompting the need for improved health infrastructure and cost-effective prevention strategies. Effective surveillance and data collection systems are necessary for addressing the epidemic and improving health outcomes.

1.
Burden of cardiovascular diseases in Indians:
Estimating trends of coronary artery disease and
using low cost risk screening tools

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. 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. 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. 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. 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. 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
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j.apme.2014.07.002

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