Angioplasty and Bypass Surgery 

• An estimated 47 million Indians had coronary artery disease (CAD) in 2010.¹ While efforts are being made to contain this epidemic by educating public and applying preventive measures, the ever increasing burden of patients with symptomatic and life threatening manifestations of the disease is posing a major challenge.²

• Indian patients undergoing bypass surgeries are often young (average age of 60 yrs) and yet reveal a high burden of major modifiable CVD risk factors. The prevalence of obesity (BMI>25) is 51%; diabetes 48%; hypertension 71%; smoking 40%; and high LDL-C  >100 mg/dl  86%.³  Early and aggressive attention to these risk factors could drastically reduce the need for coronary procedures such as angioplasty, stent, and bypass surgeries.

• Symptomatic relief in patients with advanced heart disease can be rapidly achieved with coronary procedures. It is worth highlighting that coronary procedures have limited success in preventing death or heart attack except in a small subgroup of patients with acute coronary syndrome (ACS), left main disease or three-vessel disease with left ventricular dysfunction.⁴

• There has been a steady 25-30 percent annual increase in the number coronary procedures over the past several years.² Approximately 70,000 angioplasties done in 2007 and 73% were drug eluting stents. Of these, 10% of the patients were <40 years and another 10% older than 70 years of age.^{2, 5}

• The cost of angioplasty with stent placement is generally 4-5 times higher than bypass surgery in India while it is 4-5 times lower in the US. However Indian made stents are much less expensive.

• The number of bypass surgeries is increasing in India but it is decreasing in the US. About 60,000 coronary bypass surgeries are done annually in India. Endarterectomy is needed frequently, because of advanced diffuse plaque build up from malignant heart disease.²

• In a contemporary study of 3500 patients undergoing CABG, 75% had 3 vessel disease, 10% had left main, 25% had severe LV dysfunction,and 9% had carotid stenosis. The mean body surface area was 1.6 which is much lower than the western average (1.9 in men and 1.6 in women). The small BSA could explain the wide perception of small coronary arteries among Indians.⁷

• Women are known to have smaller coronary artery size even after adjusting for smaller body surface area, than men. Indian women have markedly smaller size of coronaries than their Western counterparts.⁸ The mean LAD diameter was 1.28 mm in  smaller women (BSA <1.5 m2) and 1.65 mm in larger women ( BSA >1.5 m2) compared to 2.1 mm in men.^7,9

• The small size of women’s coronary arteries may contribute to their higher operative mortality (2.9% women  vs. l.8% men) and  the poorer outcomes following CABG.¹⁰

• The Indian heart weighs less ─ 150-250 g compared to 250 -300 g in Europid men and women.² Asian Indians have a higher operative and overall mortality following coronary bypass surgery. They also  have higher rates of  post operative complications and repeat surgeries.⁶

• Whereas the costs of angioplasty and bypass surgery are low by western standards leading to health tourism, the costs are very high (2-5 times the annual income of most Indians).

• The lack of social security and rarity of health insurance makes these procedures beyond the reach of 99% of the population or results in catastrophic health expenditure, distress financing and even bankruptcies.

Sources

1. Enas  EA, Singh V, Gupta R, Patel R, et al. Recommendations of the Second Indo-US Health Summit for the prevention and control of cardiovascular disease among Asian Indians. Indian Heart J. 2009;61:265-74.

2. Kaul U, Bhatia V. Perspective on coronary interventions & cardiac surgeries in India. Indian J Med Res. Nov 2010;132(5):543-548.

3. Kasliwal RR, Kulshreshtha A, Agrawal S, Bansal M, Trehan N. Prevalence of cardiovascular risk factors in Indian patients undergoing coronary artery bypass surgery. J Assoc Physicians India. May 2006;54:371-375.

4. Enas EA. How to Beat the Heart Disease Epidemic among South Asians: A Prevention and Management Guide for Asian Indians and their Doctors. Downers Grove: Advanced Heart Lipid Clinic  USA; 2011.

5. Indrayan A. Forecasting vascular disease cases and associated mortality in India. 2010;http://www.whoindia.org/LinkFiles Sept 25,  2010.

6. Brister SJ, Hamdulay Z, Verma S, Maganti M, Buchanan MR. Ethnic diversity: South Asian ethnicity is associated with increased coronary artery bypass grafting mortality. J Thorac Cardiovasc Surg. Jan 2007;133(1):150-154.

7. Yadava OP, Arvind Prakashl Anirban Kundur MY. Coronary Artery Bypass Grafting in Women -Is OPCAB Mandatory ? Indian heart journal. 2011;63:425-428

8. Dodge JT, Brown BG, Bolson EL, Dodge HT. Lumen diameter of normal human coronary arteries: Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation. Circulation. 1992;86(1):232-246.

9. Edwards FH, Carey JS, Grover FL, Bero JW, Hartz RS. Impact of gender on coronary bypass operative mortality. Ann Thorac Surg. 1998;66(1):125-131.

10. O’Connor NJ, Morton JR, Birkmeyer JD, Olmstead EM, O’Connor GT. Effect of coronary artery diameter in patients undergoing coronary bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation. 1996;93(4):652-655.