Heart Disease India─ Overview

• India has a young population of 1.2 billion people of whom only 5.5% is >65 years of age or elderly. Approximately 30% of this population is <15 years and 65% is between the ages of 15-64.The elderly Indians number 65 million (compared to 41 million in the US or 13% of the population) but are usually excluded from heart disease statistics.

•  Life expectancy increased to 64 years in 2008 from 58 in 1991. Per capita income rose to $3,270 in 2009 from $921 in 1990 according to the World Bank. Yet, one quarter of India’s 1.2 billion population earns less than 1US$ per day¹¹. Literacy increased from 18% in 1950 to 65% in 2008.¹¹

• In 1998, cardiovascular disease (CVD) contributed to 27% of all deaths in India with crude mortality rate of  227/100,000.¹ There is a wide disparity in prevalence and mortality from CVD in different Indian states.¹ CVD  mortality rates vary from 75-100/100,000 in sub-Himalayan states of Nagaland, Meghalaya, Himachal Pradesh, and Sikkim to as high as 360-430/100,000 in Andhra Pradesh, Tamil Nadu, Punjab, and Goa.¹ Kerala has even higher CAD and CVD death rates.² (See Kerala Heart Disease)

• There are larger regional differences in CVD mortality in India as shown in Figure 112. These large disparities in cardiovascular disease mortality among different Indian states is attributed to the differences in dietary consumption of fats, milk, sugar and green-leafy vegetables and prevalence of obesity.¹

• The latest data from the WHO shows that the age-standardized CVD mortality has increased to 415 per 100,000, several times higher than high income countries like UK and Canada (Figure 014).^{3, 4}

• An estimated 47 million Indians had coronary artery disease (CAD) in 2010 and an estimated 2.3 million died from CAD compared to 404,000 in the US.⁵ Over the past 40 years the prevalence of CAD increased by 300% or more in India and is increasing now at a rate of 5 to 6% per year (Figure 015).

• During the same period, heart disease has decreased by 50% to 80% in the US, Finland and many other countries, despite escalating epidemics of obesity and diabetes that are sweeping the entire world. This dramatic decrease in CAD mortality is attributed to nationwide decrease in cholesterol, blood pressure and smoking. These observations suggest that directly controlling these 3 risk factors will have direct and substantial effect on cardiovascular disease (CVD), while obesity and diabetes rates continue to increase.⁶

• The vast majority of CVD can be attributed to conventional risk factors, most of which are double in urban areas than in rural areas.⁷ Due to the lag time associated with CVD risk factors, especially in children, the full effect of exposure to these factors will only be seen in the future.

• However, at a given level of traditional risk factors, Indians have double the risk of CAD due to high prevalence of emerging risk factors, especially lipoprotein(a)─ a genetic risk factor for premature CAD found in 35-40% of Indians.^{8, 9}

• World-class medical facilities already exist in India to provide a high caliber of care to the minority who can afford it. Ironically, the focus on high-tech interventions may be distracting from the goal of providing evidence-based, safe, effective and relatively inexpensive drugs on a much wider scale.

• In 2009, the world mobilized against the threat of pandemic influenza, which killed approximately 15,000 people. Similar mobilization of resources is lacking in India to stem the tsunami of heart disease in India which is killing 900 Indians younger than 30 years of age every day.³

• Population-wide efforts to reduce risk factors through multiple economic, educational policies, and programs will reap savings later in medical and other direct costs, as well as indirectly in improved quality of life and economic productivity. Until that time, many currently available treatments for acute and chronic management of CVD exist and ought to be utilized in countries such as India where they are underutilized.

• Given the relatively young age of patients with advanced disease necessitating bypass surgery and the high prevalence of the major CVD risk factors, more aggressive lifestyle changes beginning at age two are needed to prevent the onset of risk factors.⁵ Use of medications to control cholesterol, blood pressure and other modifiable risk factors should also begin at a lower threshold and at a younger age.^{3, 5, 10}

Sources

1. Gupta R, Misra A, Pais P, Rastogi P, Gupta VP. Correlation of regional cardiovascular disease mortality in India with lifestyle and nutritional factors. Int J Cardiol. Apr 14 2006;108(3):291-300.

2. Soman C. R, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-Cause Mortality and Cardiovascular Mortality in Kerala State of India: Results From a 5-Year Follow-up of 161 942 Rural Community Dwelling Adults. Asia Pac J Public Health. May 10 2010.

3. Enas EA, Singh V, Munjal YP, Bhandari S, Yadave RD, Manchanda SC. Reducing the burden of coronary artery disease in India: challenges and opportunities. Indian Heart J. Mar-Apr 2008;60(2):161-175.

4. World Health Organization. Preventing Chronic Disease: A Vital Investment  World Heath Organization, Geneva 2005. 2005.

5. 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.

6. Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. Feb 12 2011;377(9765):529-532.

7. Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: the need & scope. Indian J Med Res. Nov 2010;132(5):634-642.

8. Enas EA. Lipoprotein(a) is an important genetic risk factor for coronary artery disease in Asian Indians. Am  J  Cardiol. 2001;88:201-202.

9. Enas EA, Chacko V, Senthilkumar A, Puthumana N, Mohan V. Elevated lipoprotein(a)–a genetic risk factor for premature vascular disease in people with and without standard risk factors: a review. Dis Mon. Jan 2006;52(1):5-50.

10. 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.

11. Prabhakaran D, Ajay VS, Mohan V, et al. Chronic diseases in India. In: Stuckler D & Siegel K. (Eds), ed. Sick Societies: Responding to the global challene of chronic disease.  : Oxford University Press Inc, Oxford, New York; pp 581- 601.; 2011.