Since the late 1990s, India has had the dubious distinction of being the coronary artery disease (CAD) capital of the world. CAD is more prevalent among Indians than any other ethnic group in the world, and occurs earlier here than anywhere else. It results in more deaths worldwide than any other disease, and the prevalence and severity of the disease has shown no signs of letting up.
The 101 on CAD is simple—it occurs when the vessels that supply blood to the heart get damaged; this restricts the flow of blood to the heart. This, in turn, can lead to chest pain (angina) and shortness of breath, while a complete blockage can result in a myocardial infarction (heart attack). But here’s the twist: The biggest factors for this CAD epidemic are not genetic or external sources or lack of medical intervention—it is the choices we make.
Diet control: Keep a check on what you eat to pre-empt expensive bypass surgery-snack on an apple rather than a burger
According to the World Health Organization (WHO), 80% of the CAD cases across the world are the result of lifestyle choices—these include lack of exercise, unhealthy eating habits and regular use of tobacco. This is similar to the results from a study by INTERHEART, a Canadian-led global survey of the risk factors for heart attacks conducted in 52 countries (the results were first published in September 2004). The study examined 15,152 people who had suffered a heart attack and compared them with 14,820 people of the same age and sex who did not have a prior history of heart attacks or heart disease
Once the data was analysed, the South Asia component of the INTERHEART study identified nine factors that accounted for 86% of the cases of heart attacks in Indians: abnormal lipids (fat), smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low fruit and vegetable consumption, alcohol use and a lack of physical activity
While it is challenging to put a number on exactly how many people are suffering from CAD in India, one recent study found a prevalence of 11%—the Chennai Urban Population Study, a population-based study, was done by V. Mohan and colleagues at the Madras Diabetes Research Foundation, a WHO collaborating centre for noncommunicable disease prevention and control, and published in the Journal of Diabetes Science and Technology in January 2010.
The way ahead
On paper, the solution to CAD is deceptively simple—follow a healthy diet, exercise regularly, don’t smoke and reduce stress. You don’t need a study to tell you that, but one conducted by the Harvard Medical School, and published in the American Heart Association journal Circulation in June 2008, comes to just that conclusion.
Atul Biniwale, who has a private practice in Pune and is a consultant cardiologist at the University of Liverpool, UK, narrates the story of one of his patients.
This Pune-based, 67-year-old man, who now works as a consultant, travels at least once a week on work. He doesn’t smoke, eats healthy, drinks a few glasses of wine a week and walks for an hour on the treadmill five-six days a week.
It wasn’t always so. Five years ago, he suffered from chest pain and Dr Biniwale recommended an angiogram. The angiogram found one blockage and an angioplasty was recommended to open it. After the angioplasty, however, it was business as usual for him. This meant no exercise and a diet rich in fats, but not in fruits or vegetables. Dr Biniwale recommended he change his lifestyle and start exercising every day while eating a low-fat diet, with a stress on fresh fruits, vegetables and whole grains. He also warned him that the angioplasty had treated the symptoms of CAD, not the disease itself. The patient didn’t follow the advice.
Last year, he felt some discomfort in the chest again. This time, his angiogram showed blockages in three blood vessels. While a simple angioplasty, which is a non-surgical procedure, had sufficed earlier, this time he had to undergo a triple bypass surgery to create a new route for the blood to reach the heart muscle.
When a bypass is needed
Bypass surgeries are the most common heart surgeries performed in India, and account for 70-80% of the total open-heart surgeries in this country, according to Saurabh Juneja, consultant cardiothoracic and vascular surgeon, Artemis Health Institute, Gurgaon.
“This is a useful procedure because it relieves angina and significantly reduces the risk of heart attacks in future,” says Balbir Singh, chairman, cardiology department, Medanta—The Medicity, Gurgaon.
Bypass surgery is recommended when the blood vessels that supply the heart muscle with oxygen and nutrient-enriched blood get blocked. During the procedure, the cardiac surgeon uses healthy blood vessels from other parts of the body to “bypass” the blocked heart blood vessels.
However, CAD varies a great deal from person to person, and so does the treatment. Your doctor should try medication and angioplasty before advising surgery.
Dr Singh says he has observed an increase in the number of bypass surgeries being performed in the last five years, especially among post-menopausal women—CAD was earlier considered a man’s disease and doctors often failed to evaluate the risk factors in women. This despite the fact that in his practice he finds only 50% of the patients who are advised to get a bypass done actually opt for the procedure.
Dr Singh attributes this unwillingness to three factors: The typical patient is conservative when exploring medical treatment options; most health insurance companies cover 30-50% of the cost of surgery and the rest can be a significant out-of-pocket expense (a bypass surgery usually costs Rs 2-3 lakh); and a fear of hospitalization.
In his forthcoming book Rethinking Aging, Nortin Hadler, a professor of medicine at the University of North Carolina, US, says it may not be such a bad thing that Indians often choose not to get a procedure done. He argues that far too many elective surgeries, particularly angioplasties, done every year in the US could be avoided and patients would be in better health with a restricted diet, exercise and the necessary medicines.
If surgery is needed, says Dr Biniwale, the cardiologist should make the patient comfortable with the idea. He emphasizes that prior to a bypass surgery the patient should be counselled carefully on the complications and benefits of surgery, and be reassured that he or she can usually resume driving, work and daily chores four-six weeks post-surgery.
Surgery at the right time will bring down the mortality rates of CAD, but this is the hard road to take. For many Indians, the costs are prohibitive and the fear of hospitalization is not unfounded either.
Much easier, then, to pick an apple instead of a packet of chips, or a salad instead of samosas, and spend 40 minutes every day walking briskly in a neighbourhood park.
Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.
Before and after surgery
Since coronary artery disease (CAD) is an ailment where the blood vessels get blocked, tests are performed to make sure that the patient does not have kidney disease—the kidneys filter out the waste products in the blood. And if the patient is on blood thinners, these are withheld three days prior to the surgery, says Saurabh Juneja, consultant cardiothoracic and vascular surgeon, Artemis Health Institute, Gurgaon. Apart from these precautions, the routine pre-surgical tests include chest X-rays, blood tests, electrocardiogram and coronary angiogram. Doctors also give instructions, restricting activity and recommending proper diet prior to the surgery.
After a bypass surgery, a patient will be in the intensive care unit for three days before being shifted to the general ward for two-three days, and will be discharged by the sixth day.
Anil Dhall, head of interventional cardiology, Artemis Health Institute, says the patient can resume normal activity after six weeks’ rest—as long as he or she strictly follows the doctor’s instructions on diet, physiotherapy and medication. Family members can help by arranging to have a limited number of people visit the patient during the hospital stay, and not allowing relatives and friends with respiratory infections to visit the patient.
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