Madhukar Shahi, senior consultant, interventional cardiology, Artemis Health Institute, Gurgaon, remembers one patient, a 35-year-old fitness junkie.
He led a healthy life, exercised regularly, ate moderately, had normal lipid profiles with blood pressure well within limits, and sailed through his annual stress test. However, the patient was worried; his father died of a heart attack at 47, his elder brother suffered one at 37. Dr Shahi suggested a 64-slice CT angiography—and found up to 50% blockages in all three arteries. The patient was prescribed statins and aspirin to prevent a heart attack.
Illustration: Malay Karmakar/Mint
Ravi Kasliwal, senior consultant, cardiology, Indraprastha Apollo Hospitals, New Delhi, says India has more cardiovascular patients than any other country. Genetic factors predispose Indians to heart disease.
Anoop Misra, director and head, department of diabetes and metabolic diseases, Fortis Hospitals, New Delhi, points out that we have higher body fat, higher abdominal fat, higher liver fat, lower muscle mass, higher levels of free fatty acids in the blood, higher tendency to blood coagulation and higher resistance to insulin than other populations.
Clearly, the more common screening tests we undergo every year are not always enough. Cardiologists now recommend more advanced predictive tests. These are recommended for people above 35, who display no symptoms but are considered to be in the intermediate risk zone (see ‘KNOW’ below).
Many of these tests cost just a few hundred rupees, are easily available at reference labs and hospitals, and can be done in a matter of minutes.
High-sensitivity C-reactive protein (hs-CRP) test
What it does:Elevated CRP (C-reactive protein) in blood suggests an inflammation in the body that, in turn, can indicate atherosclerosis or increased risk of cardiovascular events. CRP can be lowered through diet and exercise.
Normal levels: less than 10mg/l.
Procedure: A sample is drawn from the arm after 12 hours of fasting. (Non-cardiac inflammations can also elevate CRP. So, doctors recommend that you repeat the test two weeks apart and take the average value.)
Duration: About 5 minutes.
Cost: About Rs600.
When to get it: If you have two or more risk factors. Can be done along with your annual lipid profile and blood sugar tests.
Where to go: Reference labs or super-speciality hospitals.
Pulse wave velocity (PWV) test
What it does: It measures how fast the pulse wave travels down the aorta, the major artery from the heart. A slower pulse wave means the artery is more elastic, hence healthy; a faster wave means the artery is stiff.
Normal levels: 7-8m/sec is defined as normal, 8-10m/sec as borderline and more than 13m/sec as high risk. However, age and blood pressure need to be taken into consideration.
Procedure: You lie down, cuffs are attached to wrist and ankle, and readings taken. Breathe normally.
Duration: About 15 minutes.
When to get it: Not a routine test; usually for?hypertensives.
Where to go: Super-speciality hospitals, such as EHIRC.
Electron beam computed tomography (EBCT)
What it does: For a long time, cardiologists were divided about whether this was a good marker for cardiac risk. In 2006, the American Heart Association ruled it could be used as a predictive check for heart disease. It checks for the presence of calcium in the coronary arteries.
Normal levels: Calcium has no business being present in these arteries (some amount of calcification does happen with age, so the doctor will take that into account).
Procedure: You lie still while a hand-held scanner is moved over your body to map the heart and vessels.
Duration: About 5 minutes, no disrobing required.
Cost: About Rs4,000.
When to get it: If you have any cardiac risk or history.
Where to go: Most super-speciality hospitals.
Carotid intima-media thickness (IMT) test
What it does: Thickening of arterial inner walls indicates cardiovascular risk. This test can tell the “vascular age” of a person, which to heart specialists is more important than biological age. After all, a physically active 75-year-old could be “younger” than a 45-year-old heavy smoker!
Normal levels: Arterial wall thickness of not more than 0.6mm.
Procedure: This is a non-invasive test in which a gel is applied over the throat area and an ultrasound scanner passed over the area to trace the carotid artery—the key blood vessel crossing the neck.
Duration: About 10 minutes.
Cost: About Rs500.
When to get it: If you are more than 40 (either gender), and have one or more cardiac risk factors.
Where to go: Most super-speciality hospitals.
64-slice CT (computed tomography) angiogram
What it does: The coronary arteries are checked for narrowing, bulges and large cholesterol plaques. New 128-slice and 256-slice scanners (still in clinical trials) should come to India soon, meaning a superior image with less radiation. Apollo, Chennai already has a 320-slice scanner.
Procedure: Unlike a conventional angiogram in which a catheter is inserted into the blood vessel and you are hospitalized for a day, the 64-slice CT is a walk-in test providing high-resolution 3D images of the heart and major vessels.
Duration: Less than a minute (but preparation includes checking heart rate, kidney function and any allergies)
Cost: About Rs11,000 high compared to some of the other tests, but it is emerging as the most accurate test for predicting coronary artery disease (CAD).
When to get it: Only if your doctor advises (it is not performed on obese patients since higher radiation would be required to maintain image quality. It is also difficult to perform on patients who have trouble holding their breath).
Where to go: Most speciality hospitals offer this test.
These two new tests are not yet available in India, but they have the specialists excited
Phospholipase A2 (Lp-PLA2) test
What it does: Measures the level of Lp-PLA2 (lipoprotein-associated phospholipase A2, simply called PLA2), an enzyme produced from inflammation of the arteries. In most adults, cholesterol causes a build-up of plaque deposits within arteries. PLA2 is produced within the plaques. A high Lp-PLA2 level may indicate a plaque likely to rupture, perhaps precipitating a clot that could result in a heart attack or stroke. This test is more specific than the Hs-CRP, as C-reactive protein can come from non-cardiovascular inflammation, too.
Normal levels: Below 200ng/ml (ng=nanogram).
Procedure, duration: The same as most blood tests, involving withdrawal of a blood sample from the arm.
When to get it: If you are at moderate-to-high risk.
Skin sterol test
What it does: Cholesterol provides one of the biggest clues to the risk of obstructive plaque in major arteries. But, apart from being in blood, cholesterol also shows up in the skin—the basis of this non-invasive test. In the case?of severe coronary artery disease, the values increase.
Procedure: A small foam pad is placed on the palm and liquid dropped into small “wells” in the pad. Colour changes indicate the level of sterol in the skin, “read” by an electronic wand passed over the pad (in comparison, the traditional blood test requires a sample taken after 12 hours of fasting).
Normal level: The skin normally has about 11% of the total body cholesterol. A score of 110 is considered normal.
Duration: About 5 minutes.
Readings: The deeper the colour, the higher the cholesterol.
When to get it: If you have severe cardiovascular disease or history of a previous heart attack—this test can provide more information than simply checking blood cholesterol.
There are eight risk factors for heart disease.
• Obesity (body mass index more than 25, and what really counts is abdominal obesity (see ‘PREVENT’)
• Diabetes (fasting blood sugar should be 70-110mg/dl)
• High blood pressure (more than 120/80 mmHg)
• High cholesterol (total cholesterol over 200mg/dl; triglycerides above 150mg/dl; LDL (low-density lipoprotein) above 100 mg/dl; HDL (high-density lipoprotein) under 40mg/dl are all bad)
• Family history of cardiovascular disease
• Sedentary lifestyle
For a calculation of your 10-year risk, visit http://hp2010.nhlbihin.net/atpiii/calculator.asp.
Inputs from: Madhukar Shahi, senior consultant, interventional cardiology, Artemis Health Institute, Gurgaon; Ravi Kasliwal, senior consultant, cardiology, Indraprastha Apollo Hospitals, New Delhi; Atul Mathur, associate director, interventional cardiology, Escorts Heart Institute and Research Centre (EHIRC), New Delhi.
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