On World Heart Day today, the focus is on the need for a paradigm shift
Control of blood pressure and diabetes,
reduction of triglycerides are advised
A check-up at least once in six months
The cardiovascular epidemic, which is a global health problem, is set to affect India in a big way. The incidence of cardiovascular disease (CVD) is increasing in all the developing countries. The World Health Organisation (WHO) estimates that worldwide, 24 million people a year will die of CVD or stroke by the year 2030. A study conducted in rural Andhra Pradesh found that 32 per cent of all deaths were caused by CVD.
The incidence of CVD is 47 per cent in the developing countries as against 27 per cent in the developed countries in people below 70 years. In the U.S., 13 per cent of the gross domestic product (GDP) is spent on health, whereas in India the figure is less than 4 per cent. In India, the onset of CVD is at an early age, it is more severe and the progression is rapid and aggressive. This pattern is accounted for by ethnic predisposition, genetic background, abdominal obesity, low levels of good cholesterol (HDL), high incidence of diabetes mellitus, lack of exercise, consumption of “fast food” and lack of motivation for lifestyle modification.
Symptomatic patients who come to the hospital are investigated and subjected to angiography and angioplasty or bypass surgery if so indicated. This adds to the economic burden not only of the patient but also insurance companies, employers and the nation as a whole. Surprisingly, less than 10 per cent of patients coming to corporate hospitals in India have optimal insurance coverage. There is a need to shift attention from sickness to wellness to prevent the CVD epidemic, rather than treat people after the disease manifests itself in severe form.
The primary means of prevention are modification, control, and treatment of cardiovascular risk factors before one suffers a heart attack. It is essential to detect them early and give proper direction regarding lifestyle modification, diet, exercise and drug therapy. Weight reduction and emphasis on maintaining the ideal weight are necessary for obese individuals. Control of blood pressure, optimal control of diabetes, reduction of bad cholesterol like total cholesterol, LDL cholesterol and triglycerides, are advised. The level of good cholesterol can be raised by means of regular exercise and proper dietary habits. The consumption of red meat, egg yolk and fried food should be avoided. A check-up at least once in six months is mandatory.
Stress reduction can be achieved by means of proper counselling, exercise, yoga and meditation. Smoking, the “pub culture” and fast foods should be boycotted. There is no evidence to show that lifestyle modification alone can reduce CVD. Preventive medication, including statins, is essential too.
In the developing countries, among the high-risk population CVD can cause approximately 31 deaths per 10,000 population. Lowering the cholesterol level by 1 mmol a litre (38.5 mg) can reduce the number to 21. Lowering blood pressure and cholesterol levels to normal can reduce it to 13. If smoking cessation can also be achieved, the rate can fall to as low as six per 10,000.
This data emphasise the need for preventive medication to target populations such as software professionals and diabetics. Opportunistic referrals, such as for pre-employment check-ups, could also be targeted.
Polypill (which contains a cholesterol-lowering statin, blood pressure-lowering ACE inhibitor and a blood thinner, Aspirin) is useful for the high-risk population. The compliance rates are high. Its use for five years reduces CVD risk by 65 per cent. Whether it will also reduce the incidence of stroke is not substantiated.
Polypill does have some limitations. It is a fixed-dose combination and the strength of the medicines cannot be changed as and when necessary. Coughing caused by the blood pressure-lowering component of the medicine may lead to non-compliance with drug intake.
By using Framingham Risk Scoring (JAMA 2001), the risk of CVD in a population is stratified as low-risk (if less than 10 per cent), medium risk (10-20 per cent) and high-risk (more than 20 per cent).
Polypill is not ideal for high-risk individuals with very high blood pressure, diabetes and other risk factors, where frequent dosage adjustments and different drug combinations may be essential. Supplying Polypill free of cost to a given community may not result in desired effects as there is 22 per cent less adherence seen with free medication.
Polypill costs approximately Rs. 250 a month. The cost can be subsidised by the government. The preventive strategies are ideally suited for the medium-risk subset of patients from the rural and semi-urban areas who do not generally come to hospitals. Low-risk patients do not need preventive therapies. In fact, its use in the low-risk subset will only increase the financial burden to the healthcare provider. A majority of the high-risk subset of patients is certain to go to the physician for treatment due to the multiple risk factors involved.
It is surprising that health insurance agencies and employers are willing to pay for interventions but not for preventive medication. It will be a positive step if health insurance includes preventive medication for reimbursement as it will reduce the number of heart attacks, and thereby hospitalisations and interventions that are definitely costlier.
Risk factors should be considered as points in the disease continuum, as rightly proposed by Prof. Ritchie of the University of Aberdeen, and their treatment or control should be desirable, acceptable, achievable and sustainable. For example, statin treatment for high cholesterol has a strong evidence base for its desirability. But affordability and achievability will depend on the number of people treated. And the number of people treated, in turn, depends on the CVD risk in a given population. The media can play a major role in educating and motivating the target population — which is certain to increase the rate of self-referrals.
In the next decade, there should be a paradigm shift from intervention to prevention, from sickness to wellness. To be cost effective this should be targeted at the medium-risk population whose members usually do not come to physicians.
The present healthcare delivery system is grossly inadequate to face the threat of cardiovascular epidemic. The manpower needs can be met through public-private partnerships. Governments and corporate hospitals can come together to chalk out and implement preventive strategies. Non-governmental voluntary organisations can be involved to optimise the preventive health care services to the community.
Fighting the impending cardiovascular epidemic in a developing country like India is almost akin to David fighting Goliath. I have attempted to give a few suggestions to help combat the CVD risk in India. These are the views of a clinician (cardiologist), and not of a politician, policymaker or epidemiologist. An ounce of prevention is better than a pound of cure.
(Dr. I. Sathyamurthy is an interventional cardiologist and Director, Department of Cardiology, Apollo Hospitals, Chennai. He received the Padma Shri award in 2000, and the Dr. B.C. Roy National Award in 2001.)