The high rates of CHD in India are due to combination of double jeopardy from nature (genetic factors) and nurture (lifestyle factors). From the previous chapter it is evident that the major risk factors for CHD are smoking, high cholesterol, high saturated fat diet and lack of physical activity, however risk factors such as increased cholesterol levels, hypertriglyceridemia, lipoprotein and serum homocysteine levels refine the risk factors responsible for the CHD epidemic in India. Since the adverse effects of these factors are greater in Indians, the benefits of modifying them are also correspondingly greater. It is questionable whether the prevention of these factors would alone reduce the CHD epidemic in India. It also questionable just how much motivation there is from the government side in preventing a CHD epidemic. According to the WHO, India will account for more than half of the total heart patients in the world by the end of this century (Atre, 2004) and the majority would be from the younger age group. Clearly, there is a need for intensive efforts directed at prevention and effective treatment of CHD. The aim of this chapter is to provide an insight into the primary prevention, management and control of CHDs, and to provide recommendations for reducing the toll of morbidity, disability and premature mortality due to CHDs.
Management of CHD
According to the WHO (2004), from the 1990's many people have died from CHD and two-thirds of all cardiac fatalities now occur in developing countries. A look at the risk factors in the previous chapter for CHD shows that there is need for acute interventions, including drug therapy, coronary artery bypass graft surgery and angioplasty; however none of these modify the underlying causes of the disease. These are just palliative measures for treating CHD; hence people need to make important changes in their life-style (Cox, 1997). The World Health Organization (WHO) has defined primary prevention of coronary heart disease (CHD) as prevention of the first events of these diseases beginning early in childhood and continuing through out childhood, youth and adult life (Rajedran, 2001). Recent studies have shown that lifestyle changes (smoking/tobacco cessation, increased physical activity, stress management, weight control) and poly-pharmacy (aspirin, statin, ACE inhibitor, beta-blocker and certain vitamins) can help prevent more than 75% of heart attacks (Wald et al., 2003). In order to prevent CHD it is necessary to avoid the occurrence of major risk factors. This is known as primordial prevention (Singh and Sen, 2003). According to Sir Geoffrey Rose, in prevention it is important to approach the susceptible population. A population-based strategy aims to lower the risk factors across the entire population through modification of life style. Most importantly, this ensures that children adopt healthy eating habits, slowing the rise in cholesterol level with age and creating a new generation with lower risk factor levels. A population-wide approach therefore corrects the underlying cause of the epidemic and is a safer, cheaper and more cost-effective approach than one that simply involves targeting those at high risk (Singh and Sen, 2003). A high-risk approach depends directly on the practicing physicians who opt for screening which will ordinarily include measurement of total cholesterol, systolic and diastolic blood pressure, height and weight and aerobic fitness. Subjects should be questioned regarding tobacco use and diet. In India the Ministry of Health Department and Family Welfare on June 4th 2008 launched a new pilot phase of a National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS). This programme aims to reduce the risk for prevention of CHD, diabetes and stroke as well as ensure early diagnosis and management of these conditions. The strategies for this programme include health promotions aimed at the general population and at disease prevention among the high risk group (Ministry of Health Department and Family Welfare, 2008). From this point I will detail the different methods of management of CHD in order to prevent and have control the problem in the Indian population. I will also provide an overview of drug therapy and analyze the management system in India, and will help us to recognize where all improvements should be made in the Indian health care fraternity.
achieved (Goyal and Yusuf, 2006). In 1997, WHO, reported the prevalence of tobacco habits in India to be as follows: Bidis (34%), Cigarettes (31%), Chewing tobacco (19%), Hookah (9%), Cigars-cheroots (5%), and Snuff (2%) (Shimkhada and Peabody, 2003). On a small scale in India, the Ministry of Health and Family Welfare of the Government of India has taken a positive stand and has opened 13 Tobacco Cessation Clinics all over India. In order to strengthen the tobacco control measures, the Government of India also passed a piece of anti-tobacco legislation, "The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act 2003", which came into force on 1 May 2004. However, the lack of a national authority in the regulation of smoking cessation hinders enforcement of these policies (Reddy et al., 2005). Gupta et al's (1994) cross-sectional survey showed that uneducated people have higher incidence of smoking and thus are at greater risk of having CHD. Accordingly, the first priority of the government should be increasing regulation for more smoking cessation clinics in the country. Pfizer healthcare company of India, in a partnership with the private sector, plans to open 600 smoking cessation clinics in India (Economic Times of India, 2009). Another important factor to consider is how to impart all the information to the public - especially in rural areas; this is discussed later in this assignment. Greater concentration upon tobacco cessation efforts must be applied to those groups in whom tobacco use rate trends are particularly disturbing, including the youth, and rural populations among whom the use of smokeless tobacco and use of tobacco among women are highly prevalent (Teo, 2006).
Physical activity management
Exercise is a critical part of the prevention of CHD (Rastogi et al., 2004). Physical activity may reduce the risk of CAD through different mechanisms (Lee et al, 2001). The direct action of physical activity on heart results in decreased myocardial oxygen demand through improved myocardial contraction, electrical stability, increase in the diameter and dilating capacity of coronary arteries, increased collateral artery formation and reduced rate of progression of coronary artery atherosclerosis (Hembercht, 1993). In addition, high levels of activity are associated with low blood pressure (Hagberg, 1995), high levels of HDL and lower levels of LDL (Williams, 1996) and increased insulin sensitivity and glucose tolerance. In short it prevents most of the risk factors that lead to CHD. Increased physical activity is also associated with decreased levels of homocysteine (Abraham et al., 2006) and those individuals with increased physical activity are less likely to be overweight. Hambretch et al., (2000) carried out a randomised prospective study showing the effect of exercise on coronary endothelial function. Four weeks of vigorous exercise improved coronary endothelial function in patients with asymptomatic coronary atherosclerosis. Another finding of the research was that adenosine induced flow-dependent vasodilatation after training was markedly improved. Additionally, it was also found that exercise was associated with increases in agonist-mediated blood flow velocity and coronary blood-flow reserve. These findings indicate that in the absence of clinically significant coronary-artery stenosis, the vasodilatory capacity of coronary resistance vessels was enhanced. However, there could be a potential bias where it was not solely the effect of exercise on the endothelium of the coronary vessels but also was a combination of drugs and exercise. Another bias was the sample size was very small constituting only 19 patients, affecting the generalisability of the results. In India, a hospital based case-control study conducted in the urban areas of India reported that physical exercise was inversely associated with coronary heart disease (CHD) risk. Risk for CHD decreased across levels of leisure-time exercise, with people just having a walk for at least 36 minutes in a day (Rastogi et al., 2003). However, the potential bias for this study is that selection of controls and a differential recall among cases compared with control subjects. Another factor of concern is that this study was conducted in urban areas and hence the results cannot be generalized across the entire population of India. The above analysis has showed that physical exercise helps to reduce and prevent CHD among the high risk population. It is also noted that exercise not only prevents CHD but also improves the blood flow in the endothelium thus preventing myocardial infarction.
Atherogenic dyslipidemia is common in Indians (Singh and Sen, 2003). A high caloric diet with high fat content and combined with limited physical activity contributes to obesity, insulin resistance and dislipidemia. All these abnormalities increase the risk of CHD. Not only with the cholesterol rich diet consumed by migrants in the western world, but with the traditional clarified fat consumed in India, there is an increased risk of CHD (Bedi et al., 2006). Dietary therapy involves the reduction of fat and saturated fat intake. Total fats should be of caloric intake and saturated fats should be <7%. Consumption of trans-fatty acids containing hydrogenated oils and hard margarines should be discouraged. Dietary intake of monounsaturated fats (10-15% of calories) and polyunsaturated fats (7-10% of calories) should be encouraged. Mustard-rapeseed oil and soybean oil are especially rich sources of monounsaturated fats in Indian diets. Also relevant is increased intake of omega-3 fat containing oils (mustard-rapeseed oil, fish). Invisible fats that are present in vegetables and cereals are recommended while the intake of animal fats in meat, egg and poultry is not.In the INTERHEART study, it was found that eating fruits and vegetables regularly was associated with a 30% reduction in relative risk for an acute MI (Yusuf et al., 2004). Dietary therapy also reduces LDL cholesterol, helps in weight reduction, decreases B.P. and counters insulin resistance, which is associated with truncal obesity and impaired glucose tolerance (Singh and Sen, 2003). Non-traditional cooking alternatives should be encouraged: for example baking or broiling should be encouraged instead of deep frying (Bedi et al., 2006). In a case-control study in India, the results showed that risk factors decline with the intake of green leafy vegetables and use of mustard (Rastogi et al., 2004). Use of mustard oil, which is rich in _-linolenic acid, was associated with a twofold lower risk than was use of sunflower or other oils. Alternatively, the addition of vanaspati, which is rich in trans fatty acids, to food was associated with a moderate increase in IHD risk. Potential sources of bias in the present study include the selection of controls and a differential recall among cases and controls. Another bias was that the controls in this population study were slightly more educated than were the cases but had lower incomes which could have been a reason for decreased incidence of CHD in the control group as they could not spend money on food. Control of diabetes and achievement of normoglycaemia is essential for primary prevention of cardiovascular events (Singh and Sen, 2003). Dietary modification is the key to prevention of most of the risk factors that leads to CHD such as hypercholesterolemia, insulin resistance, hypertryglyceridemia and LDL. This section helped to provide varied evidence on which foods are high risk.
It is understood that goal of preventing cardiovascular diseases is to avoid the occurrence of the major risk factors themselves. However, this can be achieved only by being with the public and providing knowledge to them. The basic aim of the public health education is to spread the message of primordial prevention of coronary heart disease through population based measures (Gupta, 2004). Improvements in educational attainments have invariably been accompanied by improvements in the health and longevity of the population and in their economic well-being. Educated people are likely to be more productive and hence better-off. They are also likely to contribute more to a country's economic growth (Sarvalingam and Shivakumar, 2004). Darr et al., 2008 carried out a qualitative study to examine the illness beliefs of South Asian and European patients with CHD related to causal attributions and lifestyle change. The results showed that there was misinterpretation about the cause of CHD and a lack of understanding about appropriate lifestyle changes was seen among both the ethnic groups in this study. The provision of information and advice relating to cardiac rehabilitation must be better tailored to the context of the specific needs, beliefs, and circumstances of patients with CHD, regardless of their ethnicity. However the findings of this study were not generalisable as the sample size was small (the number of people in the study was only 65). The need for dietary and lifestyle modification needs to be emphasized with the involvement of mainstream media through the vernacular press and also through regional societies. Healthcare professionals need to be made aware of the higher prevalence and earlier onset of CAD, as well as the increased prevalence of dyslipidemias, insulin resistance, and metabolic syndrome in South Asians.Patient education helps to provide information to the public, although more research has to be done to ensure how effective patient education is in the reduction of CHD. As there is weak evidence to show that education can help in reducing the risk factors for CHD in India it is important to undertake research to attain evidence of the effect of patient education in primary prevention of CHD.
Drug therapy is used when the above mentioned measures fail to produce optimum results (Singh and Sen, 2003). Drug therapy is prescribed for coronary heart disease to either increase myocardial oxygen supply, decrease myocardial oxygen demand, or both. The major drug categories covered are antiplatelet agents, anticoagulants, nitrates, beta-adrenergic receptor antagonists (beta-blockers), calcium channel antagonists, angiotensin-converting enzyme inhibitors, and thrombolytic agents. Here only few drugs will be discussed in detail. Sanmuganathan et al.'s (2001) meta-analysis reported that aspirin for primary prevention of coronary heart disease is safe and worthwhile. However, aspirin cannot be prescribed safely for primary prevention of coronary heart disease without formal estimation of the coronary disease event risk of the individual as intuitive assessment of coronary heart disease risk and reliance on single risk factors such as lipids or blood pressure is highly inaccurate. This study concluded that the relative risk reduction with aspirin is constant, so the benefit is linearly related to absolute risk whereas the absolute risk of bleeding is constant and independent of coronary or cardiovascular risk. The Scandinavian Simvastain Survival Study (4S) examined whether cholesterol reduction with simvastatin in persons with CHD and elevated cholesterol would reduce total mortality. A total of 4,444 patients with angina or prior MI whose total cholesterol level was between 212 and 310 mg/dL were randomized to simvastatin or a placebo. The simvastatin dose was initially 20 mg/day and was titrated to 40 mg/day in an attempt to reduce the total cholesterol level to less than 200 mg/dL. Patients were followed for a mean of 5.4 years. There were 111 deaths in the simvastatin group and 189 in the placebo group, resulting in a highly significant 30% relative reduction in total mortality. The relative risk of a major coronary event was reduced by 34% .Another epidemiological study, carried out in an urban area in India, showed that among patients with CAD managed in the urban primary care setting of India, the proportion receiving secondary preventive treatments was low, particularly among females. In 406 patients, the number receiving aspirin was 335; b-blockers, 215; angiotensin converting enzyme inhibitors (ACEI), 63; and statins, 280. Hypertension was untreated in 125 patients. Combination treatment with any two (of aspirin, b-blocker, statin, ACEI, or antihypertensive agent other than b-blocker and ACEI) was received by 249 patients; and with any three by 21. Secondary prevention is under utilized in Indian patents with CAD. Against the background of an emerging epidemic, physicians in primary care need to increase the use of widely available specific secondary preventive agents recommended by guidelines. However, patients were drawn from urban areas, and the results may not apply to rural patients. These treatments are relatively inexpensive, well within the purchasing power of urban, mostly middle class Indian patients, but for rural residents they may be unaffordable. To improve control of risk factors for CVD, Wald and Law proposed a "polypill," containing a statin, a diuretic, a -blocker, an angiotensin-converting enzyme inhibitor, aspirin, and folic acid. This combination pharmacotherapy (CP) could be made widely available without treating specific risk factors or individuals. The original formulation proposed for the polypill contained a statin, 3 antihypertensive agents at half doses (a -blocker, a diuretic, and an angiotensin-converting enzyme inhibitor), aspirin (75 mg), and folic acid (0.8 mg).
Social political and cultural issues
There is a paucity of systematically collected national data on the treatment of coronary artery disease in India. Most information is from secondary and tertiary care hospitals in various parts of the country. Because of the country's economic and cultural diversity, and the differing levels of literacy and awareness among the population, wide variations in health-seeking behaviour, access to healthcare and standards of healthcare are to be expected in different regions (Karthikeyan et al., 2007). In South Asia, an epidemiological transition is taking place against a background of economic globalisation that has greatly increased the size of the urban poor and middle classes, at the same time leaving many millions to continue living on the land at subsistence level. Development is socially and regionally uneven, and so too are the common causes of morbidity and mortality (Zaman and Brunner, 2008). In India, the traditional focus on communicable diseases and reproductive health issues places non-communicable diseases in the background. Therefore, there should be a recognition of the need to include prevention of CHD as part of the primary health care strategy in India (Nishtar, 2002). In addition, there are no satisfactory context specific, resource-sensitive guidelines to assist doctors in choosing appropriate treatments for their patients (Karthikeyan et al., 2007). International health organisations, bilateral donors, and economic development agencies that contribute a substantial share towards public sector expenditure for health development are in a position to influence health care agendas in South Asian countries and should use this influence effectively (Nishtar, 2002). In India, although specialised healthcare centres do provide state of the art technologies for cardiovascular care, healthcare delivery varies from State to State as well as within states. Not only is the number of primary and community healthcare centres inadequate, there is a shortage of physicians (particularly with specializations in cardiology) and other healthcare staff. In cardiac care, more than 75 percent of the care is provided by the private sector, which is concentrated in urban areas (Chaturvedi, 2007). This highly inadequate preventive and therapeutic cardiac care, especially in rural/remote areas, poses a challenge for development of a sustainable cardiac disease surveillance system. India is one of the few countries of the world where most of the costs of medicine are borne directly by the patient (Wald et al., 2003). According to the World Health Organization World Health Report (2004) only 17% of the costs of medical treatment are borne by third-party payers or the government in India. However, Gupta et al., (2005) clearly suggest that the focus in prevention of CHD should move away from pharmacological approaches to lifestyle therapies. A large number of lifestyle factors - smoking cessation, increased physical activity, dietary manipulation, weight and obesity control, and stress management - that are also applicable to Indians, have been evaluated and are available. These lifestyle measures are cost effective and provide an enjoyable alternative to the pharmacotherapeutic approach.
This section will list the key factors identified in this chapter: * In order to achieve primary prevention the major risk factors have to be controlled. * The Ministry of Health Department and Family Welfare on June 4th 2008 launched a new pilot phase of National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS). This programme is being initiated to treat and control CHD in India, and is similar to the Coronary Heart Disease National Service Framework in the UK. * India has launched a smoking cessation policy. Lack of a national regulatory authority for tobacco hinders the enforcement of the policy. * Uneducated people have a higher incidence of CHD and of smoking. * Physical exercise and dietary management tends to reduce the risk for CHD. * The combination therapy 'polypill' is considered more effective than a single therapy of aspirin, beta-blokers, ACE and statins. * Health education or patient education is an effective tool for imparting knowledge to high risk groups. * Access to healthcare and standards of healthcare are to be expected in different regions of the country because of economic and cultural diversity. * Poor people have less access to medicine and care. * Higher income groups have an increased prevalence of CHD; this is due to dietary risk factors
Implications for practice
Coronary heart disease represents a complex condition with an intricate web of causation. The excess CHD burden among Indians, along with differences in risk factors and cultural patterns, requires that steps be taken at prevention (Mathews and Zachariah, 2008). Accordingly, primary preventive assessment and intervention strategies will be briefly discussed here. The most striking feature of the management of patients with cardiovascular disease (CVD) in India, is its heterogeneity among the classes:, from patients treated at tertiary and teaching hospitals, who receive the best possible evidence-based care; to patients who have poor or, even no, access to specialist care and whose condition, therefore, is poorly treated (Karthikeyan et al., 2007). Hence, the challenge in CHD management will be first correcting this imbalance. The literature suggests that Indians are at high risk for increased morbidity and mortality because of CHD therefore, primary prevention efforts are particularly important for this population (Ratogi et al., 2004; Gupta et al., 2005). For preventing coronary heart disease, the main risk factors relevant to Indians are diet, routine exercise, and weight. One of the effective keys for opening all three doors is health education or counseling. However, nurses and other health care providers need to be educated themselves so that they in turn can effectively educate their patients in the hospital or members of the family in the community (Mathews and Zachariah, 2008). Health promotion information can be posted as posters in public areas, and in grocery and specialty stores that attract the public in India. Healthy cooking seminars relevant for Indian women and families are an effective activity to encourage diet and to promote discussions on health within the community (Rastogi et al., 2004). Ways to incorporate daily moderate exercise for adults and vigorous activities for children can also be discussed and culturally acceptable changes negotiated during these events and seminars (Gupta, 2004; Mathews and Zachariah, 2008). To be most effective, health teaching during client visits or community activities as to the risk factors for CHD needs to be done taking into account the needs of individuals and families (Bedi et al., 2006). Primary prevention through education must be based on a needs assessment (Gupta et al., 2006). If the specific daily patterns need to be changed and if lack of knowledge regarding the impact of dietary practices, exercise, early screening, and regular health care is identified, teaching can be a highly effective intervention (Mathews and Zachariah, 2008). As the literature suggests, heart disease is common in younger Indians; therefore, South Asian patients should be evaluated and referred for appropriate care at a younger age, than for any other high risk group. Assessment of family history of coronary diseases and diabetes can be combined with screening for other risk factors such as hypertension, total cholesterol, triglycerides, HDL, LDL, and lipoprotein (a) levels (Mathews and Zachariah, 2008). Once diabetes or other risk factors are identified, dietary restrictions and exercise for weight control and careful monitoring must be implemented to control diabetes and to reduce the probability of coronary disease. For Indians, controlling diabetes and CHD requires a conscious change in diet to include more fresh fruits, vegetables, higher fiber intake, and consumption of foods with low glycemic values as well as reducing salt and cholesterol intake (Rastogi et al., 2004). For Indian populations, this can mean for example, reducing consumption of potatoes, white flour, and white rice and increasing consumption of whole grains for blood sugar control while also lowering salt intake for hypertension and control of cholesterol (Mathews and Zachariah, 2008). Screening for obesity in a South Asian population is recommended using lower criteria than are traditionally considered standard clinical management (Mathews and Zachariah, 2008). A BMI of =23 should be used as an indicator of being overweight for South Asians (WHO, 2004) and of a need for clinical intervention. Waist circumference measurements of =90 cm for men and =80 cm for women should be used as the criteria for obesity (IDF, 2006). Early and periodic identification of people with weight-associated factors is key to effective management of risks and prevention of chronic disease and disability (Gupta, 2004).
More research into the effectiveness of health education on lifestyle changes and exercise is required. Prevention of CHD should be recognised as part of primary health care and given appropriate priority alongside reproductive and nutritional health and communicable disease prevention. CHD prevention should be regarded as synergistic with poverty reduction strategies, and thus addressed in development projects. Policies should be made to ensure availability of effective drugs, devices, procedures at affordable prices to be used cost-effectively - especially in rural areas. Human resource and infrastructure capacity should be developed to support practically relevant epidemiological studies, implementation research for heart health programmes, and research on the political economy of heart health. Cardiovascular disease prevention should be integrated with primary health care, while cardiovascular health education should be integrated with other health promotion initiatives.
This work has presented strong evidence that CHD is highly prevalent in the South Asian population. Numerous factors, including the high prevalence of conventional risk factors (diabetes, hypertension, smoking, and so on), insulin resistance, metabolic syndrome, and genetic predispositions, have been shown to be responsible for this. Dietary and lifestyle modifications, a lower threshold for initiating pharmacotherapy, and maintaining a rigorous control of diabetes, hypertension, and dyslipidemias are required in this population. In short, coronary heart disease in India can be prevented by controlling intake of tobacco, salt, saturated fats, and calories; by increasing both work-related and leisure-time physical activity; increasing consumption of heart healthy foods such as fruits and vegetables, high fiber cereals, oils containing balanced amounts of polyunsaturated and monounsaturated fats (e.g., canola (genetically engineered mustard-rapeseed) oil, soybean oil), and spices and cereals with high flavonoid content.