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Cardiovascular Disease Trends in India

Naresh Trehan
Escorts Heart Institute and Research Centre New Delhi, India

Cardiovascular Disease
According to recent estimates, ! Cases of CVD may increase from about 2.9 crore in 2000 to as many as 6.4 crore in 2015 ! Deaths from CVD will also more than double. ! Most of this increase will occur on account of coronary heart disease AMI, angina, CHF and inflammatory heart disease
Source:NCMH Background PapersBurden of Disease in India (New Delhi, India), September 2005

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Cardiovascular Disease
Data also suggest that although the ! Prevalence rates of CVD in rural populations will remain lower than that of urban populations, they will continue to increase, reaching around 13.5% of the rural population in the age group of 6069 years by 2015. ! The prevalence rates among younger adults (age group of 40 years and above) are also likely to increase ! Prevalence rates among women will keep pace with those of men across all age groups.
Source:NCMH Background PapersBurden of Disease in India (New Delhi, India), September 2005

Largest Share in Noncommunicable Diseases

Cancers, 10% Others, 21% Diabetes, 2%

Oral diseases, 1% COPD and asthma, 5% Mental health disorders, 26%

Cardiovascular disease, 31%

Blindness, 4%

Priority non-communicable health conditions in India, by share in the burden of disease (1998)

Source: Peters et al. 2001

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Rising Population

Projected trends in population Source: Report of the Registrar General of India 1996

Forecasting the prevalence rate (%) of coronary heart disease (CHD) in India

Rising Prevalence and Mortality

Estimated mortality from coronary heart disease (CHD)

Source:NCMH Background PapersBurden of Disease in India (New Delhi, India), September 2005

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Estimates and trends of coronary heart disease (CHD) cases in various age groups Source:NCMH Background PapersBurden of Disease in India (New Delhi, India), September 2005

Trends of CAD Prevalence in India

% Prevalence

14 12 10 8 6 4 2 0

URBAN
Trivandrum Delhi Jaipur

% Prevalence

RURAL

Chandigarh Rohtak Delhi Agra

14 12 10 8 6 4 2 0

Kerela Rajasthan Punjab Haryana UP

1960 1970 1980 1990 2000 Year of Study

1960 1970 1980 1990 2000 Year of Study

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Burden of CVD: 1990-2020

50

DALYs (millions)

India

40 30 20 10 0

China SSA Mexico LAC EME PSE QAI

1990

2000

2010

2020

CORONARY ANATOMY
INDIANS HAVE MORE COMMON ! Involvement at younger age ! Smaller Coronary Arteries ! Diffuse Distal Disease ! Multi-vessel Disease ! Higher incidence in women

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Metabolic Syndrome: Prevalence

Prevalence in India: EHIRC Data

Metabolic Syndrome

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Prevalence in India: EHIRC Data

Metabolic Syndrome

40.0% 29.0% 20.0% 7.1% 0.0% 19.3% 33.7% 20.6% 30.0%

Overall

21-30

31-40

41-50

51-60

61-70

299 consecutive subjects aged 20-65 years, without any evidence of CVD, undergoing routine health check-up

Prevalence in India: EHIRC Data

76.3%

Metabolic Syndrome

80.0% 60.0% 40.0%

16.7%

20.0% 0.0%

60.0% 40.3%
Diabetics Nondiabetics

40.0% 24.4%

p <0.001 for comparison

20.0%

0.0%

Males

Females

p <0.001 for comparison

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contd. Prevalence of individual metabolic abnormalities

50.0%
46.8% 45.80%

EHIRC data

30.0%

28.4%

28.5%

12.70%

10.0%

Increased WC

Low HDL

High TG

Increased FBS

HT

Prevalence of Metabolic Syndrome

EHIRC data

1000 consecutive patients undergoing CABG included Overall prevalence of metabolic syndrome by modified ATP III criteria 60.0%

Submitted for publication; Accepted for presentation at CSI 2005

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1000 CABG patients

Mean age- 59.73 9.5 years 88.4% males; 11.6% females Obesity (BMI)-

EHIRC data

100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 14.6% 50.8% 75.2%

>30.0 kg/m2

Obese

>25.0 kg/m2

Overweight

>23.0 kg/m2

Overweight (Asian criteria)

1000 CABG patients

Diabetes Mellitus
60.0% 55.2% 47.5% 46.5%

EHIRC data

Hypertension
80.0%

40.0%

Overall

Males

Females
70.9%

70.8%

71.6%

p 0.078 for comparison between males and females

60.0%

Overall

Males

Females

p 0.869 for comparison between males and females

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1000 CABG patients

100.0%

EHIRC data

Dyslipidemia
93.9%

85.6%

84.5% 81.4%

80.0%

Overall (LDL cut-off 100mg%)

Males

Females

Overall (LDL cut-off 130mg%)

p 0.023 for comparison between males and females

Lipid abnormalities
72.5%

80.0%

60.0% 37.0% 23.3% 20.0% High LDL Low HDL High TG

40.0%

Parameter N Age (years) Male gender Body-mass index (kg/m2) Hypertension Diabetes mellitus Dyslipidemia* Family h/o CAD

Year 2000 1747 50.0 11.1 (79.9%) 24.73.9 (47.4%) (13.0%) (76.4%) (16.8%)

Year 2005 1302 43.2 13.1 (78.3%) 25.03.9 (42.1%) (16.5%) (62.0%) (33.5%)

p value

<0.001 0.309 0.034 0.004 0.012 <0.001 <0.001

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Escorts Heart Institute & Research Centre New Delhi

1988

Angiographies / Year
11000 9000 7000
5544 6520 4826 4092 2527 2917 3430 8829 7945 8974 8990 9123 9603 10011

5000 3000
1623 1011 2135

1000

117

-1000 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

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Angioplasties / Year
2800 2600 2400 2200 2000 1800 1600 1400 1200 1000 800 600 400 200 0
2565 2370 2185 2035 1815 1818 1376 1206 651 717 192 256 365 468 860 3000

94

1988

1990

1992

1994

1996

1998

2000

2002

2004 2005

Cardiac Surgeries / Year

6000 5000 4000 3000 2000 1000
86 806 1145 1283 1555 1737 1750 1863 2106 2493 2751 3142 3360 3680 4176 4016 4150 4280

0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005

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Total Cardiac Surgeries 1988 2005 Dec (N = 51,599)

8097

MISCELL
4040

CONGENITAL VALVES

CABG
33686

5555

Age group wise Admissions ( Jan. - Aug. 2006)

28000 24000
No. of patients

26238

20000 16000 12000 8000 4000 0 < 14 Years 14 - 18 Years 19 - 30 Years 31 - 40 Years 41 - 50 Years 51 - 65 Years Above 65 Years
3241 581 4488 5838 11580 13387

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Ejection Fraction of Surgical Patients (Jan. - Aug. 2006)

1000 800
620
Off CPB On CPB

742

600 400 200

23 20 186 76 61 96 336 155

0 <= .20 .21 - .30 .31 - .40 .41 - .50 > .50

Growth of OPCABs : 1995 - 2005

3500 3000 2500 2000 1500 1000 500 0 OPCAB 125 204 349 355

423 1411 2907 3011 2117 1416 225 268

3022 3400 3444

1598 1388 1492

1783

286 2003

352 2004

255 2005

1995 1996 1997 1998 1999 2000 2001 2002 CCAB

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Age wise Mortality rate in Isolated CABG (Jan. - Aug. 2006)

3.0% 2.5%
Percentage (%)

(n=287) 2.3%

2.0% n=687) 1.5% 1.0% 0.5% 0.0% <= 30 Years 31 - 40 Years 41 - 50 Years 51 - 60 Years 61 - 70 Years > 70 Years (n-4) 0.0% (n=23) 0.0% (n=230) 0.9% (n=702) 1.2% 1.0%

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TECAB using DaVinci Computer Enhanced Telemanipulation System EHIRC Data

December 2002 Dec 2005 Robotic surgery done TECAB
Beating heart TECAB Arrested heart TECAB -

255 22
20 2

EndoACAB
LIMA Skeletonized ThoraCAB

231
152 79

ASD,Valve Repair

Postoperative Data
Complete Ventilation time (hrs) -4.36 Chest tube drainage 360ml) ICU stay Hospital stay Perioperative MI Reoperation for bleeding New onset atrial fibrillation Wound Infection Mortality - 164 (55ml- 1.2 days - 4.5 days - Nil - 6 - Nil - Nil - Nil

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Functional Ischemic MR
Myocardial Infarction LV Remodeling Mitral Annular Dilatation Papillary Muscle Mitral Valve Tenting Functional Ischemic MR

Coapsys Mitral Annuloplasty System

Annular Dilatation Type I

Restricted Leaflets Type IIIb

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Patient Selection
CABG Patients Ischemic Functional MR Baseline MR Grade ! 2
EF>25%

N = 75

MR ! 2

Intra-Op TEE: Post CABG and Hemodynamic Challenge

MR " 1

Group 1 Coapsys (Mitral Valve Repair + CABG) Intra-op MR = 2.7 N=35

Group 2 Untreated (CABG Only) Intra-op MR = 1.0 N=40

Coapsys Effect: Intraoperative MR Reduction

Pre-tightening

Post-tightening

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10 9 8 7 6 5 4 3 2 1 0

Change in MR Grade With Time

Grade 4 Grade 2 Grade 3 Grade 1/0

Untreated Group
Baseline Discharge 3 Months 12 Months

12 10 8 6 4 2 0
Baseline

Grade 4 Grade 2

Grade 3 Grade 1/0

Coapsys Group

Discharge

3 Months

12 Months

LVED and LVED Changes in Coapsys Patients

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THE HEART FAILURE CLINIC AT EHIRC SINCE SEPTEMBER 99

HEART FAILURE CLINIC AT EHIRC

50 40 30 20 10 0 20.6 2000 2002 2001 2005 35.6 28.8 47.4

No. of Patients Per OPD

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THE HEART FAILURE CLINIC

CLINICAL EVALUATION OPTIMIZE MEDICAL THERAPY MONITORING & FOLLOWUP IS IT SURGICAL DISEASE? RESEARCH REHABILITATION

HF CLINIC

PATIENT EDUCATION

DATA REGISTRY TRAINING

REASONS FOR REFERALS

! OPTIMIZING MEDICAL CARE
" PHARMACOLOGICAL " DIET, EXERCISE " PATIENT EDUCATION " PSYCHO-SOCIAL REHABILITATION

! REFRACTORY HEART FAILURE TO CONSIDER FOR

" OPTIMIZATION OF MEDICAL CARE " ALTERNATIVE MEDICINE, SECP, PACEMAKER, AICD " INTERMITTENT / DOMICILLIARY INOTROPES " PLAN SURGICAL INTERVENTION

! RESEARCH TRIALS

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HEART FAILURE CLINIC

!91% HAD CAD, 85% WERE OPERATED CASES !REDUCED HOSPITAL READMISSION RATE !SIGNIFICANT IMPROVEMENT IN EXERCISE CAPACITY

IMPACT OF HEART FAILURE CLINIC ON 3 MONTHS POST CABG FOLLOW UP IN PATIENTS WITH LV DYSFUNCTION

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No OF POST CABG PATIENTS

240 220 200 180 160 140 120 100
Oct 1997Apr 1998 Oct 1998Apr 1999 Oct 1999Apr 2000

224

188 167

Heart Failure Re-Admission Rates: 3 Months Post CABG

12 10 8 6 4 2.33 2 0
Oct 1997Apr 1998 Oct 1998Apr 1999

11.11 9.76
Oct 1999Apr 2000

7 6 5 4 3 2 1 0 5.99

6.91

1.34

LVEF <20%

LVEF <30%

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Coronary thrombosis Myocardial Ischemia

Myocardial Infarct Arrhythmia & Loss of Muscle

Sudden Death

CAD

ENDSTAGE HEART Remodeling DISEASE Ventricular - CHAIN OF EVENTS

dilatation

Atherosclerosis LVH Coronary Risk Factors

CHF
Endstage Heart Disease
Dzau and Braunwald, 1991

Thank You
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