ROUND THE TABLE

CORONARY HEART DISEASE : The Changing Scenario

S.P. Singh1, P. Sen2
th
Second half of the 20 century has witnessed a global spread of the coronary artery disease
1
(CAD) epidemic especially in developing countries, including India. Framingham Heart Study in USA
played vital role in defining the risk factors for CHD incidence in general population. Major risk factors
are sedentary lifestyle, cigarette smoking, hypertension, high LDL cholesterol, low HDL cholesterol
and diabetes mellitus. Other factors that influence CHD risk are obesity, family history of premature
CHD, insulin resistance, hyper-triglyceridaemia, small dense LDL particles, lipoprotein A, serum
homocysteine and abnormalities in several coagulation factors. Psychosocial and socioeconomic
factors are also important. Multiple studies have clearly shown that CHD is a significant problem in
India and coronary risk factors: hypertension, smoking, physical inactivity, obesity and truncal obesity,
2
and improper diet leading to hypercholesterolaemia and hypertriglyceridaemia are widespread.
Genetic factors that are modified by environment could be important and studies among emigrant
South Asians provide important clues in this direction. Epidemiological transition, with increasing life
expectancy and demographic shifts in population age-profile, combined with lifestyle related increases
in the levels of cardiovascular risk factors is accelerating CHD epidemic in India. CHD prevalence in
urban populations increased from 3.5% in 1960s to 9.5% in 1990s. In rural areas it increased from 2%
3-4 5 6
in 1970s to 4% in 1990s. The rates appear to be higher in South India with highest in Kerala.

The high rates of CAD in urban India compared to rural, despite lower rates of smoking,
suggest important roles for nutritional and environmental factors. There is a significant increase in BMI
in urban compared to rural (BMI 24 versus 20 in men, 25 versus 20 in women).

1 & 2. Department of Preventive & Social Medicine, Institute of Medical Sciences, Banaras Hindu University,
Varanasi- 221 005.
SP Singh & P. Sen Coronary Heart Disease

There is also a higher rate of abdominal obesity among the urban population, with urban men
having a waist to hip ratio (WHR) of 0.99 compared to 0.95 among rural men, These increases in BMI
and WHR result in significant insulin resistance and dyslipidaemia. Urban-rural differences in
prevalence of coronary risk factors also provide important information regarding risk factors that need
7-8
prevention . These include sedentary life style, hypertension, BMI, WHR / truncal obesity, total and
LDL cholesterol / hypercholesterolaemia, triglycerides levels, fasting insulin levels / insulin resistance
etc.

Based solely on projected demographic trends, it has been estimated that deaths attributable
to CAD would nearly double, in both sexes, in the period 1985-2015 and CAD would emerge, over
this period, as the single largest contributor to mortality, accounting for nearly a third of all deaths,
globally.

Several factors appear likely to have contributed to the acceleration of CAD epidemic in India
in recent times. These are: (i) Demographic transition to an older population, as a result of increasing
life expectancy (ii) Confluence of both conventional risk factors and non-conventional risk factors in
9
Indians . Conventional factors like hypertension, diabetes, hypercholesterolaemia, smoking etc. owe
their origin to growing urbanization and western 'acculturation' amongst Indians. Non-conventional risk
factors like hyperinsulinaemia, insulin resistance, lipoprotein A etc are determined by genes or other
'programming' factors and their high prevalence amongst Indians probably explain the malignant,
precocious nature of CAD that typically affects Indians (iii) Recently indicated relationship between
low birth-weight which is widely prevalent amongst Indian newborns and enhanced susceptibility to
CAD in adult life ('Barker hypothesis'). These multiplicative effects of conventional and emerging risk
factors appear to provide a plausible explanation for the excess burden of CAD among Indians, many
10
of whom are lean, non-smoking, vegetarian, yoga guru and marathon atheletes .

The excess risk of CAD in Indians appears to be greater at younger ages. When people move
from a rural to an urban environment, they become sedentary and/or may adopt western lifestyles.
Decreased physical activity and increased consumption of calories and saturated fat result in
abdominal obesity, insulin resistance and atherogenic dyslipidaemia. These acquired metabolic
abnormalities appear to have a synergistic effect on the development of CAD in genetically
predisposed individuals.

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SP Singh & P. Sen Coronary Heart Disease

Cardinal features of coronary artery disease among Indians compared to other populations

• Higher rates
- 2 to 4 fold higher prevalence, incidence, hospitalization, mortality
• Greater prematurity
- 5 to 10 years earlier onset of first Myocardial infarction (Ml)
- 5 to 10 fold higher rate of Ml and death in young «40 years of age)
• Greater severity
- Three vessel disease common even among young premenopausal women
- Large Ml with greater muscle damage
• Higher prevalence of glucose intolerance
- Insulin resistance syndrome, diabetes, central obesity
• Lower prevalence of conventional risk factors
- Hypertension, obesity, cigarette smoking
- Cholesterol levels: similar to Whites but higher than other Asians
• Higher prevalence of emerging (thrombogenic) risk factors
- High levels of lipoprotein A, homocysteine, Apoprotein B
- High levels of triglycerides, fibrinogen
- Low levels of HDL
- Small dense LDL
• Higher rates of clinical events for a given degree of atherosclerosis
- Double that of Whites
- 4 fold higher than Chinese
- Higher proportion of unstable or vulnerable plaques
11
The ambient average cholesterollevels among Indians are similar to Whites but significantly
12
higher than other Asians. However, Indians have low levels of HDL resulting in a high TC/HDL ratio,
perhaps the single best predictor of CAD. The major determinant of cholesterol level is the proportion
of saturated fat in the diet, with dietary cholesterol having only a small impact. A diet high in saturated
fat includes not only meat but also whole milk as well as high-fat diary products and certain vegetable
oils (coconut, palm and palm Kernel oil). The likelihood of an Ml is five to seven times higher in

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SP Singh & P. Sen Coronary Heart Disease

patients with CAD, which increases to 25 times higher if the patient also has elevated levels of
13
cholesterol

Preventive strategy:
The major risk factors responsible for the CAD epidemic in India are smoking, high blood
pressure, high cholesterol, high saturated fat diet and lack of physical activity. These factors should
remain the focus of action in arresting and reversing this epidemic. Since adverse effects of these
factors are greater in Indians, the benefits of modifying them are also correspondingly greater. The
role of lifestyle modification in the prevention and treatment of CAD in Indians has been reviewed
14
recently. To achieve the goal of preventing cardiovascular diseases it is important to avoid the
occurrence of the major risk factors themselves. This is known as primordial prevention. Better social,
economic and cultural statuses correlate inversely with lifestyle factors of smoking, abnormal food
patterns and exercise. Also recommended is psychosomatic modulation by relaxation and yoga. WHO
15
recommends changes in attitudes, behaviour and social values. Primordial prevention begins in
childhood when health risk behaviour begins. In Indian urban adolescent school children there is a
high prevalence of obesity, hypertension, hypercholesterolaemia and high fat diet. The need to
promote dietary discretion and physically active lifestyle in children is important. All adults should
know their B.P. and blood cholesterol levels, should not smoke, should monitor their salt and fat
intake, and should engage in at least moderate exercise. A low saturated fat diet and maintenance of
16
ideal body weight and waist circumference is also advocated as individual based preventive strategy
for those with markedly elevated risk factors. Drug therapy is used when these measures fail to
produce optimum results. The cholesterol levels should be reduced to <200 mg/100 ml in individuals
without risk factors and <160 mg/100 ml in those with CAD or risk factors. All patients with CAD or
vascular disease should maintain an LDL level of <100 mg/100 ml. Naicin can substantially raise HDL
and lower triglycerides levels. Vitamin preparations containing an adequate-dose of folic acid, B12 and
17
B6 can substantially reduce elevated homocysteine levels. Aggressive detection and treatment of
hypertension and diabetes using both lifestyle modification and medications should be pursued.

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SP Singh & P. Sen Coronary Heart Disease

18
Sir Geoffrey Rose initially suggested that a population approach to prevention is important .
The population based strategy aims to lower the risk factors in the entire population through
modification of life style. The population-based strategy can create a new generation in which low-risk
is the rule and high-risk the exception. 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. Population-wide approach corrects the underlying cause of the epidemic and is
safer, cheaper and more cost-effective than the high-risk approach.

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.
19
American Heart Association recently published guidelines for prevention of CHD . These are based
on compelling scientific evidence and demonstrate that interventions extend overall survival, improve
quality of life, and reduce the incidence of Ml. The interventions are smoking cessation, lipid
management, increased physical activity, weight management and blood pressure control.

Comprehensive risk reduction for high risk subjects

Risk intervention Goal and recommendations

• Smoking Complete cessation

• Lipid management Primary goal: LDL <100 mg/dl

HDL >35 mg/dl
Secondary goal <
triglycerides <200 mg/dl

• Physical activity Minimum physical activity is >30 minutes of moderate intensity 3-4

times per week (walking, jogging, cycling or other aerobic activity)

• Weight management Maintain <120% of ideal weight for height

• Blood pressure <140/90 mm of Hg. Initiate life style modification in all patients with
hypertension. Drug therapy when required.

20
Hypertension has emerged as a major public health problem in our country . There exists
clear scientific evidence that proper control of hypertension reduces cardiovascular risk by 20% and

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SP Singh & P. Sen Coronary Heart Disease

CHD risk by 15%. Mild hypertension can be managed by lifestyle changes alone while moderate and
severe ones require drug treatment.

Antherogenic dyslipidaemia is common in Indians. This condition is characterized by

borderline high LDL cholesterol (130-160 mg/dl), low HDL cholesterol (<35 mg/dl), high triglyceride
21
(>150 mg/dl) and increased small dense LDL particles. An observational study showed that total
cholesterol ≥200 mg/dl was associated with increased long-term cardiovascular mortality in Indian
22
CHD patients. Dietary therapy includes reduction of total fat and saturated fat intake. Total fats
should be <30% of caloric intake and saturated fats should be <7%. Consumption of trans-fatty acid
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 soyabean 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. Dietary therapy reduces LDL cholesterol, helps weight
reduction, decreases B.P. and counters insulin resistance, which is associated with truncal obesity
23
and impaired glucose tolerance. Truncal obesity is associated with increased CHD risk . Control of
diabetes and achievement of normoglycaemia is essential for primary prevention of cardiovascular
24
events.

Since CAD is a multifactorial disease involving both genetic and environmental factors, a
multi-pronged approach for prevention and treatment is warranted. Since sudden death or a silent Ml
is the first manifestation of CAD in about half of all patients and two-thirds of CAD deaths occur before
reaching the hospital, these people can be helped only through preventive strategies directed at
reduction of risk factors. Since atherosclerosis has its origin in childhood, particularly in Indians,
preventive strategies should also begin in childhood, though it is probably never too late.

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