Ravi Jandhyala, MD, FACCDirector Interventional CardiologyKaiser Permanente, Orange County, CA

Being Indian -

A setup for a Heart Attack !

Despite therapeutic advances, cardiovascular disease remains the leading cause of death (USA)

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Heartdisease and

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National Center for Health Statistics 2004Data for 2002

In the past three decades, heart disease rates have:

doubled in rural areas of India, and

tripled in its urban areas. 

A major study found that the prevalence of heart disease in New Delhi and Chennai, was 10% and 11% respectively—slightly higher than the 10% rate among the Indian participants in the American based CADI Study

♥ Coronary heart disease among Indians strikes early, strikes hard, and strikes unexpectedly. 

♥ Heart disease among young Indians (young defined as under 45) is often severe and diffuse, and it follows a malignant course that may be classified as Type I heart disease. 

♥ Indians typically develop a heart attack 10 years earlier than other populations. 

♥ Young Indians have a much higher risk of heart attack than similarly aged people in other populations. 

♥ Approximately one-third of all first heart attacks among Indians occur in Indians younger than 45, and their heart disease is often comparable in severity to that of older Indians. 

♥ Serious forms of coronary artery disease, especially left main coronary artery disease and three- vessel disease are twice as common among Indians as in whites, and even more common among Indian women. 

♥ Diabetes only partially explains the prematurity and severity of Indian heart disease. In addition to traditional risk factors such as diabetes. Indians have high levels of newly discovered "emerging" risk factors such as homocysteine, CRP and LP(a). Together, these constitute the most likely cause of the prematurity and severity of heart disease among Indians. 

♥ Heart disease rates continue to increase on the Indian subcontinent and are now as high there as in Indians living in other parts of the world. 

♥ The rates are as high in Pakistan, Bangladesh, and Sri Lanka as they are in India. 

♥ A 2005 study found that one in four Pakistani adults above age 40 has heart disease. 

♥ Although heart disease rates were virtually identical in India and the US 30 years ago, they are currently four times higher in India. 

♥ This marked difference is due to a more than 50% decrease in heart disease in the US and a more than 200% increase in India. 

By 2020, according to the WHO the number of Indian citizens dying each year from heart disease will exceed 2.4 million, more than twice the number in 1990.

One of every four cardiac patients in the world will be Indian. 

Animation of how a blockage develops and causes a heart attack

• What causes the blockage to build up ?

• High levels of Bad Cholesterol• High Blood Sugar• Smoking• High Blood Pressure• High Body Weight especially Waist size• Inactivity

Cigarette smoking is the leading preventable cause of mortality, responsible for nearly six million deaths worldwide and over 400,000 deaths in the United States annually.

If current trends continue, tobacco will kill more than eight million people worldwide each year by the year 2030.

Metabolic Syndrome

Metabolic Syndrome ( Syndrome X )

• Waist Size

– > 36 inches (90 cms) (Men)– > 32 inches (80 cms) (Women)

Plus any two of the following:

• Sugar – > 100mgs/dl

• Cholesterol HDL – < 40mg/dl (men)– < 50 mg/dl (women)

• Triglycerides – > 150mg/dl

• Blood Pressure • Systolic >130 mm Hg • Diastolic > 85 mm Hg

Unmet clinical need associated with abdominal obesity

Patients with

abdominal obesity

(high waist

circumference) often

present with one or

more additional

CV risk factors

CV risk factors in a typical patient with abdominal obesity

USa 36.9 55.1 46.0

Spainb 30.5 37.8 34.7

Italyc 24.0 37.0 31.5

UKd 29.0 26.0 27.5

Francee – – 26.3

Netherlandsf 14.8 21.1 18.2

Germanyg 20.0 20.5 20.3

Abdominal obesity has reached epidemic proportions worldwide

aFord et al 2003; bAlvarez-Leon et al 2003; cOECI 2004; dRuston et al 2004; eObepi 2003; fVisscher & Seidell 2004; gLiese et al 2001

Men (%) Women (%) Total (%)

High waist circumference: >102 cm (>40 in) in men or >88 cm (>35 in) in womenexcept in Germany (>103 cm [41 in] and >92 cm [36 in], respectively)

Growing prevalence of abdominal obesity

+ 18%55.1%46.7%Women

+ 28%36.9%29.5%Men

Relative change

NHANES (1999–2000)

NHANES III(1988–1994)

Ford et al 2003

US National Health andNutrition Examination Survey (NHANES)

Abdominal obesity defined as waist circumference: >102 cm (>40 in)in men or >88 cm (>35 in) in women

Abdominal obesity increases the risk of developing type 2 diabetes

<71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3

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Metabolic syndrome has a negative impact on CV health and mortality

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Tape Measure as Important as the Stethoscope

What to do ?

• Stop Smoking• Keep active 30 to 80 minutes of moderate

intensive activity 3 to 4 times a week• Eat a balanced diet• Weight management especially waist size• See a Doctor

• Sleep

• Stress

Why see a Doctor?The risk factors have no symptoms

High Blood PressureHigh Blood Sugar –DiabetesHigh Cholesterol and Triglycerides

Do not have any symptoms.

Diabetes

• One in 7 CA residents has Diabetes

• A 32% increase in last decade

• Costs tax-payers and businesses $ 24 billion annually

High Blood Pressure

By decreasing daily salt intake to 3 gms a day:

A reduction in the number of new cases of coronary heart disease by up to 120,000; stroke by up to 66,000 and myocardial infarctions by up to 99,000 annually.

A reduction in the number of deaths from any cause by up to 92,000 annually.

A savings in health care costs of up to 24 billion annually.

The projected cardiovascular benefits are similar to those of population-wide reductions in smoking, obesity and cholesterol levels.

Cigarette smoking is the leading preventable cause of mortality, responsible for nearly six million deaths worldwide and over 400,000 deaths in the United States annually.

If current trends continue, tobacco will kill more than eight million people worldwide each year by the year 2030.

Exercise

• Energy consumption: Metabolic equivalent MET- 3.5ml O2/kg/min

– Sleeping 1 MET/hr– Desk work 1.5 MET/hr– Walking 2mph 2 METS– Tennis Singles 5 METS

Exercise

How much?

How frequent ?

Points to take home:

Even 15 minutes a day of walking briskly, reduced Coronary Heart Disease (CHD) significantly.  Exercise of 150 minutes of moderate intensity per week ( minimum recommended by US Federal Guidelines ) reduced CHD by 14%.

For those who achieved 300 minutes per week reduced CHD by 20% compared to sedentary.

And for those who exercised 750 minutes of moderate intensity of exercise reduced their risk by 25%.

Lack of exercise:

contributing to diseases such as diabetes and cancer, is now causing as many deaths as smoking across the world.

 Published in Lancet

Exercise

• Each ONE MET increase in exercise capacity confers 12% reduction in Major adverse cardiovascular outcomes ( Death, Stroke, Heart attack)

• Increase in 4 METS confers almost 50% reduction in Major adverse cardiovascular events

Walking pace and associated relative risk of cardiovascular disease

Walking paceWalking pace Relative Relative riskrisk

Normal (2-2.9 mph)Normal (2-2.9 mph) 0.820.82

Brisk (3-3.9 mph)Brisk (3-3.9 mph) 0.580.58

Very brisk (Very brisk (>>4 mph)4 mph) 0.170.17

p for the trend, <0.001, compared with "easy pace" of <2 mph

Tanasescu M et al. Circulation. 2003. Available at: http://circ.ahajournals.org.

 We wonder how to quantify the benefits of exercise.  This study looked at 26 published studies since 1995.

Points to take home:

Even 15 minutes a day of walking briskly reduced Coronary Heart Disease (CHD) significantly.  More is better.  Keep moving.

Exercise of 150 minutes of moderate intensity per week ( minimum recommended by US Federal Guidelines ) reduced CHD by 14%.

For those who achieved 300 minutes per week reduced CHD by 20% compared to sedentary.

And for those who exercised 750 minutes of moderate intensity of exercise reduced their risk by 25%.

A lack of exercise, contributing to diseases such as diabetes and cancer, is now causing as many deaths as smoking across the world, a study suggests.

 Published in Lancet

1940’s

Non Violent Movement

50 years later

Non Movement Violence on the body

Diet

• Balanced Diet:

– Carbohydrates 55%– Fats 30%– Proteins 15%

A study of 44,500 people in England and Scotland showed vegetarians were 32% less likely to die or need hospital treatment as a result of heart disease.

Good

• Complex carbohydrates : Whole grains, legumes, vegetables.

• Fiber: 25 grams a day.

• Fats: Monounsaturated fats like Canola, Olive, Safflower oils, many nuts like almonds cashews, pecans.

• Omega-3 Fatty acids: Fatty fish including Salmon, Tuna. Lesser amounts in canola oil, tofu, flaxseed and dark green leafy vegetables.

Not so good

• Added and refined sugars: Soft drinks, sweetened fruit drinks, sweet desserts

• Salt• Saturated fats: Red meat, whole milk, butter

cheese• Hydrogenated fats: a mixture of saturated and

trans fats- fried foods• Trans fats: deep fried foods, processed foods,

crackers, cookies

* Healthy life style is for 'all' not just the over weight.

*  Healthy living should be 'Excuse-Proof'.

*  Choose 'elegance' over force.   Dietary battles are not won when you work hard, but when

you work smart.

*  Make your eating plan 'automatic'.

*  Know your body.

*  Stay satisfied, Stay Positive.   To lose weight, you need to eat.

* Add support.  Enlist a friend, family member or a cyber buddy as your partner.

* Know that it's OK to make mistakes.

* You move, you lose.

* Make a gesture.Buy walking shoes or pedometer or club membership

or throw away the unhealthy foods from the pantry.

* The do it.

Calories don’t lie !

We can no longer eat

rich food like a poor man !

We should all: Eat less

Eat out less

and

Move more.

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” – Plato

“Take care of your body. It’s the only place you have to live.” – Jim Rohn

“To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life.” – William Londen

AyurAveda•Eat right

•Exercise right

•Don’t take yourself too seriously!

Lifetime risk (to age 95) for CVD and mortality at age 50

Lloyd-Jones DM et al. Circulation 2006; available at: http://circ.ahajournals.org.

Risk factor level Men: Lifetime CVD risk (%)

Women: Lifetime CVD risk (%)

Men: Median survival (y)

Women: Median survival (y)

Optimal risk factors*

5.2 8.2 >39 >39

>1 not-optimal risk factor

36.4 26.9 36 39

>1 elevated risk factor

45.5 39.1 35 39

1 major risk factor 50.4 38.8 30 35

>2 major risk factors

68.9 50.2 28 31*Optimal risk factor levels=total cholesterol <180 mg/dL (4.65 mmol/L), blood pressure <120/80 mm Hg, nonsmoker, and nondiabetic

• 23 ½ hours by Dr. Mike Evans on YouTube

• ravijandhyala@gmail.com

• Though we have several times increased risk.

• We can prevent death and heart attacks!

• Yes !!!

• Thank You.