Epidemiology of CAD in Epidemiology of CAD in India and KeralaIndia and Kerala

Dr.Vinit KumarMCH.Trivandrum

IndiaIndia

CVD accounts for 20% of all deaths in the SAR.

In 1990- 1.18 million people died in India as a consequence of CHD

2010 -this number increased to an estimated 2.03 million.

CVD probably represents 25% of all deaths in India.

Prevalence of CHD in India more than 10% in urban areas and 4.5% in rural areas.

Between 1965 and 2005, CHD prevalence increased from approximately 4% to 12% in urban populations.

Symptoms of CHD arise a full 5 to 10 years earlier in this region than in Western European and Latin American countries

51% of all CVD deaths occurred in individuals younger than 70 years of age

CirculationCirculation. 2009. 2009 53 villages in the Godavari region of

Andhra Pradesh Mortality surveillance system during a 12-

month period in 2003 to 2004 4535 adults (>30 years of age) The average age at cardiovascular death

was 65 years 51% of all cardiovascular deaths occurred

in patients <70 years of age

Coronary heart disease was estimated to be 4.8%

Cerebrovascular disease was estimated at 2.0%

41% took a blood pressure–lowering medication,

5% reported using a cholesterol-lowering medication

Show significant underuse of proven, low-cost preventive medications.

Life Insurance Statistics:Employees'Life Insurance Statistics:Employees'State Insurance SchemeState Insurance Scheme

1957-58 1958-59

Bombay 0.50 0.22

Delhi 0.14 0.13

Kerala 0.97 0.32

Madras 0.56 1.33

Punjab 0.33 0.24

U.P. 0.14 0.11

West Bengal 0.88 0.90

Hospital Data: Incidence of Coronary Artery Hospital Data: Incidence of Coronary Artery Disease in IndiaDisease in India

(Percentage of Cardiac Cases)(Percentage of Cardiac Cases)Delhi, 1951-55 11.8Bombay, 1949 13.5Bombay, 1956 12.1Calcutta, 1956 17.3Amritsar, 1953 21.6Madras, 1946 13Lucknow, 1953 10.2Agra, 1958 7Himachal Pradesh,1956-57 6

Gupta et al :Gupta et al :Indian Heart J 1996;Indian Heart J 1996;48: 241-548: 241-5..

Meta analysis of coronary heart disease prevalence in India

Increase in the prevalence of CHD from Urban Indian 1960 1995 1% 9.6%. Rural Indian 1974 1995 2% 3.74%

Prevalence of Ischemic Heart Disease AmongPrevalence of Ischemic Heart Disease AmongUrban Population of Siliguri, West BengalUrban Population of Siliguri, West Bengal

Mandal et al. Sample size- 250 individual Population aged ≥40 years old IHD- 11.6%. Male- 13.5 % Female- 9.4 % HTN – 47.2%

Cardiovascular mortality rates per 1000 population forCardiovascular mortality rates per 1000 population formen and women in rural Andhra Pradesh and the United men and women in rural Andhra Pradesh and the United

StatesStates

A Survey for Prevalence of Coronary Artery A Survey for Prevalence of Coronary Artery DiseaseDisease

and its Risk Factors in an Urban Population in and its Risk Factors in an Urban Population in Andhra PradeshAndhra Pradesh

Murthy et al. Tenali town, Andhra Pradesh (A.P) July 2009 and October 2009 534 people aged 20 years and above CAD- 5.4% Normal glucose tolerance- 3% Impaired glucose tolerance- 23.5% Diabetes mellitus – 11.3%

Prevalence of coronary artery disease and Prevalence of coronary artery disease and coronary risk factors in rural and urban coronary risk factors in rural and urban

populations of north Indiapopulations of north India R. B. Singh et.al. Moradabad in north India Urban- 9.0% Rural- 3.3% Significantly (P<0-001) higher in the

men compared with the women in both urban (11.0 vs 6.9%) and rural (3.9 vs 2.6%) populations, respectively.

Key results of the South Asian component Key results of the South Asian component of the INTERHEART studyof the INTERHEART study

Deaths due to AMI in south Asians occur at 5-10 years earlier than western.

South Asian men encountering AMI were 5.6 yr younger than women

Low education level - increased risk of AMI

Regular alcohol consumption is not protective for AMI in south Asians

Nine conventional risk factors (abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits & vegetables, alcohol and regular physical activity) collectively explain 86 per cent of the AMI risk in south Asians.

Prevalence of Coronary ArteryPrevalence of Coronary ArteryDisease and Its Relationship toDisease and Its Relationship to

Lipids in a Selected Population in South IndiaLipids in a Selected Population in South India

Chennai Urban Population Study(CUPS) (JACC 2001)Vishwanathan Mohan et al.Two residential areas in Chennai1,262 subject (age >20years)

CAD - 11.0% NGT- 9.1% IGT – 14.9% DM- 21.4% Prevalence of CAD increased with an

increase in • total cholesterol (trend chi-square: 26.2),• LDL cholesterol (trend chi-square: 24.5),• TG (trend chi-square: 9.96) • total cholesterol/HDL ratio (trend chi-square:

6.14).

7 villages in Kerala Follow-up of the 161 942 participants July 1, 2002 to June 30, 2007 Circulatory system contributed 40% Coronary heart disease men (31.1%) and

women (17.6%). Approximately 60% of CAD deaths in men

and 40% of CAD deaths in women occur before the age of 65 years

In United States only 18% of the CAD death occur in people younger than 65 years

The CAD death rates in Kerala are also higher than that of rural Andhra Pradesh and similar to urban Chennai

The average age of a first heart attack decreased by at least 10 years in Kerala, in sharp contrast to a 20 year increase in many western countries

Girija G. Risk factor profile of patients with acute MI. In: Vijayaraghavan G, ed. Cardiovascular

Disease Prevention: Trivandrum; 1996:78 – 83.

In the 1960s and 70s, heart attack in the very young (< 40) was very uncommon in Kerala.

Heart attack rate among men in this age group increased 40-fold by 1990

At least 20% heart attacks occurring before age 40

50% before age 50.

 Joseph A, Kutty VR, Soman CR. High risk for coronary heart disease in Thiruvananthapuram City: A study of

serum lipids and other risk factors. Indian heart journal. 2000;52(1):29-35.

Prevalence of heart disease in rural Kerala is 7%, which is nearly double that of north India and parallel the high levels of cholesterol in Kerala ─ the state named after the ubiquitous coconut.

The burden of CVD deaths in this community now exceeds that of industrialized countries

Sample Registration System (SRS) CVD was the largest cause of deaths in

males (20.3%) as well as females (16.9%)

The Global Status on Non Communicable Diseases Report (2011) more than 2.5 million deaths from CVD in India in 2008, two-thirds due to CHD and a third to stroke

Prevalence of CHD among Male & Female in Prevalence of CHD among Male & Female in Urban Indian Population from Community Urban Indian Population from Community

Based Cross- sectional studiesBased Cross- sectional studiesLocation Year Male(%) Female(%)

Chandigarh 1968 6.54 6.72

Haryana - Rohtak

1975 4.53 2.29

Jaipur 1992-95 5.96 10.54

Delhi 1991-94 10.9 10.3

Tamil Nadu 1994 3.5 4.5

Chennai 1996-97 6.2 14.8

Rajasthan 2001 6.18 10.12

Overall Prevalence of CHD in Overall Prevalence of CHD in Urban Indian PopulationUrban Indian PopulationLocation Year Overall(%)

UP Agara 1961 5.3

UP Varanasi 1986-87 6.48

Jaipur 1992-95 7.59

Delhi 1991-94 10.6

Tamil Nadu 1994 3.9

Kerala 1995 13.9

Chennai 1996-97 11

Rajasthan 2001 8.19

Overall Prevalence of CHD in Overall Prevalence of CHD in Rural Indian PopulationRural Indian PopulationLocation Year Prevalance overall(%)

Maharashtra Sevagram 1998 4.36

Kerala, Trivandrum 1990-91 7.4

Haryana 1990-94 6.1

Rajasthan 1994 4.61

Punjab Pohir 1994 3.1

Thirty year trends of (1960 -1990) hospital admissions reveal that admissions due to coronary disease have increased from 5% of hospital admission to almost 30% and rheumatic admission have declined from 52% to 30%

Prevalence of CHD in the rural population of Prevalence of CHD in the rural population of thiruvananthapuram district Keralathiruvananthapuram district Kerala

V Raman Kutty et al. Cluster sample of 500 household from

five villages. 1253 individual, >25 yrs.

Possible evidance of CHD 7.4% HTN 17.9% DM 4% Obesity 5.5% Lower prevalance of CHD in rural

Thiruvananthapuram when compared to urban centre in India

Prevalence of risk factors for coronary Prevalence of risk factors for coronary artery disease in an urban Indian populationartery disease in an urban Indian population

Civilian government employees working in various parts of the country

10 642 men and1966 women; age 20-60 years

Recruitment was carried in 20 cities across 14 states and in one union territory

Recruitment began in 2009 and phase 1 evaluation was completed in 2012.

Family history of premature CAD – 4.6%

Diabetes-16% Hypertension- 21% Dyslipidemia(high total cholesterol/HDL

ratio)- 45% Two or more risk factors for CAD-

78.6%

Kerala ACS RegistryKerala ACS Registry The largest, contemporary ACS registry

in Kerala, and in India overall.

Data from 25 748 consecutive ACS admissions were collected from125 hospitals from May 2007 to May 2009

Hospital participatedHospital participated

10 (8%) - academic affiliation, 15 (12%) - government hospitals, 28 (22%) - on-site cardiac cath lab, 72 (58%) - staff cardiologists, 74 (59%) - urban centres

Inclusion criteriaInclusion criteria18 years old and presented with chest pain and one or more of the following: ST-segment elevation in two contiguous leads with or without reciprocal ST-segment depression,Troponin or CK-MB elevation, or ST-segment depression or T-wave inversion in two contiguous leads with a history of coronary heart disease

Mean age at presentation was 60 +/-12 years and did not differ among ACS

(STEMI) - 37%; non-STEMI - 31%; unstable angina - 32%.

In-hospital anti-platelet use was high (90%).

Thrombolytics were used in 41% of STEMI, 19% of non-STEMI, and 11% of unstable angina admissions

Inappropriate thrombolytic use appears to represent an opportunity for improved process of care.

After adjustment, STEMI diagnosis (vs. unstable angina), symptom-to-door time .6 h or more ,and inappropriate use of thrombolysis were associated with higher risk of in-hospital mortality

Door-to-needle time ,30 min was associated with lower mortality

Indian J Med Res Indian J Med Res 2010:2010:Results of a Results of a community-based study in Kerala, Indiacommunity-based study in Kerala, India

Thankappan et al, Adults 15 – 64 years of age in

Thiruvananthapuram, Overall- 16.2% Men- 14.3%, women- 17.8% Hypertension – 28.8%

Hypertension was more common in men than women and in urban areas than rural areas.

Mean cholesterol level (in mg/dL) was 203.9+/- 40.2.

For Kerala women it was still higher at 209.7 +/- 38.6.

Mean cholesterol levels were higher in urban areas compared to rural areas, surprisingly rural women had the highest value at 210.5 +/- 39.5.

36.9% of the state population had low HDL Cholesterol (defined as <40mg/dL in men and <50mg/dL in women).

CSI Kerala CRP StudyCSI Kerala CRP Study

Adults 20 – 79 years age group (unpublished data)

Over-all prevalence of diabetes was 14.9%. Prevalence was 21.5% for Thiruvananthapuram.

Overweight/obesity is a significant problem in the state. 30.8 % of adults in the state have a BMI > 25 more.

44.8 % of women living in urban areas being overweight/obese.

60.2 % of women and 54.7% of men had high serum cholesterol levels

Smoking in men was 31.3%. Smoking was more common in rural

areas rather than urban areas

THANK YOU

Among adults > 20 yr of age, the estimated prevalence of CHD is around

Rural - 3-4 % Urban - 8-10 % Representing a two-fold rise in rural

areas and a six-fold rise in urban areas between the years 1960 and 2002