on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52:e1–e142.3. Elkayam U, Bitar F. Valvular heart disease and pregnancy part I. Native valves. J Am Coll Cardiol. 2005;46(2):223–30. 4. Desai DK, Adanlawo M, Naidoo DP, Moodley J, Kleinschmidt I. Mitral stenosis in pregnancy: a four- year experience at King Edward VIII Hospital, Durban, South Africa. Br J Obstet Gynaecol. 2000;107(8):953–8. 5. Nishimura RA, McGoon MD. Perspectives on mitral- valve prolapse. N Engl J Med. 1999;341(1):48–59. 6. Silversides CK, Coleman JM, Sermaer M, Farine D, Siu SC. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol. 203;91:1386–9.7. Tzemos N, Silversides CK, Colman JM, Therrien J, Webb GD, Mason J, et al. Late cardiac outcomes after pregnancy in women with congenital aortic stenosis. Am Heart J. 2009;157(3):474–80. 8. Whittemore R, Hobbins JC, Engle MA. Pregnancy and its outcome in women with and without surgical treatment of congenital heart disease. Am J Cardiol. 1982;50:641–51. 9. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease. 10. Hameed A, Karaalp IS, Tummala PP, Wani OR, Canetti M, Akhter MW, et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol. 2001;37(3):893–9. 11. Report of a WHO expert consultation Geneva, 2001.

Address for correspondenceDr. Anand Sagar: Email: dranandsagar@hotmail.com

Severe AS: • Aortic velocity +4.0 m/second or mean pressure gradient +40 mm Hg

2 2 2• Valve area <0.8 cm or valve area index <0.5 cm /m

Severe MS: 2• Mitral valve area <1.5 cm or valve area index <0.6

2 2 cm /m

Secondary prevention

In RHD it is defined as the continuous administration of specific antibiotics to patients with previous attack of rheumatic fever or a well-documented RHD.

Prophylaxis in pregnant patients with rheumatic heart disease is same as with the other cases except that oral sulfadiazine or sulfasoxazole are contraindicated in

11pregnancy due to teratogenic effects.

Abbreviations

AS: aortic stenosis, AR: aortic regurgitation, VHD: valvular heart disease, AF: atrial fibrillation, MS: mitral stenosis, MR: mitral regurgitation, RHD: rheumatic heart disease, HF: heart failure, ACE: angiotensin converting enzyme, ARB: angiotensin receptor blocker

References

1. McAnulty JH. Rheumatic heart disease. In: Gleicher N, Gall SA, Sibai BM, et al, eds. Principles and Practice of Medical Therapy in Pregnancy. 2nd ed. Norwalk, CT: Appleton & Lange, 1992:783–8.2. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force

Sagar A, et al

The rising incidence of cardiovascular diseases in India: Assessing its economic impact

Shraddha Chauhan, PhD Scholar; Bani T. Aeri, PhD

Department of Foods and Nutrition, Institute of Home Economics (Delhi University), Hauz Khas, New Delhi, India

Abstract

Cardiovascular diseases (CVDs) are showing an escalation among the Indian population with a trend of reaching the younger age groups. It is now known to have a major share in the burden of diseases. A number of studies have been conducted time and again to find out the prevalence of CVDs and it has been found that they have a widespread prevalence in India, with regional variations. It is now affecting almost all sections of the society from young to old and most affluent to least affluent. Statistics also show an increased prevalence of CVDs in India as compared to other developing countries. Large scale and widespread incidences show downgrading of the cardiovascular health status of Indians and emergence of CVDs as a chronic manifestation across the population. Future trends predict that in the coming decade CVDs will inflict every section of the population irrespective of age, gender, economic status, and locale. Owing to such a large rate of prevalence, India is set to lose on it is productive population on accounts of CVD mortality and morbidity hampering the advantage of a posit ive demographic transition. This affects the country’s productivity owing to the disease-related economic burden in an otherwise beneficial phase of demographic transition. The need of the

Received: 25-03-14; Revised: 06-06-15; Accepted: 06-07-15

Disclosures: This article has not received any funding and has no vested commercial interest

Acknowledgments: None

Key Words

• Prevalence• Cardiovascular disease• India• Economic impact

Introduction

With the coming of the age of massive development, India has gone through dramatic lifestyle changes – moving from agrarian diets and active lifestyles to fast foods and sedentary lifestyles in a much shorter span of time than other nations. Consequently, mortality rates related to chronic non-communicable diseases like cardiovascular diseases (CVDs), coronary heart diseases (CHDs), diabetes and stroke have increased rapidly in the last decade with CVDs having a major share. Recent figures suggest that CVDs have outgrown the barriers of gender, locale, and economic status. Moreover, it is affecting the productive population imposing a huge socioeconomic burden. Future forecasts predict a continuing trend in the coming decades, where CVDs will lead to major loss of the

hour is to track down and closely monitor the prevalence of disease and encounter it with better intervention policies aimed at prevention, control, and treatment of CVD.

735734 J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015

human resource pool of the country. At this rate, being one of the youngest nations in the world, India is set to lose its productive population to CVD morbidity and mortality projecting a setback to the economy in an otherwise beneficial phase of demographic transition.

Materials and methods

Journal articles were referred online through PubMed and Google Scholar search engines. Original articles from the journals like Indian Journal of Medical research, Journal of the Association of the Physicians of India, Journal of Cardiovascular Disease Research, and the Internet Journal of Cardiology were studied. Articles published by authors in international journals such as Journal of American College of Cardiology, British Medical Journal, Bio Med Central were also reviewed. Reports of organizations such as World Health Organisation (WHO), National Commission on Macroeconomics and Health (NCMH), a government of India undertaking, Centre for Chronic Disease Control (CCDC), National Cardiovascular Disease Database (supported by Ministry of Health and Family Welfare, Government of India and WHO) were studied to project the data. The keywords used for the search were “prevalence,” “coronary heart disease,” “cardiovascular disease,” “heart disease,” “in India,” “risk factors,” etc. Only those articles that were available in full text format were analyzed to arrive at the data collated. Criteria for selection of articles were the year in which studies were undertaken and published. Studies conducted after year 2000 were referred to. All other studies ranging in the 90s were rejected. Any recent study that presented data on the basis of old studies was also rejected. Only those articles were included that reported prevalence in Indians, residing in India. A number of studies on migrant Indians were also cited, but they were not included in this review.

Results

Prevalence: National

Cardiovascular diseases have been gaining importance in India recently because of increased incidence of the disease over the years. It is the first among top five causes of deaths in Indian population (rural vs. urban, economically backward vs. developed states, men vs.

1women and at all stages vs. middle age). In 2000, there were an estimated 29.8 million people with CHD in India out of a total estimated population of 1.03 billion or a

2,3nearly 3% overall prevalence. In 2003, the prevalence was estimated to be 3–4% in rural areas and 8–10% in urban areas according to population based cross

4,5sectional surveys. However, in 2008, they were found 6to be 6% and 12%, respectively. In 2011, World Health

Organisation (WHO) reported the age standardized CVD mortality rates among males and females in India

7(per 100,000) at 363–443 and 181–281, respectively. The country wise statistics of the WHO on non-communicable diseases (NCDs) estimates that NCDs account for 53% of the total deaths in India, out of which

8CVDs have a major share of 24%.

Prevalence: Regional

Apart from a high overall prevalence, there are regional variations in the prevalence of CVD. Unadjusted CHD rates have ranged from 1.6–7.4% in rural populations and 1–13.2% in urban populations.1 prevalence rate of CHD in urban areas of Northern states such as Jammu and Kashmir, Delhi and Uttar Pradesh, and Western states such as Rajasthan is reported to be around 6–10%. The rates in the rural areas were 6–7% in Jammu and Kashmir, 3–5% in Himachal Pradesh and Punjab among

3the Northern states while in Rajasthan it was 3–5%. In Andhra Pradesh, the overall prevalence of CVDs was found to be 5.4% while the age standardized prevalence

9rate was 5.1%. Studies conducted in urbanized states of Kerala and Mumbai reported very high CVD mortality rates approaching 500/100,000 for men and 250/100,000

10,11for women. In urban and rural communities of Delhi, the prevalence of CHD was 14.8% (urban) and 9.7%

12(rural) while in Lucknow district, the overall prevalence was found to be 7.1% with 8.8% in urban

13areas and 3.8% in rural areas. Overall, the mortality is highest in the South Indian states, Eastern and North-eastern states and Punjab in both men and women while mortality is lowest in the Central Indian states of

14Rajasthan, Uttar Pradesh, and Bihar.

Future trends: Gender, age groups and area

The forecast of prevalence rates (in percentage) by the National Commission on Macroeconomics and Health (NCMH) predicted that from 2000 to 2015 the number of urban males in the 20–29 years age group suffering from CHD will be almost double and the females of the same age group will keep up with their pace. Thus, indicating younger age of escalation of CVDs. In fact, the prevalence rate among women is likely to keep pace with that of men in all age groups. When the prevalence rates in the estimated data were compared across age groups, i.e., from 20–69 years in males and females, an increasing trend was observed. Also, it has been estimated that at the later stages of life, more number of women will contribute to the CVD inflicted population as compared to men. In case of rural men and women, the

trend is anticipated to be static in the 20–29 years age group for 2000–2015. However, across age groups, it shows an increase in percentage prevalence in both males and females. On comparing the percentage prevalence of males and females across age groups from 2000 to 2015, a similar pattern is estimated wherein more number of females will suffer from CVD at a later age as

15compared to men.

Data also suggest that although the prevalence rates of CVD in rural population will remain lower than that of

urban populations, they will continue to increase reaching around 13.5% of the rural age group of 60–69 as compared to 22% of urban age group of 60–69. The prevalence rates among younger adults (40 years and

16above) are also likely to increase. This trend can also be observed in terms of the number of cases projected as follows (Table 1):

Economic impact

CVD affects Indians with greater frequency and at a younger age than counterparts in developed countries, as

Chauhan S, et al The rising incidence of cardiovascular diseases in India

Year/area 20–29 years 30–39 years 40–49 years 50–59 years 60–69 years Total

2000

Urban

Rural

Total

2,711,501

1,799,691

4,511,192

2,635,019

2,854,247

5,489,266

2,776,974

3,342,472

6,119,446

2,288,412

3,590,855

5,879,296

1,888,199

3,153,512

5,041,711

12,300,104

14,704,808

27,040,912

2005

Urban

Rural

Total

2010

Urban

Rural

Total

2015

Urban

Rural

Total

4,138,045

5,992,412

8,167,924

2,012,363

2,324,772

2,324,087

6,150,408

8,317,184

10,492,011

3,869,904

5,154,766

7,927,846

3,383,816

3,940,722

4,523,697

7,253,720

9,095,489

12,451,542

4,116,830

5,606,731

8,493,463

4,217,201

5,367,797

5,816,588

8,334,032

10,974,527

14,310,051

3,171,320

4,223,273

6,156,089

4,544,974

5,817,363

6,852,050

7,716,294

10,040,636

13,008,140

2,582,790

3,710,938

5,346,975

3,849,544

4,829,922

5,913,624

6,432,334

8,540,860

11,260,599

17,878,889

24,688,119

36,092,297

18,007,899

22,280,577

25,430,046

35,886,789

46,968,695

61,522,343

NCMH, 2005CVDs are expected to be the fastest growing chronic illness by 2015, growing at 9.2% annually from 2000 onward. However, the downward escalation of CVDs is of primary concern as it is affecting the productive population of India. The incidence has gone up significantly for people between ages 25–69 to 24.8%. International Heart Protection Summit, 2011. These figures project an alarming situation of the incidence of CVDs in the Indian population.

Table 1: Forecasting the number of cases (males and females) of coronary heart disease (CHD) in India

737736 J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015

human resource pool of the country. At this rate, being one of the youngest nations in the world, India is set to lose its productive population to CVD morbidity and mortality projecting a setback to the economy in an otherwise beneficial phase of demographic transition.

Materials and methods

Journal articles were referred online through PubMed and Google Scholar search engines. Original articles from the journals like Indian Journal of Medical research, Journal of the Association of the Physicians of India, Journal of Cardiovascular Disease Research, and the Internet Journal of Cardiology were studied. Articles published by authors in international journals such as Journal of American College of Cardiology, British Medical Journal, Bio Med Central were also reviewed. Reports of organizations such as World Health Organisation (WHO), National Commission on Macroeconomics and Health (NCMH), a government of India undertaking, Centre for Chronic Disease Control (CCDC), National Cardiovascular Disease Database (supported by Ministry of Health and Family Welfare, Government of India and WHO) were studied to project the data. The keywords used for the search were “prevalence,” “coronary heart disease,” “cardiovascular disease,” “heart disease,” “in India,” “risk factors,” etc. Only those articles that were available in full text format were analyzed to arrive at the data collated. Criteria for selection of articles were the year in which studies were undertaken and published. Studies conducted after year 2000 were referred to. All other studies ranging in the 90s were rejected. Any recent study that presented data on the basis of old studies was also rejected. Only those articles were included that reported prevalence in Indians, residing in India. A number of studies on migrant Indians were also cited, but they were not included in this review.

Results

Prevalence: National

Cardiovascular diseases have been gaining importance in India recently because of increased incidence of the disease over the years. It is the first among top five causes of deaths in Indian population (rural vs. urban, economically backward vs. developed states, men vs.

1women and at all stages vs. middle age). In 2000, there were an estimated 29.8 million people with CHD in India out of a total estimated population of 1.03 billion or a

2,3nearly 3% overall prevalence. In 2003, the prevalence was estimated to be 3–4% in rural areas and 8–10% in urban areas according to population based cross

4,5sectional surveys. However, in 2008, they were found 6to be 6% and 12%, respectively. In 2011, World Health

Organisation (WHO) reported the age standardized CVD mortality rates among males and females in India

7(per 100,000) at 363–443 and 181–281, respectively. The country wise statistics of the WHO on non-communicable diseases (NCDs) estimates that NCDs account for 53% of the total deaths in India, out of which

8CVDs have a major share of 24%.

Prevalence: Regional

Apart from a high overall prevalence, there are regional variations in the prevalence of CVD. Unadjusted CHD rates have ranged from 1.6–7.4% in rural populations and 1–13.2% in urban populations.1 prevalence rate of CHD in urban areas of Northern states such as Jammu and Kashmir, Delhi and Uttar Pradesh, and Western states such as Rajasthan is reported to be around 6–10%. The rates in the rural areas were 6–7% in Jammu and Kashmir, 3–5% in Himachal Pradesh and Punjab among

3the Northern states while in Rajasthan it was 3–5%. In Andhra Pradesh, the overall prevalence of CVDs was found to be 5.4% while the age standardized prevalence

9rate was 5.1%. Studies conducted in urbanized states of Kerala and Mumbai reported very high CVD mortality rates approaching 500/100,000 for men and 250/100,000

10,11for women. In urban and rural communities of Delhi, the prevalence of CHD was 14.8% (urban) and 9.7%

12(rural) while in Lucknow district, the overall prevalence was found to be 7.1% with 8.8% in urban

13areas and 3.8% in rural areas. Overall, the mortality is highest in the South Indian states, Eastern and North-eastern states and Punjab in both men and women while mortality is lowest in the Central Indian states of

14Rajasthan, Uttar Pradesh, and Bihar.

Future trends: Gender, age groups and area

The forecast of prevalence rates (in percentage) by the National Commission on Macroeconomics and Health (NCMH) predicted that from 2000 to 2015 the number of urban males in the 20–29 years age group suffering from CHD will be almost double and the females of the same age group will keep up with their pace. Thus, indicating younger age of escalation of CVDs. In fact, the prevalence rate among women is likely to keep pace with that of men in all age groups. When the prevalence rates in the estimated data were compared across age groups, i.e., from 20–69 years in males and females, an increasing trend was observed. Also, it has been estimated that at the later stages of life, more number of women will contribute to the CVD inflicted population as compared to men. In case of rural men and women, the

trend is anticipated to be static in the 20–29 years age group for 2000–2015. However, across age groups, it shows an increase in percentage prevalence in both males and females. On comparing the percentage prevalence of males and females across age groups from 2000 to 2015, a similar pattern is estimated wherein more number of females will suffer from CVD at a later age as

15compared to men.

Data also suggest that although the prevalence rates of CVD in rural population will remain lower than that of

urban populations, they will continue to increase reaching around 13.5% of the rural age group of 60–69 as compared to 22% of urban age group of 60–69. The prevalence rates among younger adults (40 years and

16above) are also likely to increase. This trend can also be observed in terms of the number of cases projected as follows (Table 1):

Economic impact

CVD affects Indians with greater frequency and at a younger age than counterparts in developed countries, as

Chauhan S, et al The rising incidence of cardiovascular diseases in India

Year/area 20–29 years 30–39 years 40–49 years 50–59 years 60–69 years Total

2000

Urban

Rural

Total

2,711,501

1,799,691

4,511,192

2,635,019

2,854,247

5,489,266

2,776,974

3,342,472

6,119,446

2,288,412

3,590,855

5,879,296

1,888,199

3,153,512

5,041,711

12,300,104

14,704,808

27,040,912

2005

Urban

Rural

Total

2010

Urban

Rural

Total

2015

Urban

Rural

Total

4,138,045

5,992,412

8,167,924

2,012,363

2,324,772

2,324,087

6,150,408

8,317,184

10,492,011

3,869,904

5,154,766

7,927,846

3,383,816

3,940,722

4,523,697

7,253,720

9,095,489

12,451,542

4,116,830

5,606,731

8,493,463

4,217,201

5,367,797

5,816,588

8,334,032

10,974,527

14,310,051

3,171,320

4,223,273

6,156,089

4,544,974

5,817,363

6,852,050

7,716,294

10,040,636

13,008,140

2,582,790

3,710,938

5,346,975

3,849,544

4,829,922

5,913,624

6,432,334

8,540,860

11,260,599

17,878,889

24,688,119

36,092,297

18,007,899

22,280,577

25,430,046

35,886,789

46,968,695

61,522,343

NCMH, 2005CVDs are expected to be the fastest growing chronic illness by 2015, growing at 9.2% annually from 2000 onward. However, the downward escalation of CVDs is of primary concern as it is affecting the productive population of India. The incidence has gone up significantly for people between ages 25–69 to 24.8%. International Heart Protection Summit, 2011. These figures project an alarming situation of the incidence of CVDs in the Indian population.

Table 1: Forecasting the number of cases (males and females) of coronary heart disease (CHD) in India

737736 J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015

8well as many other developing countries. In addition to high rates of mortality, CVD manifests here almost 10 year earlier on an average than other countries in the world resulting in substantial number of deaths in

5,18working age group. In Western countries where CVD is considered to be a disease of the aged, 23% of CVD deaths occur below 70 years of age while in India 52% of

19,20CVD deaths occur below 70 years of age. The economic impact was estimated to be 9 billion dollars in national income from premature deaths due to heart disease, stroke, and diabetes in 2005 alone, with

21projected estimates of 237 billion dollars by 2015. The total years of life lost due to cardiovascular disease among the Indian men and women aged 35–64 has been estimated to be higher than comparable countries such as Brazil and China. These estimates are predicted to increase by 2030, when differences may be even more marked (Table 2). Thus, India suffers a tremendous loss of productivity due to increased prevalence of CHD.

Age standardized CVD death rates in people 30–69 years old are 180 per 100,000 in Britain, 280 per 100,000 in China, and 405 per 100,000 in India. Also, 50% of CVD related deaths in India occur in people <70 years of age, whereas only 22% of CVD related deaths in Western

23countries occurs in this age group. According to the INTERHEART STUDY, the median age for the first presentation of acute Myocardial Infarction in South Asian (Bangladesh, India, Nepal, Pakistan, Sri Lanka) is 53 years, whereas that in Western Europe, China and Hong Kong is 63 years with more men than women affected. This median age in Asian men and women was also higher (58 and 54 years, respectively). Studies carried out in India and other places suggest that Asians in general and Indians in particular are at increased risk of myocardial infarction at a younger age (< 40 years), irrespective of whether they have migrated to other

18countries or are resident Asians. The latest data estimates the age standardized burden of CVD (per

100,000) in males to be 3315–4228 DALYs (Disability Adjusted Life Years) while in females it is estimated to be

72584–3438 DALYs.

The growing health burden of CVD potentially translates into increased economic burden at both national and household level. Estimates from recent studies indicate that CVD related aggregate medical care ranged from approximately 3 billion dollars in 2004 to 7.5 billion

24,25dollars in 2010. CVD affected households experience greater financial hardships as compared to their non-affected counterparts. They spend more on inpatient and outpatient care which results in lower non-medical expenditure per person in the household. There is an estimated loss of 110.64 international dollars per person on non-medical spending. However, this decline is less as compared to the annual inpatient and outpatient out-of-pocket expenditures of the CVD affected households, i.e., an annual equivalent of 5.16 international dollars over a 15 day period. They also have lower employment rates. Such scenario propels the households to use coping

mechanisms to protect their non-medical expenditure against the CVD related economic losses. The worst affected are the lower socioeconomic strata household which have to rely on borrowing and sale of assets to meet the expenditure having long-term implications for

26household economic well-being. Another recent study reported that CVD affected household spent as much as 3.4 million rupees per year on CVD related health expenditure with major shares spent on direct and indirect health costs. The annual wage loss of the patient was approximately 5% of the overall healthcare expenditure on CVD. Majority of such household resorted to spending their savings to meet the healthcare expenditure. An alarming 30% of the household included in the study

27underwent catastrophic expenditure.

Discussion and conclusions

These figures indicate an alarming rate of prevalence of CVDs in India. In fact, the prevalence in India is higher

than other countries of the same region. The escalation in the prevalence rates have been observed since the last decade and are expected to continue with the same pattern if the current situation prevails. These rates indicate newer patterns of the disease incidence. Previously thought to affect only high income countries, CVD burden is now being transferred to the developing countries as evident by its presence in India. Moreover, these rates seem to be increasing disproportionately as compared to other countries. It is catching up in lower income groups also, in spite of the difference in the lifestyle, culture, etc. indicating the urgency of addressing the associated risk factors. As indicated by the data, the prevalence is now indicated in rural areas, also other than the clichéd urban areas indicating that as the disease matures and gets a stronger grip in the country, it will percolate to all categories of the population affecting the whole society. This can be confirmed as recent studies in India show that individuals with lower levels of income or education are at a higher risk suggesting that the prevalence is following the pattern seen with advanced epidemics in developed countries – the highest prevalence is shifting

19from the affluent to the less affluent. There is an increasing trend for reversal in the socioeconomic gradient for CVD (as already manifested in developed nations), with the poor and disadvantaged having equal and sometimes higher, burden of CVD, and its risk factors. This could be due to change in the pattern of dietary habits, lack of healthcare facilities, etc. in the lower strata. This analysis also highlights the need to protect CVD affected households from the economic burden of the disease. The heavy out-of-pocket spending and resorting to coping mechanisms such as borrowing or selling of assets prevails due to limited government financing and other insurance mechanisms that continue to be inadequate. Even though, many programs and policies have been designed to address the issue of financing healthcare, a large part of the affected population either remains uncovered or covered inadequately due to lack of comprehensiveness of the policies or ineligibility due to their non-poor status. These coverage gaps call for policies that extend beyond the poor when considering conditions that are expensive to treat. From a long-term perspective, more attention should be paid to the prevalence and prevention of CVD related risk factors like tobacco consumption, smoking, hypertension, etc. to avoid the situation from growing into a bigger epidemic.

The stark observation of the trend of CVD is the incidence of disease in younger age groups. An increased prevalence of CVD related risk factors have been reported in this age group owing to lifestyle changes,

work routines, cultural influences, etc. This means that India’s productive population is getting affected causing an economic setback to the country. Between 2005 and 2015, India is projected to cumulatively lose USD 236.6 billion because of heart disease, stroke, and diabetes costing 1% of the GDP. In 2000, in the age group of 35 to 64, India lost 9.2 million years of productive life. As CVD rates increase, this estimate will increase to 17.9

17million by 2030. This is when the estimates do not include the indirect losses, such as losses incurred from not investing the same amount in other areas of human development such as education.

In older age groups, an increased prevalence can be collated to the demographic transition in India with a sharp decline in the death rate as well as the birth rate. The life expectancy of an average Indian male is 67.3 years and that of females is 69.6 years (as per the

2estimates for 2011–15). This transition has brought a larger number of people to the age group where the CVDs manifest. Thus, India has a larger population of vulnerable older adults that contribute to the CVD inflicted population.

To conclude, CVDs are slowly reaching out to all sections of the society. Large scale and widespread incidence shows downgrading of the cardiovascular health status of Indians and emergence of CVDs as a chronic manifestation across the population. This affects the country’s productivity owing to economic burden in an otherwise beneficial phase of demographic transition. Need of the hour is to track down and closely monitor the prevalence of disease and tackle it with aggressive, effective and efficient intervention policies that aim at prevention, control and treatment of CVDs in all sections of the population. More efforts are needed to encounter the epidemic at the level of risk factor prevalence. Also, more targeted and comprehensive policies need to be extended to the masses for healthcare financing.

References

1. Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India Heart Watch. World J Cardiol. 2012;4(4):112–20.2. Census of India 2001. Population Projection for India and States 2001-2026: Report of the Technical Group on Population Projections Constituted by the National Commission on Population, Office of Registrar General and census Commissioner, India. 2006.

739738

Chauhan S, et al The rising incidence of cardiovascular diseases in India

J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015

Country 2000 2030

Total years of life lost Rate per 100,000 Total years of life lost Rate per 100,000

India

Brazil

China

9,221,165

1.060.840

6,666,990

3,572

2,121

1,595

17,937,070

1,741,620

10,460,030

3,070

1,957

1,863

Table 2: Estimates of total years of life lost due to CVD in 2000 and 2030

Leeder et al., 2004

8well as many other developing countries. In addition to high rates of mortality, CVD manifests here almost 10 year earlier on an average than other countries in the world resulting in substantial number of deaths in

5,18working age group. In Western countries where CVD is considered to be a disease of the aged, 23% of CVD deaths occur below 70 years of age while in India 52% of

19,20CVD deaths occur below 70 years of age. The economic impact was estimated to be 9 billion dollars in national income from premature deaths due to heart disease, stroke, and diabetes in 2005 alone, with

21projected estimates of 237 billion dollars by 2015. The total years of life lost due to cardiovascular disease among the Indian men and women aged 35–64 has been estimated to be higher than comparable countries such as Brazil and China. These estimates are predicted to increase by 2030, when differences may be even more marked (Table 2). Thus, India suffers a tremendous loss of productivity due to increased prevalence of CHD.

Age standardized CVD death rates in people 30–69 years old are 180 per 100,000 in Britain, 280 per 100,000 in China, and 405 per 100,000 in India. Also, 50% of CVD related deaths in India occur in people <70 years of age, whereas only 22% of CVD related deaths in Western

23countries occurs in this age group. According to the INTERHEART STUDY, the median age for the first presentation of acute Myocardial Infarction in South Asian (Bangladesh, India, Nepal, Pakistan, Sri Lanka) is 53 years, whereas that in Western Europe, China and Hong Kong is 63 years with more men than women affected. This median age in Asian men and women was also higher (58 and 54 years, respectively). Studies carried out in India and other places suggest that Asians in general and Indians in particular are at increased risk of myocardial infarction at a younger age (< 40 years), irrespective of whether they have migrated to other

18countries or are resident Asians. The latest data estimates the age standardized burden of CVD (per

100,000) in males to be 3315–4228 DALYs (Disability Adjusted Life Years) while in females it is estimated to be

72584–3438 DALYs.

The growing health burden of CVD potentially translates into increased economic burden at both national and household level. Estimates from recent studies indicate that CVD related aggregate medical care ranged from approximately 3 billion dollars in 2004 to 7.5 billion

24,25dollars in 2010. CVD affected households experience greater financial hardships as compared to their non-affected counterparts. They spend more on inpatient and outpatient care which results in lower non-medical expenditure per person in the household. There is an estimated loss of 110.64 international dollars per person on non-medical spending. However, this decline is less as compared to the annual inpatient and outpatient out-of-pocket expenditures of the CVD affected households, i.e., an annual equivalent of 5.16 international dollars over a 15 day period. They also have lower employment rates. Such scenario propels the households to use coping

mechanisms to protect their non-medical expenditure against the CVD related economic losses. The worst affected are the lower socioeconomic strata household which have to rely on borrowing and sale of assets to meet the expenditure having long-term implications for

26household economic well-being. Another recent study reported that CVD affected household spent as much as 3.4 million rupees per year on CVD related health expenditure with major shares spent on direct and indirect health costs. The annual wage loss of the patient was approximately 5% of the overall healthcare expenditure on CVD. Majority of such household resorted to spending their savings to meet the healthcare expenditure. An alarming 30% of the household included in the study

27underwent catastrophic expenditure.

Discussion and conclusions

These figures indicate an alarming rate of prevalence of CVDs in India. In fact, the prevalence in India is higher

than other countries of the same region. The escalation in the prevalence rates have been observed since the last decade and are expected to continue with the same pattern if the current situation prevails. These rates indicate newer patterns of the disease incidence. Previously thought to affect only high income countries, CVD burden is now being transferred to the developing countries as evident by its presence in India. Moreover, these rates seem to be increasing disproportionately as compared to other countries. It is catching up in lower income groups also, in spite of the difference in the lifestyle, culture, etc. indicating the urgency of addressing the associated risk factors. As indicated by the data, the prevalence is now indicated in rural areas, also other than the clichéd urban areas indicating that as the disease matures and gets a stronger grip in the country, it will percolate to all categories of the population affecting the whole society. This can be confirmed as recent studies in India show that individuals with lower levels of income or education are at a higher risk suggesting that the prevalence is following the pattern seen with advanced epidemics in developed countries – the highest prevalence is shifting

19from the affluent to the less affluent. There is an increasing trend for reversal in the socioeconomic gradient for CVD (as already manifested in developed nations), with the poor and disadvantaged having equal and sometimes higher, burden of CVD, and its risk factors. This could be due to change in the pattern of dietary habits, lack of healthcare facilities, etc. in the lower strata. This analysis also highlights the need to protect CVD affected households from the economic burden of the disease. The heavy out-of-pocket spending and resorting to coping mechanisms such as borrowing or selling of assets prevails due to limited government financing and other insurance mechanisms that continue to be inadequate. Even though, many programs and policies have been designed to address the issue of financing healthcare, a large part of the affected population either remains uncovered or covered inadequately due to lack of comprehensiveness of the policies or ineligibility due to their non-poor status. These coverage gaps call for policies that extend beyond the poor when considering conditions that are expensive to treat. From a long-term perspective, more attention should be paid to the prevalence and prevention of CVD related risk factors like tobacco consumption, smoking, hypertension, etc. to avoid the situation from growing into a bigger epidemic.

The stark observation of the trend of CVD is the incidence of disease in younger age groups. An increased prevalence of CVD related risk factors have been reported in this age group owing to lifestyle changes,

work routines, cultural influences, etc. This means that India’s productive population is getting affected causing an economic setback to the country. Between 2005 and 2015, India is projected to cumulatively lose USD 236.6 billion because of heart disease, stroke, and diabetes costing 1% of the GDP. In 2000, in the age group of 35 to 64, India lost 9.2 million years of productive life. As CVD rates increase, this estimate will increase to 17.9

17million by 2030. This is when the estimates do not include the indirect losses, such as losses incurred from not investing the same amount in other areas of human development such as education.

In older age groups, an increased prevalence can be collated to the demographic transition in India with a sharp decline in the death rate as well as the birth rate. The life expectancy of an average Indian male is 67.3 years and that of females is 69.6 years (as per the

2estimates for 2011–15). This transition has brought a larger number of people to the age group where the CVDs manifest. Thus, India has a larger population of vulnerable older adults that contribute to the CVD inflicted population.

To conclude, CVDs are slowly reaching out to all sections of the society. Large scale and widespread incidence shows downgrading of the cardiovascular health status of Indians and emergence of CVDs as a chronic manifestation across the population. This affects the country’s productivity owing to economic burden in an otherwise beneficial phase of demographic transition. Need of the hour is to track down and closely monitor the prevalence of disease and tackle it with aggressive, effective and efficient intervention policies that aim at prevention, control and treatment of CVDs in all sections of the population. More efforts are needed to encounter the epidemic at the level of risk factor prevalence. Also, more targeted and comprehensive policies need to be extended to the masses for healthcare financing.

References

1. Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India Heart Watch. World J Cardiol. 2012;4(4):112–20.2. Census of India 2001. Population Projection for India and States 2001-2026: Report of the Technical Group on Population Projections Constituted by the National Commission on Population, Office of Registrar General and census Commissioner, India. 2006.

739738

Chauhan S, et al The rising incidence of cardiovascular diseases in India

J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015

Country 2000 2030

Total years of life lost Rate per 100,000 Total years of life lost Rate per 100,000

India

Brazil

China

9,221,165

1.060.840

6,666,990

3,572

2,121

1,595

17,937,070

1,741,620

10,460,030

3,070

1,957

1,863

Table 2: Estimates of total years of life lost due to CVD in 2000 and 2030

Leeder et al., 2004

3. Gupta R, Joshi P, Mohan V. Epidemiology and Causation of coronary heart disease and stroke in India. Heart. 2000;94:16–26.4. Gupta R. Coronary heart disease in India: Absolute numbers and economic burden. Rapid response to Ghaffar A, Reddy KS, Singhi M. “Burden of non- communicable diseases in South Asia”. BMJ. 2004;328:807–10. 5. Gupta R. Burden of coronary heart disease in India. Indian Heart J. 2004;57:632–8.6. Enas EA, Singh V, Munjal YP, Gupta R, Patel KC, Bhandari S, et al. Recommendations of the second Indo-US health summit on prevention and control of cardiovascular disease among Asian Indians. Indian Heart J. 2009;61:165–274.7. WHO. Global Atlas on Cardiovascular Disease Prevention and Control 2011 [Internet]. [cited 2014 May 6]. Available from: www.who.int.8. WHO. Non- communicable diseases country profile: India 2010 [Internet]. [cited 2014 May 9]. Available 9. Murthy PD, Prasad KT, Gopal PV, Rao KV, Rao RMB. A survey of prevalence of coronary artery disease in an urban population in Andhra Pradesh. JAPI. 2012;60:17–20. 10. Pednekar MS, Gupta R, Gupta PC. Illiteracy, low education status and cardiovascular mortality in India. BMC Pub Health. 2011;11:567.11. Soman CR, Kutty VR, Safraj S, Vijaykumar K, Rajmohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5 year follow-up of 161942 rural community dwelling adult. Asia Pac J Pub Health. 2010;23:896–903.12. Mahajan H, Chaturvedi M, Lal P, Saha R, Grover VL. Urban rural difference in prevalence of CHD: a population based study. Indian J Pub Health Res Dev. 2012;3(2):53–5.13. Joshi P, Idris MZ, Saran RK, Natu SM. A study of coronary heart disease and the associated risk factors in Lucknow district, India. Int J Biol Med Res. 2013;4(1):2966–72.14. Mony PK. Geographical epidemiology of cardiovascular disease in India: an exploratory study, University of Toronto, Canada 2010 [Internet]. [cited 2014 May 12]. Available from: tspace.library. utoronto.ca/handle/1807/18899.15. Indrayan A. Forecasting Vascular Disease Cases and Associated Mortality in India”. Burden of disease in India, National Commission on Macroeconomics and Heal th , Minis t ry of Health and Family Welfare, Government of India, New Delhi, India. 2005.

16. Mahal A. Estimation and Causal Analysis. Overview based on ‘Choosing Investments in Heal th’ for the Nat ional Commiss ion on Macroeconomics and Health, NCMH background papers- Burden of Disease in India. 2005.17. Cardiovascular disease in India. Challenges and way ahead: International Heart Protection Summit. 2011 [Internet]. [cited 2014 May 6]. Available from: www.deloitte.com/in18. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364: 937–52.19. Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ. 2004;328:807–10.20. Huffman MD, Engelgau MM. Economic impact of non-communicable diseases in India. India Health Beat. 2012;6(2).21. WHO. Preventing chronic disease: vital investment. Geneva. World Health Organisation. 2005.22. Leeder S, Raymond S, Greenberg H. A Race against Time: The challenge of Cardiovascular Disease in Developing Economies, Columbia University, New York City, New York. 2004.23. Gaziano T, Reddy KS, Paccaud F, Horton S, Chaturvedi V. Cardiovascular Disease. In: Jamison DT, JG Breman, AR Measha , G Alleyne, M Claeson, DB Evans, P Jha, A Mills, P Musgrove. Disease control priorit ies in developing world, Oxford: Oxford University Press, 2006, p. 645–62.24. Bloom D, Cafiero E, Llopis EJ, Abrahams- Gessel S, Bloom LR, Fathima S, et al. The global economic burden of non-communicable diseases. Harvard School of Public Health and World Economic Forum, Boston MA. 2011.25. Mahal A, Karan A, Engelgau M. Economic implications of non-communicable diseases for India. The World Bank. Washington DC. 2010.26. Karan A, Engelgau M, Mahal A. The household level economic burden of heart diseases in India. Trop Med Int Health. 2014;19:581–91.27. Mukherjee K, Koul V. Economic burden of coronary heart diseases on households in Jammu, India. The heath agenda. 2014; 2(1):29–36.

Address for correspondenceMs. Shraddha ChauhanEmail: Shraddha.phd11@gmail.com

OHA and heart: Current perspectives

Dr. A. K. Pancholia, MD, FACC

Head Department of Clinical and Preventive Cardiology, Arihant Hospital and Gokuldas Heart Center, Indore, India

are inconsistent; their benefits may be negated by increased risk of hypoglycemia which in turn increases adverse cardiovascular events. Increased cardiovascular r isk of some antidiabetic drugs was missed during drug development and detected only on meta-analysis of clinical trial data. Regulatory agencies in North America and Europe have therefore proposed stringent guidelines for study design, data analysis and quantification of cardiovascular risk of new antidiabetic drugs.

Abstract

We’ve been treating diabetes for 70 or 80 years, and despite the fact that 70% of people with diabetes die from heart disease. Our therapies for treating diabetes have not been shown to reduce the very high rate of CV death. Our mainstays of therapy is to get sugars down but that don’t seem to reduce heart attack and stroke and cardiac death Better control of diabetes mellitus reduces microvascular complications, but has limited effect on macrovascular complications including cardiovascular mortality. It has shown that some new oral antidiabetic drugs may paradoxically increase cardiovascular events and mortality. Literature search showed that some sulfonylureas increase cardiovascular risk presumably by preventing protective ischemic cardiac preconditioning. Rosiglitazone increases risk of myocardial infarction and death possibly by increasing serum triglycerides and LDL-cholesterol levels. Muraglitazar increased risk of cardiovascular death, myocardial infarction, or stroke due to as yet unidentified reasons. Only insulin sensitizing drugs like metformin and piogl i tazone have been consistently shown to reduce cardiovascular risk but increased heart failure with pioglitazone. The newer agents like DPP4 inhibitors in different trials showed neutral effect, neither increase nor decrease the CV events. Beneficial effects of tight glucose control with insulin or insulin secretagogues on macrovascular complications

Key Words

• Glitazone

• Metformin

• DPP4 inhibitors

• Cardiovascular events

• Ischemic preconditioning

Received: 17-07-14; Revised: 12-06-15; Accepted: 20-07-15

Disclosures: This article has not received any funding and has no vested commercial interest

Acknowledgments: None

Introduction

Patients with type 2 diabetes have cardiovascular morbidity and mortality at least four times higher

1,2compared to patients without diabetes. Moreover, it is well established nowadays that the cardiovascular risk of diabetic patients without a history of a prior myocardial infarction is similar to the risk of nondiabetic patients

3who have already had one. Hence, the reduction of cardiovascular risk in type 2 diabetic patients using antidiabetic medication is of great importance.

741740

Chauhan S, et al

J. Preventive Cardiology Vol. 4 No. 4 May 2015J. Preventive Cardiology Vol. 4 No. 4 May 2015