INTERVENTION IN CHD INTERVENTION IN CHD

WHEN WHEN AND AND HOWHOW

SCENARIO OF CARDIOVSCILAR SCENARIO OF CARDIOVSCILAR DISEASE IN NEPALDISEASE IN NEPAL

DR. YADAV BHATTDR. YADAV BHATT

MBBS, MDMBBS, MD (Med)(Med)

DM DM ((Cardiology)Cardiology)

DNB Fellow in Interventional CardiologyDNB Fellow in Interventional Cardiology

(Escorts heart institute)(Escorts heart institute)

CARDIOLOGISTCARDIOLOGIST

GANGALAL NATIONAL HEART CENTERGANGALAL NATIONAL HEART CENTER

DR. YADAV BHATTMBBS, MD (Med)

DM (Cardiology)

DNB Interventional Cardiology

(Escorts Heart Institute)

PROFESSOR CARDIOLOGY

NATIONAL ACADEMY OF MEDICAL SCIENCES

GANGALA NATIONAL HEART CENTER

CHIEF OF CATH LAB,

NORVIC ESCORTS INTERNATIONAL HOSPITAL

SCENARIO OF CARDIOVASCULAR DISEASE IN NEPAL

CHINA

INDIA

• Area: 147171 sq. kilometers

• Population: 27,000,000

HIMALAYASHILLS

CHINA

NEPAL IS CLEARLY DEMARCATED INTO THREE REGIONS

TARAIINDIA

THE HIMALAYA REGION

THE HILLS

ACCESSIBILITIES

• International & domestic airports

• International flight connections

– 13 online carriers: Thai Airways, Austrian Air, Indian Airlines, Jet Airways, Sahara Air, China Southwest Airlines, Druk Airlines, Gulf Air, Qatar Airways, PIA, RNAC, Cosmic Air, Air Nepal

– Catering Services to: 20 major international cities including Mumbai, – Catering Services to: 20 major international cities including Mumbai, Bangkok, New Delhi, Singapore, Hong Kong, Kolkata, Dubai, Shanghai, Osaka, Dhaka, Karachi, Thimpu, Abu dhabi, Varanasi, Kuala Lampur

– 22 Direct flights per week from Europe

– 15 Direct flights per week from middle east

– 24 Direct flights per week from far east

– 53 Direct flights per week from south asia

– 8-10 flights from china/week

• Adequate local ground transportation

Cardiovascular disease

has become

ubiquitous cause of

morbidity and morbidity and

mortality

TRAGEDY WITH CVD

• ACCORDING TO WHO 30% OF GLOBAL DEATH

IN 1998 DUE TO CVD = 15.3 MILLION LIVES

LOST THAT YEARLOST THAT YEAR

• LOW AND MIDDLE INCOME COUNTRIES

CONTRIBUTED 78% OF DEATHS

SAHID GANGALAL NATIONAL HEART CENTER

80000/ year

TobaccoTobacco consumptionconsumptionYearYear PlacePlace PopulationPopulation PrevalencePrevalence RemarksRemarks

19831983 Kathmandu (urban)Kathmandu (urban) >>2020 ,both,both sexsex 3737 CurrentCurrent

19831983 Kathmandu (rural)Kathmandu (rural) >>2020 ,both,both sexsex 68.468.4 CurrentCurrent

19831983 Parsauni (Terai , rural)Parsauni (Terai , rural) >>2020 ,both,both sexsex 54.754.7 CurrentCurrent

19831983 Jumla (mountain, rural)Jumla (mountain, rural) >>2020 ,both,both sexsex 77.777.7 CurrentCurrent

19991999 Dharan (East Nepal, urban)Dharan (East Nepal, urban) CollegeCollege studentsstudents 24.824.8 CurrentCurrent

20012001 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, females>35 years, females 30.330.3 CurrentCurrent

20012001 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, females>35 years, females 16.516.5 SmokelesSmokeles

CARDIOVASCULAR RISK FACTORS

13

Pandey MR. Hypertension in Nepal. Mrigendra Medical Trust 1983.Niraula SR. Tobacco Use among Women in Dharan, Eastern Nepal. J Health Popul Nutr 2004;22(1):68-74Jha N et al. Prevalence of tobacco use among college students of Dharan, eastern Nepal. Nepal Journal ofScience and Technology 2002; 4: 107-110.Research report on NCD risk factors surveillance in Nepal, 2003Vaidya A et al.Prevalence of Coronary Heart Disease in the Urban Adult Males of Eastern Nepal: A population-based analytical cross-sectional study

20012001 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, females>35 years, females 16.516.5 SmokelesSmokeles

ss

20042004 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >>3535 years,years, malesmales 7474 Current/eCurrent/e

xx

CARDIOVASCULAR RISK FACTORS

Diabetes mellitusDiabetes mellitus

YearYear PlacePlace AgeAge Prevalence %Prevalence %YearYear PlacePlace AgeAge Prevalence %Prevalence %

20052005 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, males>35 years, males 6.7 6.7

20062006 Kathmandu (urban)Kathmandu (urban) >40 ,both sex>40 ,both sex 19.019.0

HypertensionHypertensionYear Year PlacePlace Population Population Prevalence %Prevalence %

1983 1983 Kathmandu (urban)Kathmandu (urban) >20 ,both sex>20 ,both sex 9.989.98

1983 1983 Kathmandu (rural)Kathmandu (rural) >20 ,both sex>20 ,both sex 5.985.98

1983 1983 Parsauni (Terai , rural)Parsauni (Terai , rural) >20 ,both sex>20 ,both sex 8.118.11

1983 1983 Jumla (mountain, rural)Jumla (mountain, rural) >20 ,both sex>20 ,both sex 5.305.30

19981998 Kathmandu (low altitude) Kathmandu (low altitude)

Khumbu (high altitude) Khumbu (high altitude)

Sherpa, men Sherpa, men 21.721.7

24.824.8

20042004 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, males>35 years, males 22.722.7

CARDIOVASCULAR RISK FACTORS

15

Pandey MR. Hypertension in Nepal. Mrigendra Medical Trust 1983.

Research report on NCD risk factors surveillance in Nepal, 2003

Vaidya A, et al. Exploring the iceberg of hypertension: A community based study in an Eastern Nepal town. KUMJ (2007), 5(3): 349-359

Shrestha UK et al.

20042004 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, males>35 years, males 22.722.7

20052005 KathmanduKathmandu >18 Men>18 Men

FemaleFemale

OverallOverall

22..222..2

17.517.5

19.719.7

HYPERTENSION

• STUDY NUMBER 1114 ( 2005)

• MEN 541• MEN 541

• FEMALE 573

• AGE 18 – 97 YEARS MEAN 37.8 ±16.3

HYPERTENSION

PREVALENCE OF HTN

• 22.2% IN MEN

• 17.3% IN WOMEN

• OVERALL PREVALENCE 19.7%• OVERALL PREVALENCE 19.7%

AGE DISTRIBUTION

• 4.1% < 30 YEARS

• >40% IN > 50YEARS

PREVALENCE OF HYPERTENSION AGE DISTRIBUTION

AGE AGE

GROUPGROUP

HTN HTN

SUBJECTSSUBJECTS

TOTAL TOTAL

NUMBERNUMBER

PREVALENPREVALEN

CE %CE %

<30<30 1818 434434 4.14.1

3030--3939 4141 236236 17.417.4

4040--4949 4141 159159 25.825.8

5050--6464 8080 192192 41.741.7

>64>64 3939 9393 41.941.9

HTN JNC VII

CATEGORYCATEGORY NUMBERNUMBER PERCENTAGEPERCENTAGE

NORMALNORMAL 649649 58.358.3

PREPRE-- HTNHTN 246246 22.022.0

HTNHTN 219219 19.719.7

HTN AWARENESS

• 44.7% ASYMPTOMATIC

• 55% SYMPTOMATIC

• 76% HEADACHE

• 48.8% DIZZINESS

• 58.9% UNAWARE OF THEIR HTN

• 41.1% AWARE OF THEIR HTN

CHANGING TREND IN HTN

• STUDY IN 1981: PREVALENCE 5.98% (WHO 1978

CRITERIA ± 165/95)

• LATEST 2005 STUDY (SAME CRITERIA) PREVALENCE

WOULD BE 11%

Diagnosedand controlled

(34.01%)

Diagnosed

and uncontrolled (24.13%)

EXPLORING THE ICEBURG OF HTN

Undiagnosed(41.86%)

LIPIDSLIPIDS

mg%mg%

NAKANISHINAKANISHI

19971997

KARKIKARKI

20042004

LIMBULIMBU

20082008

TCTC 152152±±4343 177.32177.32±± 184184±±50.750.7

CARDIOVASCULAR RISK FACTORS

TCTC 152152±±4343 177.32177.32±±

33.733.7

184184±±50.750.7

TGTG 121121±±7474 176.12176.12±±65.865.8 147.4147.4±±88.788.7

HDLHDL 2828±±99 49.0849.08±±11.511.5 45.045.0±±11.711.7

LDLLDL __________ 84.9784.97±±2525 111.9111.9±±42.042.0

CARDIOVASCULAR RISK FACTORS

SEDENTARY LIFESTYLE

• < 10 mins of walk / day

• No physical activity Job, leasure time, house hold 4 days a week

• Broca’s index- ht in cm – 100

• Smokeless--- khaini etc

CARDIOVASCULAR RISK FACTORS

METAB0LIC SYNDROME

• IN INDIA 1/3rd URBAN POPULATION HAVE METABOLIC SYNDROME

• ONSET AT AGE 15-20

• MENIFESTATION 15- 20 YEARS LATER

• Ie. AT AGE 30- 40 YEARS

ObesityObesity

YearYear PlacePlace PopulationPopulation PrevalencePrevalence RemarksRemarks

19831983 Kathmandu (urban)Kathmandu (urban) >20 ,both sex>20 ,both sex 24.324.3 Broca’sBroca’s IndexIndex

19831983 Kathmandu (rural)Kathmandu (rural) >20 ,both sex>20 ,both sex 1212 Broca’sBroca’s IndexIndex

19831983 Parsauni (Terai , rural)Parsauni (Terai , rural) >20 ,both sex>20 ,both sex 9.29.2 Broca’sBroca’s IndexIndex

19831983 Jumla (mountain, rural)Jumla (mountain, rural) >20 ,both sex>20 ,both sex 8.38.3 Broca’sBroca’s IndexIndex

20042004 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, males>35 years, males 40.140.1 BMIBMI

20042004 Dharan (East Nepal, urban)Dharan (East Nepal, urban) >35 years, males>35 years, males 51.251.2 WHRWHR

CARDIOVASCULAR RISK FACTORS

26Pandey MR. Hypertension in Nepal. Mrigendra Medical Trust 1983.

Vaidya A et al. Association of Obesity and Physical Activity in Adult Males of Dharan, Nepal. KUMJ 2006; 4(2): 192-197.

World Health Organization. World Health Survey, Nepal.

Research report on NCD risk factors surveillance in Nepal, 2003

SedentarySedentary lifestylelifestyle

YearYear PlacePlace PopulationPopulation PrevalencePrevalence RemarksRemarks

20032003 NationalNational 1818--6969,, bothboth sexsex 66--2828

20032003 KathmanduKathmandu (urban)(urban) 2525--6464,, bothboth sexsex 3030

20042004 DharanDharan (East(East Nepal,Nepal, urban)urban) >>3535 years,years, malesmales 44.144.1

MALES 16.9%

FEMALES 8.7 %

Prevalence of Metabolic Syndrome

FEMALES 8.7 %

TOTAL 12.4Sharma D at al , NHJ 2009

RISK FACTORS in CAD PATIENTTRISK FACTORS in CAD PATIENTTSS

� SMOKING 82%

� HTN 40%� HTN 40%

� DAIBETES 22%

� HLP 25%

METABOLIC SYNDROMECRITERIA AHA / NHBLI

1. WAIST CIRC: >= 90 cm male

>= 80 cm female

2. TG >= 150 mg%

3. HDL <= 40 mg% male

<= 50 mg female

4. BP >= 130 mmHg

>= 85 mmHg

5 BLOOD SUGAR >= 100 mg % (F)

• Nepalese in general have poor knowledge of CV health

CARDIOVASCULAR DISEASES

30

Limbu YR, et al. Public knowledge of heart attack in a Nepalese population Survey. Journal of Acute & Critical Care. 2006; 35(3):164-169

RHEUMATIC HEART DISEASE

PREVALENCE

• RHD: 1.2/1000

PATTERN OF VALVULAR INVOLVEMENT IN RHD

• N= 9521 RHD CASES

• 2002-2008

• 3867 MALES ( 40.6%)

• 5654 FEMALES (50.4%)

RHD - VALVULAR INVOLVEMENT

MS/ MRMS/ MR 16.7%16.7%

MRMR 16.1%16.1%

MSMS 15.5%15.5%

MR/ARMR/AR 12.1%12.1%

MR/MS/ARMR/MS/AR 11.8%11.8%

AVAV 4.21%4.21%

MV INVOLVEMENTMV INVOLVEMENT 95.79%95.79%

VALVULAR INVOLVEMENTVALVULAR INVOLVEMENT 7.2%7.2%

RHD INTERVENTIONS

• 400 PERCUTANEOUS MITRAL VALVOTOMIES LAST

YEAR

• 1300 SURGERIES DONE LAST YEAR

• 30% WERE RHD CASES

CONGESTIVE HEART FAILURE

• BECOMING COMMONEST DISEASE IN THE

WORLD

• SAME TREND IN OUR COUNTRY

ADMISSION IN INTENSIVE CARE

28%20%

5% RHD

DCM

VHD

18%8%

13%

8%

VHD

IHD

Arrhy

ACS

HTN

ADMISSION IN INTENSIVE CARE

20%

5%CHF

IHD

54%

13%

8%

IHD

Arrhy

ACS

HTN

Population studies indicate high CHD burden

PopulationPopulation--based Estimation of Prevalence of CHD in based Estimation of Prevalence of CHD in

NepalNepal

CORONARY ARTERY DISEASE

40

NepalNepal

Year Year PlacePlace Prevalence Prevalence

19971997 Kathmandu (urban)Kathmandu (urban) 4.84.8

20042004--55 Dharan (urban)Dharan (urban) 5.7 (5.7 (4.26 4.26 –– 7.13)7.13)

Shrestha UK et al. (Personal communication)

Vaidya A et al.Prevalence of Coronary Heart Disease in the Urban Adult Males of Eastern Nepal: A population-based analytical cross-sectional study

CORONARY ARTERY DISEASE

Among hospital admissions

• CAD 21.7%

• MALES 74%

• FEMALES 26%

RISK FACTORS in CAD PATIENTTS

• SMOKING 82%

• HTN 40%• HTN 40%

• DAIBETES 22%

• HLP 25%

RISK FACTORS in CAD PATIENTS

22

82

40

25 SMOKING

HTN

HLP

DIABETES

%

TRENDS IN CAD

• YOUNGER POPULATION

• NO PREVIOUS ANGINA• NO PREVIOUS ANGINA

• INFERIOR MI FREQUENT CAUSE OF DEATH

CONGENITAL HEART DISEASE

• CONGENITAL HEART DISEASE PREVALENCE

1.3/1000

• COMMONEST LESION ATRIAL SEPTAL DEFECT• COMMONEST LESION ATRIAL SEPTAL DEFECT

• VENTRICULAR SEPTAL DEFECT

CATH LAB PROCEDURES

3000 CASES/ YEAR

10%5% 2%

CAG

PTMC

51%

14%

9%

9%

PTMC

PTCA

RHC

PACING

EP/RFA

OTHERS

CARDIOVASCULAR SURGERY 1300/ YEAR

39%

17%5%

Congenital

valvular

30%

9%

valvular

CABG

Vascular

others

WHAT ARE WE DOING

• Where advanced health care service is in

accessible.accessible.

RHD

• FREE PENICILLINE PROPHYLAXIS

Problems

• Lack of adequate research on risk factors and other

aspects on CVD

• Lack of intermediate-level manpower

• No national policy/programme on CV diseases• No national policy/programme on CV diseases

• Centralization of specialist heart care

• CVD not included in primary health care system

• Cost of intervention/surgery unaffordable

• Insufficient emphasis on preventive measures

THANK YOU