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ESCALATING BURDEN OF CHD-an overview

DR HARIVANSH CHOPRA

D.C.H.,M.D

PROFESSOR

COMMUNITY MEDICINE

LLRM MEDICAL COLLEGE MEERUT

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THREE REAL STORIESEighteen year

old smart boy son of a doctor suffered from myocardial infarction and could not be saved despite getting best available treatment

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Thirty eight year old a famous specialist doctor, son of professor of Medicine Died at home on the first floor. Unfortunately no medical assistance was possible due to acuteness of episode

THREE REAL STORIES

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THREE REAL STORIESFourty two year old

faculty member of a medical college had an episode of impending infarction and fortunately was given treatment in private sector in first thirty minutes and survived.

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Facts 50% of Mortality in MI / CHD occurs in first thirty minutes

CHD is occurring a decade earlier in india as compared to developed countries.

Risk factor assessment is not prevalent in public health system

Deaths below 70 Years

• Gupta R. Burden of coronary heart disease in India. Indian Heart J 2005; 57 : 632-8.• Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 :

807-10.

Western countries India

23%

52%

Deaths due to NCDs

Deaths below 70 Years age

7

8

Non communicable diseases

50%Communicable diseases

40%

Injuries10%

Estimated percentage of deaths by cause in India, 2008

Source: Global Health Observatory. World Heath organization 2011

9

0%

10%

20%

30%

40%

50%

60%

70%

80%

38%

50%

16%15%

75%

14%

20042030

Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PloS Medicine, 2006, 3(11):e442.

Trends in estimated percentage of deaths by cause of death,

South-East Asia region, 2004 and 2030

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Estimated burden of CHD in India

Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 : 807-10.

19902010

0

0.5

1

1.5

2

2.5

1.17

2.03

CHDs Burden In millions

11

0%

2%

4%

6%

8%

10%

12%

14%

12%

9%

3%

1%

Percentage of deaths due to CVDs* of subtype CVD, India, 2008

CVDs: Cardiovascular diseasesSource: Global Health Observatory. World Heath Organization 2011.

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AGE

HYPERTENSION

SMOKING

DIABETES

DYSLIPIDEMIA

OBESITY/LACK OF EXERCISE

PREMATUREFAMILY HISTORY OF CAD

TRADITIONAL RISK FACTORS

NON TRADITIONAL RISK FACTORS

ABNORMAL ABI

HOMOCYSTEINUREA

METABOLIC SYNDROME

LVH

RENAL DISEASE

CALCIUM SCORE

CHRONIC INFLAMATION

CHRONIC INFLAMATORY DISEASE

LIPOPROTIEN a

HIV

BNP FIBRINOGEN

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CRP

14

Schematic representation of an iceberg for NCDs

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28%

72%

IDSP DATAMedicine OPD LLRM MEDICAL

COLLEGE,MEERUT 2012-13

NCD CD

16

57%16%

5%

22%

IDSP DATA OF MEDICINE OPD(Aug.2012-July 2013)

HTIHDDM IDM II

17

17%

3%

80%

OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM

medical college,meerut 2008

HTHT+DMOTHERS

18

26%

9%66%

OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM medical college,meerut

2009

HTHT+DMOTHER

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TRADITIONAL RISK FACTORS

DIABETES

DIABETES

DIABETES

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Diabetes mellitus: In India

King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21 : 1414-31.

1995 2025

19.3

57.2

DM in Millions

20

21

ICMR estimates

Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51.

Rural areaUrban area

3.80%

11.80%

Prevalence of Diabetes

21

22

MalesFemales

0%

2%

4%

6%

8%

10%

12%

11%11%

Percentage of adult population with raised blood glucose level*,

India, 2008

* Fasting glucose> 7.0 mmol/L or on medication for diabetesSource: World Health Organization. Global status report on non communicable diseases, 2010. Geneva, 2011

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Diabetes: Top 10 Countries (absolute numbers)

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PECULARITY OF CHD IN DIABETES

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DIABETIC SUBJECTS HAVE 2-4 TIMES MORE RISK OF CHD

CHD MAY BE SILENT

OCCURS AT YOUNGER AGE

RESULT IN MICROVASCULAR ANGINA

WORSE OUTCOME FOLLOWING REVASCULARISATION

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TRADITIONAL RISK FACTORS

HYPERTENSION

HYPERTENSION

HYPERTENSION

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Males Females0%

5%

10%

15%

20%

25%

30%

35%

40%36%

34%

Percentage of adult population with high blood pressure*, India, 2008

Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability*Systolic BP>140 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP

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Hypertension:

• Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18 : 73-8.

Urban Rural0%

5%

10%

15%

20%

25%

30%

35%

40%

40%

17%

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2000 2025

No. of Persons with HYPERTENSION

118 Million 214 Million

No. of Persons Dying from TOBACCO

900,000 2 Million +

Rising Chronic Disease Burdens

Source: Jha et al, NEJM, Feb 2008 . WHO infobase

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TRADITIONAL RISK FACTORS

SMOKING SMOKING

SMOKING

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Cigarette smoking

An alarming rate of current tobacco use of

56 % among

Indian men aged

12-60 yr.

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Survey of sixth and eighth graders attending school in an urban setting revealed that the prevalence of tobacco use (any history of use or current use) was 2-3 times higher among sixth graders compared with eighth graders.

Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51.

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0%

10%

20%

30%

40%

50%

60%

70%

Males

Females

68%

61%

49%

30%

32%

22%

11%

4%

Percentage of adults, who are current users of tobacco products, by education, India,

2009

MalesFemales

Source: India Global Adult Tobacco Survey 2009

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TRADITIONAL RISK FACTORS

NUTRITIONALDYSLIPIDEMIA

FAMILIALDYSLIPIDEMIA

METABOLICDYSLIPIDEMIA

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Males Females0%

5%

10%

15%

20%

25%

30% 26%

29%

Percentage of adult population with raised total cholesterol,

India, 2008

Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability

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TRADITIONAL RISK FACTORS

OBESITY

FAMILIAL METABOLIC

ENDOCRINAL

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OBESITY RUNS IN THE FAMILY

NO BODY RUNS IN THE FAMILY

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Overweight(BMI>=25 kg/m2)

Overweight(BMI>=30 kg/m2)

0%

2%

4%

6%

8%

10%

12%

14%

10.00%

1.30%

13.00%

2.50%

11.00%

1.90%

Percentage of adult population that is overweight and obese, India, 2008

MaleFemaleBoth sexes

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability

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Childhood obesity is an emerging issue.

In a Mysore (India) study on 43 152 school children, obesity and overweight prevalence was 3.4% and 8.5%, respectively.

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NUTRITIONAL STATUS OF CHILDREN (5-15 YRS) IN URBAN MEERUT

48%

39%

10%

4%

Under weightNormal weightOver weightObese

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Physical activity

Daily moderate intensity physical activity (e.g., the equivalent of briskly walking 35-40 min per day) is associated with

a 55 percent lower risk for CHD.

Rastogi T, Vaz M, Spiegelman D, Reddy KS, Bharathi AV, Stampfer MJ, et al. Physical activity and risk of coronary heart disease in India. Int J Epidemiol 2004; 33 : 759-67.

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Male Female0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

14%

19%

Percentage of adults with in-sufficient physical activity,

India, 2008

Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 based for comparability*Less than 30 minutes of moderate-to-vigorous activity at least five days a week.

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Males Females0%

5%

10%

15%

20%

25%

21%

2%

Percentage of adults consum-ing alcohol*, by sex, India,

2007

Source: National NCD risk-factor surveys in Member countries*People who have consumed alcohol in the past 30 days.

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2010 20500%

10%

20%

30%

40%

50%

60%

30%

55%

Projected mid-year popula-tion, residing in urban areas,

India, 2010-2050

Series 1

Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs Population Division.United Nations New York, 2008.

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2006 2015 Cumulative GDP loss by 2015

0

4

8

12

16

20

1.35 1.96

17

Projected cost of cardiovascular disease in terms of lost GDP, India, 2006 and 2015

Fore

gon

e G

DP

*(U

S$

billion

s)

Source: Abegunde DO, et al. The burden and cost of chronic diseases in low-income and middle-income countries.Lancet 2007;370:1929-38.*GDP: Gross Domestic product

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Cardiovascular disease

Hypertension Diabetes0

20

40

60

80

100

120

140

80

130

110

4232

55

20

0 1

Annual income loss from missed work, time for caregiving, and premature death among

household with a member suffering from NCD, India, 2004

Missed work

Caregiving

Premature death

Incom

e loss (

billion

ru

pees)

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The total income loss due to chronic diseases in India was between Indian Rupee (INR) 1094–1113 billion.

Income loss due to hypertension : INR 199 billion

Due to diabetes: INR 163 billion

Due to CVDs : INR 144–158 billion

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Physicians 2000-2010

Nursing and midwifery personnel 2000-2010

Public health workers 2000-2010

Community health workers2000-2010

Number

Density*

Number Density*

Number Density*

Number Density*

660801

6.0 1430555

13 --- --- 507150

0.5

Source: World Health Statistics 2011, World Health Organization 2011*per 10 000 population

Health workforce in India

Source: Global Health Observatory. World Heath organization 2011

All India Uttar Pradesh

Medical Colleges

381 27

M.B.B.S seats

44,418 2909

M.D- General Medicine

2266 122

D.M- Cardiology

269 23

Mch- Cardio-thorasic surgery

80 3

Annual Intake of medical students in India and Uttar Pradesh

Source: Medical Council of India

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National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS)

Ministry of Health & Family Welfare GOI

c.

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Objectives of NPCDCS

Prevent and control common NCDs through behavior and life style changes,

Provide early diagnosis and management of common NCDs,

Build capacity at various levels of health care for prevention, diagnosis and treatment of common NCDs,

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Train human resource within the public health setup viz doctors, paramedics and nursing staff to cope with the increasing burden of NCDs, and

Establish and develop capacity for palliative & rehabilitative care.

Objectives of NPCDCS

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India Map showing the States to implement NPCDCS

21 STATES

100 DISTRICTS

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Packages of services to be made available at different levels under NPCDCS

At Sub Center Level:

Health promotion for behavior change

‘Opportunistic’ Screening using B.P measurement and blood glucose by strip method

Referral of suspected cases to CHC

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At CHC Level:

Prevention and health

promotion including counseling

Early diagnosis through clinical

and laboratory investigations (Common lab investigations:

Blood Sugar, lipid profile, ECG, Ultrasound, X ray etc.)

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At CHC Level:

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Management of common CVD, diabetes and

stroke cases (out patient and in patients.)

Home based care for bed ridden chronic cases

Referral of difficult cases to District Hospital/

higher health care facility

At District Hospital Level:

Early diagnosis of diabetes, CVDs, Stroke and Cancer

Investigations: Blood Sugar, lipid profile, Kidney Function Test (KFT),Liver Function Test ( LFT), ECG, Ultrasound, X ray, colposcopy , mammography etc. (if not available, will be outsourced)

Medical management of cases (out patient , inpatient and intensive Care )

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57

At District Hospital Level:

Follow up and care of bed ridden cases

Day care facility Referral of

difficult cases to higher health care facility

Health promotion for behavior change

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Cardiac Care Unit (CCU) Support of Rs. 1.5 crores Functional in 20 districts so far

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CCU at Pattanamthita, Kerala

CCU at Kupwara, J&K

Issues: Procurement of equipments Non availability of specialists Lack of space in some district hospitals

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During 2010-12:

The strategies proposed will be implemented in

20,000 Sub Centres and 700 Community Health

Centre in 100 Districts across 21 States

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Districts Covered during 2010-11 TOTAL

States- 21Distt.- 30 CHCs- 205 Sub Centers- 6482

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Uttar Pradesh

Distt. Rae Bareli CHCs-11 Sub Centers-

377

Distt. Sultanpur CHCs-14 Sub Centers-

403

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Screening for Diabetes and Hypertension -1 Logistics & training provided:

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2010-11 2011-12 Total Glucometers 6617 21500 28117

Glucostrips 1.3crore 4.3 crore 5.6crore

Lancets 1.6crore 4.9crore 6.5crore

Training to Health Workers : completed in 82 districts (out of 100 districts, 4 districts of TN : logistics not required)

Target population : 5.6 crore

Screened: 1.02 crore, 3.48 to be screened

Suspected for diabetes : 7.5 lakh (7.4%)

Suspected for hypertension :6.5 lakh (6.5%)

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MISSING LINK

Stress

Strength

Traffic

control

Redesign

Erase

Share

Surrender to God

STRESS

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“Live sensibly - among a thousand people, only one dies a natural death; the rest succumb to irrational modes of living.” - Maimonides

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Avoid alcohol Be physically active

Cut down on salt and sugar

Don’t use tobacco products

Eat plenty of fruits and vegetables

Being healthy is as easy as ABCDE

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