The Tribune, Chandigarh, India

CAD: wake-up call for the young
Dr H. S. Rissam

AT the personal level I did not know Dewang Mehta beyond "nice to see you." the same here (handshake)". But today I am, like so many others, one of the deeply aggrieved persons after the sudden vanishing away of one of the most hard-working and sincere souls amidst us. The situation is sorrowful because Mehta died at a young age — a very young age — below 40, much before most of the people would settle in their careers. He died of a heart attack which was sudden, severe, fatal, first and final.

It is the suddenness and unpredictability of such a disaster that is unnerving for me as a fellow-citizen and as a cardiologist. It also makes me wonder at the fragility of others around me. "Coronary Artery Disease (CAD) in young Indians — the challenge of the new millennium" has been the main subject of my lectures during the past one year. I have been speaking on this subject at many places in North India, Delhi, Agra, Chandigarh, Amritsar, Jalandhar, Patiala, Sirsa, Abohar, Ghaziabad, Jalalabad and Faridkot.

Wherever I go I emphasise the magnitude of this problem because more and more young men are falling prey to the malady of CAD.

In the sixties we saw grandfathers as patients, in the seventies fathers in eighties sons; now we see grandsons with heart attacks. We see only the survivors. Those (a large number of persons belong to this category), who perish in the first attack itself (like Dewang), are never seen by us because they are no more on the scene. That is the crux of this issue.

The survivors still have hope. The non-survivors only leave a sense of despair behind — a sense of helplessness, a question mark: "Why this man"? I think Mr Mehta's death must be taken as a wake-up call by young people — hard-working and sincere young men and women — a call for taking precautionary and preventive measures against this impending danger, which is hanging like the sword of Damocles over everybody's head.

At the threshold of this millennium, CAD is looming large as the new epidemic afflicting Indians at a relatively younger age with severe and multiple blockages in the arteries supplying blood to the heart. Recently, the subject of CAD in Indians (referred to as immigrants or Asian Indians or South Asians when outside India) has emerged as a challenge for research centres worldwide. The prevalence of CAD has progressively increased during the last half of the century, particularly among the urban population.

Indians vis-a-vis the West and the rest: The risk of CAD in the Indians is three to four times higher than in the white Americans, six times higher than in the Chinese and 20 times higher than in the Japanese. The Indians are prone, as a community, to CAD at a much younger age. The disease pattern is severe and diffuse. CAD is affecting Indians five to 10 years earlier than other communities. They also show a higher incidence of hospitalisation, morbidity and mortality than other ethnic groups. This global phenomenon of prematurity and severity suggests that the disease starts at an early age (in the twenties) and has a malignant and relentlessly progressive course.

In some studies in India the percentage of the patients below 45 years suffering from acute myocardial infarction (AMI) is reported to be as high as 25-40%. In Britain the first AMI among Indians at an age less than 40 years is reported to be 10 times higher than among the local whites. In Singapore, mortality from CAD below 30 years of age is 10 times higher in the Indian than Chinese population of the same age group. After coronary angiography (a test done to look at the blockages in the arteries), the Indians have a 15 times higher rate of blockages than the Chinese and a 10 times higher rate than the local Malays below the age of 40.

Young patients from other communities do not show extensive disease whereas in young Indians there is often three-artery disease with poor prognosis (the heart has only three arteries). The post-heart attack course in the survivors of the first attack is also worse in the Indians as compared to the whites. This is reflected by a three-times higher rate of re-infarction (the second or third heart attack) and a two times higher rate of mortality. In my personal observation in West Asia, out of the patients admitted to the CCU with acute MI below the age of 40 years, 80% were expatriates from the Indian subcontinent as compared to 20% of the native Arabs whereas, demographically, the Indian expatriates are about 10% of the local population.

The prevalence of CAD is two times higher in urban areas than in rural areas. South Indians have a still higher prevalence. The vulnerability of the urban Indians to CAD is possibly related to different nutritional, environmental and life-style factors. Migration from the rural environment to the urban environment and migration from India to industrialised countries are special risk factors for our people. Migration is usually associated with the stress of seeking and maintaining the new job, the demand for coping with the new job-expectations and the task of competing with the peer-group that is in the organisation longer. New affluence is associated with the sedentary life-style and the higher consumption of calories, saturated fats, salt, tobacco and alcohol. These factors contribute to obesity, higher cholesterol levels, hypertension, high uric acid and diabetes mellitus, which are predisposing factors for the development of CAD.

Why Indians are more vulnerable — the extra link: The greater vulnerability of Indians is possibly due to the fact that in addition to the well known conventional risk factors for CAD, Indians as a community have a host of new or additional risk factors which are not present or dominant in non-Indians.

Old or conventional risk factors include hypertension, diabetes mellitus, smoking, hyperlipidemia, tobacco consumption and central obesity at a younger age. The male sex is more prone to CAD. Post-menopausal females constitute a distinct sub-group at higher risk for CAD.

Hypertension is a well known risk factor associated. The prevalence of hypertension is increasing in the urban population as compared to the rural population. The prevalence of diabetes mellitus is about 20% in middle age and additional 20% may be potentially diabetic. Even a moderate elevation of glucose in Indians is associated with an increased risk of CAD. Diabetics are particularly prone to severe fatal attacks as they do not get warning symptoms like angina as the pain-perceiving nerves are numbed in them by diabetes (as happened in the case of Mehta, who had possibly no preceding anginal symptoms). In contrast to the decreasing mean cholesterol level in the USA, the mean serum cholesterol level in the urban Indians is rising. For example, in Delhi, the mean serum cholesterol level rose from 160 mg/dl in 1982 to 199 mg/dl in 1994. Indians, even with lower levels of serum cholesterol, have a higher risk of CAD.

Smoking increases the risk of CAD by three to five times. In the First -World countries smoking has significantly decreased and is socially looked down upon. In contrast, in India smoking is increasing particularly in the younger generation. As the demand is falling in the West, tobacco-traders are dumping this atherogenic (blockage-inducing) material in the Indian market. In the seventies, tobacco consumption in India per adult was 0.7 kg per year; it is likely to increase to 0.9 kg per adult per year.

New risk factors: Lipoprotein-a (called as - Lp-a) is recognised as an independent risk factor for CAD. I call Lp-a the "extra" link. It a is genetic risk factor.

It is not affected by any level of life-style modification like a change in diet and exercise. Lp-a is 10 times more atherogenic than LDL-C. In Indians, both in India and abroad, the levels of Lp-a are higher as compared to the Whites in Britain, suggesting a genetic propensity. Lp-a levels in the umbilical-cord blood are higher among Indian newborns than among Chinese newborns and this difference is also associated with a four-fold higher CAD - related mortality in Indians than in Chinese in Singapore. Lp-a levels above 30 mg/dl are associated with a three-fold higher risk of CAD.

In Indian patients with CAD, high triglyceride levels are seen more often than high cholesterol levels. Triglycerides bring change in the LDL particle size, density, distribution and composition, producing smaller denser and more atherogenic particles. An increase of triglycerides from 90 mg/dl to 180 mg/dl is associated with doubling the incidence of CAD. Indians worldwide demonstrate a triad of high triglycerides with high LDL-c levels and low HDL levels (good cholesterol). This triad, combined with high levels of Lp-a, constitutes the deadly lipid quartet.

The other new factors, which have been identified in Indians, are Apolipoprotien-B (Apo-B), LDL Phenotype-B, Plasminogen Activator Inhibitor-1 (PAI-I), Insulin Resistance Syndrome (IRS), Serum Fibrinogen and Hyperhomocysteinaemia.

Infections and CAD: Infectious diseases are rampant in India, particularly in the poor. Various infections, viral and bacterial, have been implicated for CAD in Indians. A systemic infective episode produces generalised inflammation, including that in coronary arteries, which may be further worsened by factors like smoking, hypertension, stress, diabetes and dyslipidemia. Whether the fuel of infection is poured over the fire of these risk factors or fire is added to the fuel is under research.

Conclusions: In order to combat the onslaught of CAD among young Indians and to reduce acute events like a heart attack, it is mandatory to have a very high index of suspicion of CAD in our population. The evaluation of conventional risk factors like hypertension, diabetes mellitus, obesity, high uric acid, high cholesterol and smoking must be done in men from the age of 30 years and in women of post-menopausal age. Triglycerides and other cholesterols (both good and bad) must be estimated as a part of routine evaluation. In major hospitals the laboratory facilities for the evaluation of newer risk factors, namely lipoprotein (a) and others, must be introduced. After the age of 30 years, investigations including TMT/stress thallium must be periodically performed. The new state of the art investigations include the assessment of coronary calcium by CT scan and MRI — angiogram. If these tests are abnormal, coronary angiography must be carried out to delineate the culprit lesions for timely and appropriate intervention like angioplasty (ballooning) or surgery.

It is very important to stop smoking, to keep optimal weight, to take regular exercise like walking and to adhere to medical advice seriously. In the industralised countries there has been a continuing decline of CAD during the last three decades. This has been possible by focussing on public education programmes for modifying the known risk factors and by targeting high risk individuals and emphasising on healthy life-styles. This achievement of the industrialised nations must become an example for the people, for physicians and policy-makers in India. Let there be no further national loss like the one we had now!

Dr Rissam is a senior consultant cardiologist at the Escorts Heart Institute and Research Centre, New Delhi. Email: hsrissam@usa.net

HEALTH BULLETIN
Guggul: Nature’s mighty weapon against arthritis
Dr R. Vatsyayan, Ayurvedacharya

GUGGUL is a familiar name in Ayurvedic medicine. The Atharva Veda dedicates a full verse of five lines to it. Ever since the Vedic period, scores of scholars and researchers have analysed and experimented with it, discovering, as they went along, its remarkable therapeutic profile. Guggul happens to be an oleoresin exuded by an ordinary-looking tree called in botanical terms as Commiphora mukul or Balsamodendron mukul. This resinous mass undergoes a typical process of purification to make it fit for human consumption.

Ancient acharyas have described guggul as bitter in taste but hot in effect. It has qualities to pacify all three doshas in the body (vata, pitta and kapha). It is also described as light, dry sharp, sticky and unctuous. The chemical composition of guggul depicts it as mixture of a variety of organic compounds and inorganic ions. It also contains mineral matter mostly consisting of silicon dioxide, calcium, magnesium, iron and a volatile oil.

Guggul is a very potent drug for various types of joint problems such as rheumatoid arthritis, osteo-arthritis and gout. Its therapeutic use helps in reducing pain, swelling and tenderness of the inflamed joints. Guggul has multiple actions on various other systems of the human body. It is alterative and anti-atherogenic. It has anti-hypercholeterolemic properties. Besides this, it is known to stimulate expectoration, and is immunostimulant and emmenogogue (that which promotes menstrual discharge).

Guggul has a dual profile — at least for the practitioners of modern medicine. It is anti-inflammatory as well anti-lipemic. In ancient times, one of its primary indications was known as medoroga which is similar to the modern descriptions of obesity.

Recent experiments have proved guggul as a medicine that significantly lowers serum triglycerides and the cholesterol level as LDL and VDL cholesterol (the bad cholesterol). At various places, trials are in progress to use guggul effectively in combination with another well-known herb, Pushkarmool, for combating chest pain and allied problems of angina.

Classical ayurvedic literature has a separate group of formulations where guggul is used as a chief ingredient. To name a few, Sinhnad Guggul and Yogaraj Guggul (for arthritis, paralysis and other disorders caused by the imbalance of vata dosha), Kaishore Guggul and Triphala Guggul (for the regulation of fat metabolism) and Kanchnar Guggul (for soft-tissue inflammation) fall in this group. The average daily dose of guggul is two to four gms.

Although the use of guggul in therapeutic dose appears to be safe and non-toxic, the following precautions are advised: Since it is a uterine stimulant, its use should be avoided in the first trimester of pregnancy. Persons with liver disease and inflammatory bowel problems are also advised to consul his physician before using it.

The writer has agreed to answer readers’ questions regarding guggul. He is based at Sanjivani Ayurvedic Centre, near the Rose Garden’s main gate, Ludhiana. (Phone - 0161-423500)

Sex after sixty
Dr Rajeev Gupta

SEX, a vital propeller of human life, is the least openly discussed topic in our country. It is not wrong to say that Indian society continues to be sexually inhibited.

In our country, traditionally, the role of sex is considered to be confined more to procreation during the grihastha ashrama and less to modes of happiness, togetherness and relaxation.

Though for millions of Indians, sex is the only easily available source of diversion of thought in their boring and poor homes, the scriptures keep celibacy or abstinence on a pedestal.

Until a few years ago, sex was an untouchable topic even for magazines and newspapers. Only lately one finds an attempt at opening healthy discussions on this highly important part of life.

For many conservative Indians, active sex life after 60 may be unthinkable or something thought to be a moral blemish. Grown up children and grandchildren cannot imagine that their parents and grandparents had an active sex life.

There is hardly any documented information on the pattern of sex life of the aged in our country. On the contrary, studies from the West clearly reveal that even after 60 or 70, it continues to remain a highly important part of normal existence. Fortunately, a similar trend is gradually emerging in the economically well-off sections in our country.

Changing trends: The average life-span in India is maintaining a significant rise. Thanks to improved diet, a better life-style, increasing health awareness and the availability of proper medical facilities, more and more elderly people are maintaining active physical, social and occupational life. Because of the fast-improving economic standards of the middle class, one frequently meets middle-aged and elderly couples going to health clubs and enjoying vacations and holidays.

Today, more and more middle-aged and elderly persons are coming out of the self-enforced inhibition to seek advice for their physical problems or dysfunctions. They keep on trying ayurvedic preparations, common "nuskhas", allopathic drugs and hormonal preparations to boost their energy and to find answers to desire. The availability of Viagra from the house of Pfizer and a plethora of "Indian Viagras" have created a new and healthy wave of awareness about this topic talked about in whispers. More and more elderly males are approaching their doctors for seeking guidance about the use of the “wonder drug". They do not want to deprive themselves of the "blessings of life", they say.

The overwhelming response to my earlier article (February 2, 2001) on "Viagra's Indian avatars", aptly called so by The Tribune, has made me aware of my responsibility as a psychiatrist to write a follow-up piece. More than 90 per cent enquiries have come from those who are above 60. One enquiry came from a Ludhiana resident who was 76-year old. He is in excellent physical health. He walks for more than 10 km daily. he is neither hypertensive nor diabetic. he does not suffer from any physical illness.

He complained, however, of his dysfunction and wanted to know whether the "Indian Viagras" would help him.

Eagerly, he looked forward to living for 20 years more. he persuaded me to advise him appropriately and warn him on certain points.

****

New scientific evidence clearly shows that sex tones up one's mind and body. it is a great stress-buster. Those who are physically healthy enjoy themselves mentally physically and socially. They become spiritually inclined too. Permissiveness, exhibitionism and self-destruction are to be dealt with ruthlessly but scientific truth must prevail.

The author is a Ludhiana-based psychiatrist. he runs a clinic named MANAS in Tagore Nagar, Ludhiana. (Ph 472822, 472899).

Q&A
No chickenpox, no regrets

Q What is chickenpox?

A It is a viral disease caused by first exposure to the varicella zoster virus (VZV). The disease is identified with fever and typical blistered rash all over the body. The virus then remains latent or dormant in the body and can later get reactivated and cause shingles (herpes zoster).

Q What are the symptoms of chickenpox?

A Common symptoms are fever, chills, nausea and vomiting. The most obvious and the most well-known is the blistered and highly itchy rash. Most children have 200-300 lesions, which later form a crust or scab.

Q Is chickenpox contagious?

A Yes, it is. Chickenpox is most contagious a couple of days before the rash appears and until scabs have formed on all the lesions, i.e, till they dry up, which usually occurs in a week's time after the onset of the rash.

Q How can you contract chickenpox?

A The virus commonly spreads from person-to-person by air-borne droplets. This occurs when an infected person coughs or sneezes and releases secretions in the surrounding air. It can also spread by direct contact with chickenpox or herpes, since the wet lesions contain infectious fluid. In a few cases, it can also occur from an infected pregnant mother to her unborn or newly born child.

Q Who is most susceptible to this virus?

A Chickenpox can occur in both children and adults, males and females. Most people contract chickenpox sometime or the other during childhood or adolescence, but adults who have not been infected before are susceptible to infection and can develop chickenpox in adulthood if and when they come in contact with a case. As chickenpox usually affects young children, those who spend a lot of time with children, like teachers and persons running day-care centres have more chances of contracting the infection. In addition, healthcare providers (doctors, nurses and hospital personnel) are at added risk of developing the infection since they may come in contact with a case during the course of their duty. Chickenpox is usually more severe in older individuals who missed getting it when they were children.

Q Does chickenpox cause complications in children?

A Although for many children chickenpox does not produce major health problems, complications can develop in some cases. Secondary bacterial infection affecting the skin lesions is the most common complication that one encounters, especially when hygiene is poor and when bathing is not regular. Rarely, in a few children, the virus could prove more aggressive and cause infection in lungs leading to pneumonia and may affect the brain leading to swelling and infection (encephalitis). These could prove fatal. Other complications have been described, but these usually have a self-limited course. Rarely, residual scarring may be unsightly, leading to cosmetic concerns later in life.

Q Is chickenpox in adults different from that in children?

A Chickenpox is more severe in adolescents and adults than in children. The fever is higher and continues for a longer time. The rash is usually heavier with deeper and more lesions. The likelihood of complications is greater too. Adults are more likely to suffer from pneumonia. The chances of complications and risk to life tend to be higher when chickenpox is contracted later in life.

Q Some viral infections are dangerous in pregnancy. What about chickenpox?

A The interaction between chickenpox and pregnancy would depend on the timing of contracting the infection during pregnancy. If chickenpox is contracted by the pregnant lady during the first three months of pregnancy, there is a risk of congenital foetal malformations, or chances of abortion. Infection later in pregnancy but not too close to delivery allows maternal antibodies to be passed on to the foetus thus offering protection. Maternal chickenpox within five days prior to delivery or two days after is dangerous as this can result in transmission of the virus without antibodies to the child. Such chickenpox in the newborn can be life threatening as the baby's immune response is poorly developed at this time.

Q What is the relation between shingles and chickenpox?

A Both these conditions are caused by the same virus i.e, varicella-zoster virus. First exposure to the varicella zoster virus results in chickenpox; that is followed by immunity against the infection, which usually lasts a lifetime. The virus, however, hides in certain nerve roots and remains dormant. The virus may get reactivated many years later, leading to shingles (herpes zoster). Shingles usually afflict adults, especially old people, as the efficiency of the immune system declines with age.

(To be concluded)