The Tribune, Chandigarh, India

HEALTH

FACE TO FACE
Heart of the matter

As many as 30 million people in India currently suffer from heart diseases. By 2010, one million Indians are expected to be suffering from this silent disease. And by 2015, heart disease is likely to be the single largest cause of death in the country, says cardiologist Dr Daljit Singh Gambhir. In a conversation with Parmindar Singh, he talks about the disease and its causes.

ONE of the renowned cardiologists of India, Dr Daljit Singh Gambhir, who joined G. B. Pant Hospital, New Delhi, as Assistant Professor of Cardiology in 1985, after obtaining his medical degree, rose to the coveted position of a professor in 1993, at the relatively young age of 44.

A leading interventional cardiologist of the country, Professor Gambhir has many firsts to his credit in the field of coronary intervention. Not only has he treated and saved countless number of patients by his masterly skills in angioplasty, but has also trained a large number of doctors in interventional cardiology through live demonstrations in and outside the country.

Professor Gambhir is a dedicated teacher and an intense researcher. He has published over 100 original papers in national and international journals, besides contributing chapters for various books. He was the Honourable Editor of Indian Heart Journal for six years and is currently on the editorial board of many international journals.

As the Chairman of Scientific Committee for its annual conference in 2002, his leadership was widely acclaimed and appreciated. As a tribute to his organisational skills, he was unanimously elected as the president of the Cardiological Society of India. Professor Gambhir is associated as a member of the Executive Committee and as an office-bearer with the Cardiological Society of India for over two decades.

Prof Gambhir is recipient of several honours and awards for his valuable contributions to the field of cardiology from various professional bodies and social organisations. The awards include: the ‘State Award’ conferred on him by the Government of Delhi, ‘Life Time Achievement Award’ from Delhi Medical Association and ‘Distinguished Physician Award’ from Association of American Cardiologists of Indian Origin, USA. He has also been conferred ‘Honorary Fellowship’ of the National Academy of Medical Sciences for his achievements in medical profession.

As many as 30 million people in India currently suffer from heart diseases. Three-fourth of them will not be aware of their ailment. By 2010, one million Indians are expected to be patients of this killer disease. And by 2015, heart disease is likely to be the single largest cause of death in the country.

According to Professor D. S. Gambhir, while in the West heart attacks have halved, the number of heart attacks in India is rising very fast. “We have the highest rate of mortality and morbidity from heart attacks in the world,” adds Dr Gambhir.

Dr Gambhir has a special word of caution for patients and teachers in respect of rheumatic fevers and sore throats, which lead to rheumatic heart disease among the children and the young. Doctors at primary health care centres, according to Dr G. S. Gambhir, should diagnose pharyngitis, institute primary prophylaxis, recognise rheumatic fever and start early treatment among children and young Indians, who have five to 10 fold higher incidence of heart attacks, comparatively.

As the coronary heart disease is assuming epidemic proportions in India, the onus is on the government to ensure proper medical facilities for the treatment of large sections of people in which according to Dr Gambhir private sector and NGOs could also contribute significantly.

“Junk food, tobacco use, high blood pressure, diabetes, sedentary habits, tensions of urban life style and liquor, if consumed in large quantity and over a long period, are the main contributing factors for this ailment,” Dr Gambhir said. We need to mount intensive awareness campaigns in the country, besides creating more and more facilities for the treatment of the killer disease,” feels Professor Gambhir.

Excerpts:

What is the current scenario regarding incidence of heart ailments in India?

Heart diseases and heart attacks have assumed epidemic proportions in India over the past two decades. It is one of the leading causes of death and long term disability. Based on the available trends, death due to heart diseases would double by the year 2015 and become the single largest contributor to mortality, accounting for almost one-third of all deaths. The prevalence of heart attacks is approximately 11 percent in city population and for percent in rural areas. At present, at least 30 million people are suffering from heart disease in India, which is expected to become 100 million by the year 2010.

Not only the incidence of heart attacks is increasing significantly, but the blockage of coronary arteries also manifests at least a decade earlier than other populations. Every sixth patient with heart attack is below 40 years of age. Young Indians have a 5-10 fold higher rate of heart attacks and death as compared to western population and have extensive disease with severe attacks and higher complications rates.

Do we have enough medical facilities to cope with the number of heart patients?

We do not have adequate medical facilities to cope with the number of heart patients in our country. The global burden data shows that the number of patients with blockages in coronary arteries in our country is about 30 million. Of these, only a fourth would be aware of their disease, and receive treatment for their heart disease. Even in metros such as Delhi, for a population of 12 million, there are only 15-16 specialised cardiac centres, which are equipped to provide all types of treatment for heart patients. The scenario is no better in other towns and cities of our country.

What are the main causes of heart problem and why is it on the increase?

The most important reason for increasing incidence of heart disease and heart attacks in our country appears to be a combination nature and nurture — of genetic predisposition (nature) and urbanisation with affluence (nurture). Genetic predisposition can be seen by increased levels of Lipoprotein (a), which is higher in Indians than Americans. Given the genetic predisposition, harmful effects of environment are highly magnified.

When people move into an urban environment, they become sedentary and adopt western lifestyle. There is decreased physical activity and increased consumption of calories and saturated fats, which result in obesity, insulin resistance and atherogenic lipid abnormalities, all of which have a synergistic effect with Lp (a).

High Lp(a), high triglyceride, high levels of bad cholesterol and low levels of good cholesterol predispose to heart disease and heart attacks.

Is the increase in incidence of heart problem a worldwide phenomenon?

Indians all over the world have the highest rate of morality and morbidity from heart attacks. Whereas the incidence of heart attacks have halved in the west during the past 30 years, the rates have markedly increased among Indians. When compared to Whites, Blacks, Hispanics and other Asians, heart attacks among Indians are two to four fold higher and 5-10 folds higher in the young individuals (less than 40 years) irrespective of gender, religion and social class. The high rates of heart attacks in Indians are in sharp contrast to very low rates in other Asians such as Japanese and Chinese.

Is the incidence of heart problem especially among young and children alarming? What can the parents, teachers, doctors and society as a whole do about it?

The most common form of heart disease, which affects children and young adults in our country, is rheumatic fever and rheumatic heart disease. The role of parents lies in attending to sore throat, fever and joint pains in children immediately by consulting their family physician. These are the early manifestations of rheumatic fever, which are often neglected by the parents.

The role of teacher lies in coordinating between school and medical personnel in arranging school surveys wherein children with the streptococcal sore throat can be identified and treated. Doctors at primary health care centres should be able to diagnose pharyngitis, institute primary prophylaxis, recognise rheumatic fever and start early treatments.

Local medical associations should be involved in community-based surveys, treatment and secondary prophylaxis. Research all over the world is underway for the development of streptococcal vaccine, which is useful in primary prophylaxis.

How can we combat this situation: awareness, diet and treatment? Particularly in remote areas as heart attack quite often needs immediate treatment.

We have to make large public awareness campaigns. Public should be told about the risk factors for heart attacks and their prevention. Primary preventive measures should be undertaken in those with risk factors but without established disease e.g. counselling for tobacco use, early diagnosis and treatment of high blood pressure, diabetes mellitus and dietary measures to treat lipid abnormalities. All these are extremely important in those individuals who have a strong family history of heart disease, angina and heart attacks. Secondary prevention measures should be taken in those with established heart disease to modify their risk factors.

The family physician should be trained to recognise signs, symptoms, and ECG evidence of heart attack, institute first-aid measures and prompt referral to a hospital where definitive therapy can be given immediately. As coronary heart disease is assuming epidemic proportions, the government must ensure that such facilities are available to a large section of our population. The government along with corporate sector should attempt to create enough facilities, at least in large cities to cater to the increasing prevalence of heart diseases.

Is it a fact that economically weaker sections are prone to heart problem? If so why and what can be done for it?

People among economically weaker sections are equally vulnerable to heart attacks. It is believed that low nutrition and low birth weight among undernourished Indian women could be an important contributing factor for development of heart disease. Tobacco use is high in lower socio-economic strata and should be discouraged through awareness campaigns. Also, patients should be made to recognise symptoms and seek advice at the earliest occurrence of symptoms of heart attack.

Do we have world class facilities to treat heart ailments in India?

The facilities for treatment of heart attacks in India are as good as anywhere else in the world. These include angiography, angioplasty and stenting and by-pass surgery. In fact, many of the Indian heart specialists, particularly interventional cardiologists, are regularly invited to perform live demonstration of angioplasties in international conferences.

Treatment of heart problems is a costly proposition. What role in your opinion, the Government, the private hospitals and NGO can play in helping the poor heart patients?

Government should improve the infrastructure in government hospitals so that the state-of-the-art equipment as well as expertise is available for treatment of heart diseases and heart attacks. All medical professionals having essential qualification to treat heart patients should be given training in specialised procedures.

Besides, paramedics should be trained to provide emergency treatment at the doorstep of patients. This service could especially be great help in smaller towns and remote places. Private hospitals should treat a certain percentage of patients at highly subsidised rates.

NGOs should come forward and arrange money through voluntary agencies for helping the poor and needy patients. Insurance companies could come forward in a big way and provide health insurance cover to every citizen at affordable cost.