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Disease Burden of Cardio-vascular

Diseases and Risk factors Prevention

Dr Rishi Sethi


Department of Cardiology
KGs Medical University Lucknow. India
Chairman and Convener -National ST Elevation MI Sub
Specialty Council
Member of Scientific Committee of Asia Pacific Society of
Interventional Cardiology

Global Life Expectancy

Life expectancy
71.4 years was the average life expectancy at
birth of the global population in 2015.
Healthy life expectancy
Healthy life expectancy at birth was 63.1 years
globally in 2015.
Global average life expectancy increased by 5
years between 2000 and 2015, the fastest
increase since the 1960s.
Global Health Observatory (GHO) data, WHO 2016

Global Mortality from Coronary

Artery Disease

Relative Mortality Rates

Economic Burden of
Cardiovascular Diseases

Four non-communicable disorders (NCD) together contribute

59% of global mortality (31.7 million deaths) and
43% of the global burden of disease in.
The Cardiovascular diseases alone accounts for 34% of all
deaths in women and 28% in men.
The World Health Report estimates that in 85% of the CV
burden arose from the low and middle income countries.

The World Health Report. Making a Difference. Geneva: World Health

Organization; 1999.

Cardiovascular diseases

Risk factors

In Terms of Attributable
Raised blood pressure (13 per cent of global
deaths is attributed),
Tobacco use (9 per cent),
Raised blood glucose (6 per cent),
Physical inactivity (6 per cent) and
Overweight and obesity (5 per cent).

Global Atlas on Cardiovascular Disease Prevention and Control.

Mendis S, Puska P, Norrving B editors. World Health Organization (in
collaboration with the World Heart Federation and World Stroke
Organization), Geneva 2011.

Modifiable Risk Factors for CV Diseases

CVD worldwide is largely driven by modifiable risk
Metabolic Syndrome
Mental Stress

Hypertension (high blood pressure)

Globally, nearly one
billion people have
The silent killer"
because it often has
no warning signs or
People with
hypertension are more
likely to develop
complications of
World Health Organization. Regional Office for Southeast Asia.
Hypertension fact sheet

Encourage an optimal blood pressure of less then

120/80 mm Hg through lifestyle approaches.
Pharmacologic therapy is indicated when blood
pressure is > 140/90 mm Hg

The Great Indian B.P. Survey Initial

The Cardiological Society of India organized a big
nationwide BP Survey on 21st September 2015
over a 8 hours period
Total sample size: 74,520
24 States of India
> 100 Cities
> 700 sites
Public and private hospitals
> 100 National Coordinators
> 7500 Volunteers and paramedics

Overall prevalence of Hypertension*

33% of people found
to be hypertensive
Indicating the need for
aggressive cardiopreventive measures



*Repeated measurements of blood pressure were

taken before diagnosing the subjects with HTN

Age-wise distribution of
Total Hypertensives: 24,502




18-30 years
31-45 years
46-60 years
Above 60

With 1/4th of
people with HTN
falling between
31-45 years, it
can no longer be
called an old age

Even Hypertension
strikes early among

Undiagnosed Hypertension
Total Hypertensives: 24,502


More than 60% of

people with HTN
were unaware that
they are
coming as evidence
of lack of
awareness and
Diagnosed good screening

Uncontrolled Hypertension
Total Hypertensives on medication: 8,060

medications, 42%
of hypertensive
people had
uncontrolled blood
pressure, putting
them at high risk
for heart disease



One third of Indians above 18 years have hypertension
Even Hypertension strikes early among Indians
2/3 of the people with high BP are not aware of their
Nearly half of known hypertensive people are not well
Other risk factors are commonly prevalent among

Tobacco use
Cause nearly 10 per cent of all CVD.
Higher risk in female smokers, young men, and
heavy smokers.
Currently about 1 billion smokers in the world
Within two years of quitting, the risk of coronary
heart disease is substantially reduced, and within
15 years the risk of CVD returns to that of a nonsmoker
KK, Ounpuu S, Hawken S, et al. INTERHEART Study
Investigators. Tobacco use and risk of myocardial infarction in 52
countries in the INTERHEART study: a case-control study. Lancet.

"Poor man's risk factor": correlation between high

sensitivity C-reactive protein and socio-economic class
in patients of acute coronary syndrome.
Sethi R1,Puri A,Makhija A,Singhal A,Ahuja A,Mukerjee S,
Dwivedi SK,Narain VS,Saran RK,Puri VK.
Indian heart Journal 01/2008;60(3):205-9
Inflammation has been proposed as one of the factors responsible for the development of coronary artery disease (CAD)
and high sensitivity C-reactive protein (hs CRP) at present is the strongest marker of inflammation. We did a study to assess
the correlation of hs-CRP with socio-economic status (SES) in patients of CAD presenting as acute coronary syndrome (ACS).
Baseline hs-CRP of 490 patients of ACS was estimated by turbidimetric immunoassay. Patients were stratified by levels of
hs-CRP into low (<1 mg/L); intermediate (1-3 mg/L) or high (>3 mg/L) groups and in tertiles of 0-0.39 mg/L, 0.4-1.1 mg/L and
>1.1 mg/L, respectively. Classification of patient into upper (21.4%), middle (45.37 percent) and lower (33.3%) SES was based
on Kuppuswami Index which includes education, income and profession. Presence or absence of traditional risk factors for
CAD diabetes, hypertension, dyslipidemia and smoking was recorded in each patient.
Mean levels of hs-CRP in lower, middle and upper SES were 2.3 +/- 2.1 mg/L, 0.8 +/- 1.7 mg/L and 1.2 +/- 1.5 mg/L,
respectively. hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0.033) and middle SES (p
= 0.001). Prevalence of more than one traditional CAD risk factors was seen in 13.5%, 37.5% and 67.67 percent; in patient of
lower, middle and upper SES. It was observed that multiple risk factors had a linear correlation with increasing SES. Of the
four traditional risk factors of CAD, smoking was the only factor which was significantly higher in lower SES (73%) as
compared to middle (51.67 percent;) and upper (39.4%) SES. We found that 62.3%, 20.8% and 26.5% patients of low, middle
and upper SES had hs-CRP values in the highest tertile. Median value of the Framingham risk score in low, middle and upper
SES as 11, 14 and 18, respectively. We observed that at each category of Framingham risk, low SES had higher hs-CRP.
We conclude from our study that patient of lower SES have significantly higher levels of hs-CRP despite the fact that they
have lesser traditional risk factors and lower Framingham risk. These findings add credit to our belief that inflammation may
be an important link in the pathophysiology of atherosclerosis and its complications especially in patients of low SES who do
not have traditional risk factors.

Raised blood glucose (Diabetes)

CVD accounts for about 60 per cent of all mortality in people with
Lack of early detection and care for diabetes results in severe
complications, including heart attacks.
Primary care access to measurement of blood glucose and
cardiovascular risk assessment as well as essential medicines
including insulin can improve health outcomes of people with diabetes.
Target HbA1C<7%, if this can be accomplished without significant

Global Atlas on Cardiovascular Disease Prevention and Control. Mendis

S, Puska P, Norrving B editors. World Health Organization (in
collaboration with the World Heart Federation and World Stroke
Organization), Geneva 2011.

Globally, one third of ischaemic heart disease is
attributable to high cholesterol.
Prevalence of raised total cholesterol among
adults is around 9.7 percent.
Global prevalence of raised total cholesterol
among adults was 39 percent.

Indians are Different..

Indian Heart J. 2002;54:59-66

Lancet 2000;356:279-84

Emerging risk factors

Unhealthy diet
Lack of exercise
Stress and depression
Obstructive sleep apnea

Overweight and obesity

Worldwide, at least 2.8 million people die each year as a
result of being overweight or obese.
In 2012, 34 percent of adults over the age of 20 were
To achieve optimal health, the median BMI for adult
populations should be in the range of 2123 kg/m2.
Weight loss of as little as 10 lbs reduces blood pressure.

The World Health Report. Making a Difference. Geneva: Wor

Health Organization.

Unhealthy diet

dietary intakes of
Saturated fat,
Trans-fats and salt, and
Low intake of fruits, vegetables and fish are
linked to cardiovascular risk.

WHO recommends a population salt intake of less

than 5 grams/person/day to help the prevention
of CVD.
Elimination of trans-fat and replacement of
saturated with polyunsaturated vegetable oils
lowers coronary heart disease risk.

Physical inactivity
Defined as less than five times 30 minutes of
moderate activity per week, or less than three times
20 minutes of vigorous activity per week, or
Approximately 3.2 million deaths and each year are
attributable to insufficient physical activity.
20 to 30 per cent increased risk of all cause mortality
compared to those who are physically active.
Higher prevalence in high-income countries.

Current guidelines call for moderate exercise for

at least 30 minutes five or more days a week, a
vigorous exercise 20 minutes 3 days a week.
Gallups November 2011 poll found that 51.6%
adults is USA say they exercise three or more
times a week. These numbers have remained
unchanged since 2008.
Physical inactivity levels are similarly high in
other parts of world.

Stress and depression

Stress and depression almost double the risk of
coronary artery disease in previously healthy
psychological stress was associated with vascular
risk in all regions of the world, in both sexes and
in all ethnic groups.

Obstructive sleep apnea

Sleep-related breathing disorders are highly
cardiovascular disease.
Obstructive sleep apnea (OSA) affects a large
proportion of patients with hypertension and in
those with other cardiovascular disorders.