New research published in The Lancet finds that India will bear 60% of the world’s heart disease burden in the next two years. In addition, researchers have determined that compared to people in other developed countries, the average age of patients with heart disease is lower among Indian people and Indians are more likely to have types of heart disease that lead to worse outcomes.

The leading cause of death in the world is ischemic heart disease, a condition characterized by reduced blood supply to the heart that is usually due to coronary artery disease. In 2001 alone, some 7.1 million deaths were attributed to ischemic heart disease, 80% of which were in relatively poor countries. Medical and public health professionals expect that in developing countries, there will be a 137% and 120% increase in the disease for males and females, respectively, whereas these predictions lie in the 30% to 60% range for developed countries.

To further investigate how the disease is affecting India, Dr. Denis Xavier (St John’s National Academy of Health Sciences Bangalore, India), Professor Salim Yusuf (Health Research Institute, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada) and colleagues performed a prospective registry study of almost 21,000 patients (the CREATE study) from 89 centers, 10 regions, and 50 cities in India. The participants fit into two categories: Some had suspected acute heart attack along with changes in their electrocardiograph (ECG), indicating STEMI (ST Elevated Myocardial Infarction, giving a definite heart attack diagnosis), non-STEMI, or unstable angina; others had suspected heart attack, prior indication of ischemic heart disease, but no changes in ECG. A diagnosis of STEMI is a worse prognosis since it means that there is greater damage to the heart.

Xavier and colleagues found that 60% of the 20,468 patients who received a definite diagnosis had STEMI, compared to the rate in developed countries of less than 40% (including the European Heart Surveys). The average age of patients in Indian was 60 years, which is younger than the range in developed countries of 63 to 68 years. As approximately 75% of CREATE patients were categorized as being from lower middle class and poor backgrounds, it proved difficult for them to afford routine hospital treatments and secondary prevention. Compared to the 140 to 170 minutes that it takes for people in developed countries to get to the hospital, it takes Indians an average of 300 minutes. This time difference is due to traffic delays, use of public/private transport rather than the ambulance, and a lack of awareness of symptoms.

Medical practice patterns were also found to be quite different in India compared to developed countries. Percutaneous coronary intervention (such as balloon angioplasty) rates were found to be lower in India than developed countries, and thrombolytic treatment (such as streptokinase) rates were found to be higher than in developed countries. The researchers write that, “This is probably because about three quarters of patients in India pay directly for their own treatments.”

Indian physicians, on the contrary, have demonstrated awareness of evidence-based treatments, as noted by the similarities with developed countries in the usage rates of important medical treatments such as antiplatelet drugs, β blockers, ACE inhibitors and lipid-lowering drugs. This also highlights the relative inexpensiveness of generic drugs in India. With the exception of antiplatelet drugs, the authors found that treatments were not consistent among socioeconomic groups – fewer poor patients received proven life-saving treatments.

CREATE Patients with STEMI had higher 30-day mortality rates (9%) than non-STEMI patients (4%), and both of these rates were higher in India than in developed countries. Poor patients had the highest mortality rates, and the rates decreased as socioeconomic status improved.

“Patients with acute coronary syndromes in India tend to be young and from low socioeconomic groups, and to have a higher rate of STEMI than do patients in developed countries. They also receive less medical attention late and proven therapies less often. Because poor patients are less likely to get evidence-based treatments, they have higher 30-day mortality than others. Therefore, strategies to reduce delays in access to hospital, and to improve the affordability of urgent care could reduce morbidity and morality from acute coronary syndromes in India,” conclude the authors.

A Comment accompanying the study and written by Professor Kim Eagle (University of Michigan Medical Centre, MI, USA) notes that rates of cardiovascular mortality have decreased in developed countries that have successfully implemented public health initiatives – such as raising tobacco taxes and educating the public about diet – focused on reducing risk factors of heart disease. Eagle says: “There is no reason why similar results cannot be achieved in India and elsewhere.”

Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data
D Xavier, et al.
The Lancet (2008). 371[9622]: pp. 1435 – 1442.
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Written by: Peter M Crosta