CAD IN ASIAN INDIANS

    This is the last one of the blog entry for 2023. I had gone on a vacation with group of people and one of the friends who was with us, had a phone call and he lost his young cousin to CAD. This struck me and thought that I will do one blog on CAD - coronary Artery Disease in  Indians. 

   The incidence of CAD id 2.5 % in US while prevalence of CAD for Indians in India is 11% if they do not have Diabetes and is 21.4% if they have diabetes. Usually the prevalence reduces from the country of origin but stays higher than Americans when one emigrates ,but with Indians that has not been the story. In UK it is 2-3 times that of national average. In Singapore the heart attack rate is 3 times higher than Chinese and in California hospitalization is 4 times that of white Americans. In rural India the prevalence is 6% in ages 34 to 64 years and in urban it is double that. This is same as Indians in US. 

   We all know the risk factors -obesity, smoking, hypertension, diabetes and lipids -metabolic syndrome. But they don't show as to why the CAD is that malignant in Indians . More than 50 % of the deaths due to CAD occur in patients less than 50 years of age and 25% of the heart attack patients are less than 40 years old  When one looks at BMI - Body Mass Index the BMI  is slightly higher than 25 -the upper cutoff of overweight in Urban areas while in rural area the BMI is 20., But the abdominal obesity -love handles is much higher in urban area Indians The waist to hip ratio is one way to know this abdominal obesity. It is 0.99 in urban area and in rural area it is 0.95. This causes type 2 diabetes and lipid problems and insulin resistance. The Visceral fat -the fat around organs in belly - can be assessed by doing MRI . But the waist to hip ratio can predict it quite well. Doing high intensity exercise prevents the CAD and most Indians do not do it.

   Type 2 diabetes in US prevalence is 5.3% while that in Indians in US it is 18 %.Indians in India it is 12 - 14% So somehow type 2 diabetes  is much higher in Asian Indians in US.50 % of Indians are vegetarian but we tend to consume more fats -butter -ghee - cheese and paneer. We eat less fruits and vegetables  and tend to REUSE OIL. Kerala has highest incidence of CAD attributed to excessive use of coconut oil. 

   Smoking is less prevalent in Indians in US  and also hypertension is also less prevalent in Indians in US But type 2 diabetes- insulin resistance is higher  and also lipid abnormality is more problem. Indians have less of 'good cholesterol' called HDL and increased of 'bad cholesterol ' called LDL we have increased triglyceride. and Lipoprotein a.

   Inflammatory markers like CRP is higher in Indians Homocysteine is also elevated  and certainly there are genetic factors .

  So, Indians are mildly overweight with more abdominal fat, have low HDL and high LDL and triglyceride and lipoprotein a  and do less exercise . We have more working hours  and more stress  and have more inflammatory markers. We also have type 2 diabetes  and also use too much fats , less fruits and vegetables and less exercise. Some of us have bad genes. 

   We can change some factors and some we cannot. I do not need to tell you what you can change.

AS WE START 2024 HOPE WE CAN CHANGE THIS.

HOW DO YOU DECIDE?

   We have all known the difficulties in diagnosing some diseases or even simple disease which may not show typical signs or symptoms of the disease. But when one knows the diagnosis and still have problem in making decision. This is due to circumstances that are there. I am talking about that kind of situation today. 

   I had known and seen this patient for  many years. She was elderly and had mild asthma and had h/o breast caner. She was doing fine . She was quite stable till she had COVID , She was admitted to hospital  and had pneumonia and had need for oxygen . With usual treatment for COVID she did well and was discharged . But then was readmitted for irregular heart beats. She was seen by cardiologist. And medications were adjusted . She did OK but continued to have problem with heart rate .She had this problem in past and had been on blood thinner but then had gastrointestinal bleeding and  so she was taken off the blood thinner. She was discharged and readmitted  and the story repeats . The next admission to hospital she had developed fluid around her both lungs and needed oxygen supplementation. I saw her  and then decided to take the fluid out with catheter to get her better quickly as she was on diuretics - water pill . She did better , but had another echocardiogram - ultrasound of the heart and that showed that one of her heart valves was not working well and had elevated pressure in lungs called pulmonary hypertension. So the cardiologist decided -this time to talk to her about surgical repair. Certainly now a days there are less invasive surgeries to repair such valves , but it is still surgery and she would need additional invasive work up . She would need TEE Ultra Sound of heart looking by putting a probe in esophagus  and then checking the coronary arteries by doing cardiac catheterization. Though not much invasive these procedures do carry a risk. And if  heart catheterization shows' blockage then she will need intervention like stent  and she will need to be on blood thinner . If the blockage is significant that it cannot be fixed with stent ,then will need bypass surgery. So the question that I have is SHOLD WE DO THE WORK UP OR NOT ? And if needs arise for major surgery , should we do it ? Not an easy decision.