Cardiovascular disease (CVD) is one of the leading causes of mortality in India. 25 % of the all deaths are attributed to the cardiovascular diseases in India. According to The Global Burden of Disease, mortality rate of CVD is higher in India as compared to the global mortality rate. Mortality rate of cardiovascular disease is 272 per 100000 per population in Inida; however it is 235 per 100000 at global level. Among all the cardiovascular disease, Ischemic heart disease (IHD) and stroke are the major causes of death in India. Ratio of IHD to stroke mortality is higher in Indian population as compared to the global population. IHD to stroke ratio is approximately 2.0 in India as compared to the global IHD to stroke ratio of 1.2. Mode of epidemic of CVD in India is a serious issue because number of cases of CVDs are increasing very fast at early age and fatality rate is very high. Prevalence of CVD is there all over the India comprising of poor states and rural areas. It is observed that in western population 23 % mortality occur due to CVD prior to 70 yrs age, while in India 52 % mortality occur prior to this age. Fatality due to CVD is also more in India as compared to the high income countries. According to the World Health Organization (WHO) estimate there is huge economic burden on India due to cardiovascular diseases. Approximately 65 % of the burden of non-communicable disease is contributed by cardiovascular related diseases. Due to large population in India, exact cause of CVDs in rural India is not known because Global Burden of Disease estimates are mostly obtained from small community based studies. Mortality of 255–525 per 100 000 population in men and 225–299 per 100 000 population in women is observed in Indian population,.
There was significant loss in the years of life expectancy in Indian population. As compared to 1990, there was 60 % loss in years of life expectancy in Indian population due to CVDs. It was observed that prevalence of CVDs increased in urban areas as compared to the rural areas. In urban areas prevalence of CVDs increased from 2 % to 14 % from 1960 to 2013, while in rural areas it increased from 1.7 % to 7.4 % from 1970 t0 2013. Incidence of stroke is higher in Indian population as compared to the western population. In India, 154 per 100 000 population are associated with stroke and there is prevalence of stroke in women as compared to the men. Recently, burden of hypertensive cardiovascular diseases significantly increased in India. In comparison with 1990, there was 138 % increase in hypertensive cardiovascular disease in 2013 with approximately 261 694 deaths in 2013. Rheumatic heart disease is also emerging as major CVD burden in India. In 2010, approximately 88 674 deaths occurred due to rheumatic diseases with 7 per 100 000 population. As compared to the Western population prevalence of atrial fibrillation is less in India,, .
As compared to the total mortality, mortality due to CVDs is varied among women and men in different states of India and different socioeconomic class people. Reason behind this difference need to be investigated. Mortality due to CVDs is higher in women of high economic class population as compared to the men. Mortality due to CVDs is higher in women of Andhra Pradesh as compared to the men. Mortality due to CVDs is higher in men of Mumbai and Kerala as compared to the women. However, mortality of due CVDs is higher in men as compared to the women in overall population in India. At global level also same trend was observed. According to Global Burden of Diseases estimate, there is more mortality rate due to CVDSs in Global and US population, .
Prevalence of hypertension in Indian adults is 30 % with 34 % urban population and 28 % rural population. In the last two years, it was observed that there was decrease in prevalence of hypertension in Western population; however in Indian population it was increased. Prospective Urban and Rural Epidemiological (PURE) study estimated that higher prevalence of CVDs in people with low socioeconomic class may be due to the lack of knowledge about the treatment of hypertension, .
According one estimate, approximately 275 million people above age 15 years having habit of tobacco consumption. Approximately 1 million deaths per year occur due to the tobacco consumption in India. Prevalence of tobacco consumption is higher in men (24 %) as compared to the women (3 %) which is proportional to the prevalence of CVDs. Prevalence of tobacco consumption is higher in individuals with age between 20 – 35 years with lower level of education, . According to, the National Family Health Survey-3 (NFHS-3), almost 50 % population of India consume one fruit or not fruit per week, despite India is considered as the vegetarian country. Due to high cost of fruits, people in the low socioeconomic class consume less fruit as compared to the people of the high socioeconomic class. However, one survey indicated that economically prosperous people also consume very less amount of fruits and vegetables. WHO recommended consumption of more than 5 fruits and vegetables on daily basis. However, 24 % and 1 % people of states with prosperous economy like Maharashtra and Tamilnadu respectively consume WHO recommended fruits and vegetable. Prevalence of CVDs may be increased due to increase in the consumption of the fat intake. It was observed that fat consumption was increased from 24 to 36 g/d and 36 – 50 g/D in rural and urban areas respectively from 1972 to 2000. Partially hydrogenated vegetable oils containing high percentage of trans fat are higher among urban population in India. Moreover, Indian people are consuming more cooked food; hence they are getting fewer amounts of nutrients. Inadequate physical activity is also one of the risk factors responsible for the occurrence of CVDs. There is very less data available for the physical activity of Indian population, . ICMR-INDIAB conducted survey in 14227 people using Global Physical Activity Questionnaire. In this survey, it was observed that 50 % populations are physically inactive. Less than 10 % people are associated with the recreational physical activity. In this study, it was observed that physical activity was more in women in urban areas and with high socioeconomic class. However, Gupta et al. mentioned that there was no difference in the physical activity in high and low educational level people. In another study, it was mentioned that people with lower educational level are more associated physical activity. Hence, it would be difficult to get accurate data of physical activity in India due to its diverse population.
Rise in the total cholesterol, low-density lipoprotein cholesterol, non–high-density lipoprotein cholesterol, and triglycerides are mainly responsible for the more prevalence of CVDs in India. In the ICMR-INDIAB study, it was observed that most of the populations of India are associated with at least one lipid abnormality. Merely, 20 % populations of India have all the parameters like total cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein cholesterol inside the normal range. In ICMR-INDIAB study, no social status was observed in the abnormally of lipid profile of individual. However, in another study, it was observed that people with low socioeconomic class were with higher level of high density lipoprotein and low level of low density lipoprotein.
Risk factors are widely distributed among all the population of India; however, it was observed that there was geographical variation in hypertension prevalence. Prevalence of hypertension is more in northeastern states as compared to the other region. This variation might be due to the variation in the dietary practices, tobacco consumption, economic status and physical inactivity patterns. In recent studies, conducted at Mumbai and Jaipur, it was demonstrated that CVDs are no longer the disease of high socioeconomic class people, . There is no different in prevalence of CVDs in people with low socioeconomic class people and high socioeconomic class people. There may different factors responsible for the differences in prevalence of CVDs in different regions and in people with different socioeconomic classes. In one study, it was observed that mortality rate in poor is 8.2 % more as compared to the rich people. This conflicting result might be observed due to less access to medical treatment for poor people. Underdiagnosis and underreporting are also responsible for the more prevalence of CVDs in poor people.
Different states of India are at different stages of transition. Hence, it would be difficult to control diseases in all the states. Hence, developed countries controlled communicable diseases and are on rise in NCDs. However, India is suffering through double burden of both communicable and NCDs. People with age 65 years are expected to rise to 7 % in 2025 and CVDs are more prevalent in older people. Hence, demographic determinants are also responsible for the CVDs burden in India. Economic factors are shifting rural population to the urban areas. Hence, urban population is expected to rise to 40 % in 2021. This urbanization and industrialization are changing lifestyle of people and increasing biological and behavioral risk factors for the CVDs, . CVDs share highest share of total health expenditure with 15.6 %. Out-of-pocket health expenditure as inpatient is highest for CVD along with cancer treatment in India. Out-of-pocket health expenditure for hypertension is highest for medicines with 65 % out of total expenditure on hypertension management. Chronic condition of the disease requires long term treatment for CVDs; hence there is significant financial burden on the family members of CVDs patients. In a study, it was evident that 25 % families of the CVD patients experience catastrophic spending. Catastrophic hospitalization expenditures are 30 % higher in patients with CVD. Between 2005 to 2015, India lost 1.5 % of its total GDP for the prevention and management of heart disease, stroke and diabetes, .
Epidemic of CVDs is a major health burden in India. However, it can be prevented by implementation of the strategies applied in the Western population. Prevalence of CVDs can be reduced by both managing risk factors for CVDs and by medication treatment. Education about the risk factors like lipid levels, tobacco consumption and blood pressure monitoring would be helpful in preventing prevalence of CVDs. There was substantial data available; however increasing taxes on the products like tobacco, palm oil, and sugar-sweetened beverages would be helpful in reducing risk factors for CVDs. In modeling studies, it was predicted that increase in 20 % tax on the sugar-sweetened beverages would be helpful in reducing obesity and type 2 diabetes mellitus by 3 % and 2 % respectively. It was estimated that, increase in the 20 % tax on the palm oil would be helpful in reducing 1.3 % reduction in deaths due to CVDs. Reduction in salt intake by 3 g/day over a period of 30 years in young generation of India would be helpful in 5 % reduction in events and death of CVDs. Smoke free legislation and increased taxation on the tobacco products would be helpful in reducing prevalence of myocardial infarction and stroke by 25 %. With the hope of success in these prevention strategies for CVDs, Indian Government also initiated efforts in this direction. Indian Government increased taxation on tobacco products from 11 % to 72 % and on sugar-sweetened beverages by 5 %. India targeted approximately 30 % relative lessening in the consumption of salt and tobacco products by 2025. Policy modifications with change in the behavior and health promotion would be helpful in prevention CVDs, ,, .
There should be implementation of the long term prevention strategies for CVDs because short term strategies failed to give satisfactory outcome to prevent CVDs. The Union Government of India has recently initiated National Program for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke. Main agenda of this initiative is to identify risk factors, to facilitate health promotion and health education in different health settings. There was implementation of cost effective management programme for CVDs through incorporation of multidrug treatment for the prevention of primary and secondary risk factors for CVDs. CVDs are multifactorial diseases, hence treatment with multiple drugs acting on the different targets would be more beneficial as compared to the single drug treatment. This strategy resulted in reducing healthcare expenditure by 3 % and reducing mortality due to CVDs by 15 %. Though promising results obtained in this strategy, more work need to do because majority of the population still need to avails this treatment strategy. Use of a Multidrug Pill in Reducing Cardiovascular Events (UMPIRE) study revealed that administration polypill resulted in the adherence to the treatment increased by 33 % as compared to the standard treatment. This polypill strategy is useful in both primary and secondary prevention of CVDs. Treatment and outcomes of acute coronary syndromes in India (CREATE) registry revealed that in most of the population in India reporting to hospitals is approximately 4 hours late after the onset of symptoms. Hence, strategies need to be implemented to improve prompt reporting to hospitals, thus fatality can be reduced effectively, .
CREATE registry also revealed that patient with ST-segment–elevation MI received thrombolytic treatment and percutaneous coronary interventions on less than 45 % patients. This data is based on the hospitals in the urban areas. In rural areas, this data would be worse. Hence, these should be effective policy implementation for the improving access to medication for poor people. There should be implementation of quality improvement programmes in hospitals to improve medication adherence. Community health care workers should be incorporated in the hospitals to improve medication adherence and lifestyle advice. Cardiac rehabilitation would be helpful in reducing occurrence of CVDs. However, in Indian population very less data is available for the efficacy of cardiac rehabilitation techniques. There should be implementation of robust surveillance system in India. This system would be helpful in making effective policies for designing intervention strategies for CVD patients. Indian population is diverse population spread in different geographical regions and these populations are with different socioeconomic classes. Hence, accurate data should be available for each segment of population to provide intervention with respect to the risk factors of that particular population,.
Qualitative methods like surveys, interviews and data analysis should be incorporated to assess epidemiology of CVDs. Quantitative methods like observational and experimental studies should be incorporated in the assessment of epidemiology of CVD and prevention of CVD. Observational studies should comprise of cross-sectional studies, cohort studies and ecological studies. Experimental studies should comprise of controlled and non-controlled clinical trials.
There should be implementation of the knowledge based communication technology tools, task shifting and task sharing strategies for improving efficiency of care of CVDs. Mobile health (mHealth) software application is useful in collecting information about the patient’s health, supporting clinical decision making and monitoring intervention in care facility. In Andhra Pradesh, such tool was used and it proved efficient and cost-effective for the management of CVDs in care facility. This system was useful for the rural primary healthcare doctors and frontline health workers in improving their skills for the management of CVDs. Quality of the CVDs management can be effectively managed by improving number of trained and skilled health care professionals. Hence, it would be helpful in improving standards of care and reducing treatment cost, specifically in secondary and tertiary settings. More focus should be given to the quality monitoring and improvement. Research in CVD should be improved to gather valid evidence for the prevention of CVDs,. Dissemination for hypertension risk reduction (DISHA) project funded by the Indian Council of Medical Research was implemented in 120 clusters and nearly 36000 study participants. Aim of this project is to give information about diet and lifestyle management in the prevention of CVDs through Angan Wadi workers. Thus incorporation of frontline health workers like Angan Wadi workers would be helpful in giving information to the majority of the population. In the same way, community health workers should be incorporated in the management, improvement in adherence and follow-up of the CVDs. There should be implementation of universal health coverage for Indian people. India implemented Cigarette and Other Tobacco Product Act for reducing consumption of tobacco related products. According to this act, there should be prohibition of smoking at public places, display of health warning on tobacco products and prohibition of advertisement and promotion of tobacco products. Implementation of this act in India is difficult task because India is a diversified country. Only 50 % states have implemented Cigarette and Other Tobacco Product Act in India. It is evident that salt reduction strategy can be helpful in preventing CVDs. However, in India salt reduction strategy would not be helpful because salt is a vehicle for iodine supplementation, which would be helpful in reducing epidemic of iodine deficiency diseases in India. Research should be carried out on the social determinants like economics, environment and development for improving positive impact of these social determinants in the management of CVDs,.
There is urgent requirement for the implementation of primordial, primary, and secondary prevention strategies for CVD. Primordial prevention strategies should comprise of cessation of tobacco products, promotion of physical exercise and healthy dietary habits. Primary prevention strategies should focus on the assessment and management of the risk factors such as hypertension, hypercholesterolemia, and diabetes. Secondary prevention strategies should eb implemented to prevent premature mortality and morbidity.
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