60 percent of world's heart disease in India by 2010 -- where it hits younger and has worse outcomes

Within two years, around 60% of the world's heart disease burden is expected to occur in India. Further, India has a higher rate of types of heart disease that lead to worse prognoses than do developed countries, and on average heart disease occurs at a younger age in Indian people. These are the conclusions of authors of an Article published in this week's edition of The Lancet.

Ischaemic heart disease is the leading cause of death globally. In 2001, the disease accounted for 7.1 million deaths worldwide, 80% of which were in low-income countries. Between 1990 and 2020, these diseases are expected to increase by 137% for men and 120% for women in developing countries, compared with 30-60% in developed countries.

Dr. Denis Xavier , St. John's National Academy of Health Sciences Bangalore, India, and Professor Salim Yusuf, Health Research Institute, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada, and colleagues did the CREATE study -- a prospective registry study in 89 centres from 10 regions and 50 cities in India, which looked at almost 21000 patients. The patients had either suspected acute heart attack with definite electrocardiograph (ECG) changes (whether elevated ST [STEMI]* or non-STEMI or unstable angina) or suspected heart attack without ECG changes but with prior evidence of ischaemic heart disease. STEMI diagnosis means a worse prognosis because it is associated with greater damage to the heart.

They found that of the 20468 patients given a definite diagnosis, 60% had STEMI -- which compares with less than 40% in developed countries, including the European Heart Surveys. And with a mean age of 60 years, these Indian patients were younger than those in developed countries (63-68 years). Three quarters of patients in CREATE were from lower middle class and poor backgrounds and were less likely to be able to afford routine treatments in hospitals and for secondary prevention. Time taken to reach hospital was much longer in India (300 mins) than in developed countries (140-170 mins). Reason for delays included using public/private transport instead of ambulance, traffic delays, and lack of awareness of symptoms.

The authors also found major differences in practice patterns in India compared to developed countries. Rates of percutaneous coronary intervention** were lower and thrombolytic treatment (eg, streptokinase) higher than in developed countries. They say: "This is probably because about three quarters of patients in India pay directly for their own treatments." However, use of key medical treatments such as antiplatelet drugs, B blockers, ACE inhibitors and lipid-lowering drugs were similar to that in developed countries, showing awareness of evidence-based treatments by Indian physicians, and also the relatively low cost of generic drugs in India. But use of all treatments except antiplatelet drugs differed across socioeconomic groups and fewer poor patients received treatments proven to save lives. 30-day mortality rates in the CREATE study were higher for STEMI (9%) than non-STEMI (4%), but both these rates were higher than the corresponding rates in developed countries. Morality in CREATE was highest in poor patients, with a gradient across socioeconomic classes.

The authors conclude: "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."

In an accompanying Comment, Professor Kim Eagle, University of Michigan Medical Centre, MI, USA, discusses the success in developed countries of government strategies to reduce the impact of risk factors. For example, both increasing tobacco taxes and education programmes on diet have reduced cardiovascular mortality. He says: "There is no reason why similar results cannot be achieved in India and elsewhere."

Notes to editors: *STEMI: An ST elevated myocardial infarction (heart attack) (STEMI) refers to part of the electrocardiogram (ST) which if raised gives a definitive diagnosis of heart attack.
**percutaneous coronary intervention: an example of this is balloon angioplasty

Dr. Denis Xavier, St. John's National Academy of Health Sciences Bangalore, India, T) +91-80-2552 6382 / +91-98861 26801 E) denis@iphcr.res.in / drdenisxavier@hotmail.com

Professor Salim Yusuf, Health Research Institute, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada T) +1 905-527-7327 E) yusufs@mcmaster.ca

Professor Kim Eagle, University of Michigan Medical Centre, MI, USA T) +1 734-936-5275 E) keagle@umich.edu