1. CORONARY HEART DISEASE IN
INDIA
By Dr Ajay Goyal
P.G.3rd year
Deptt. Of Community Medicine
S.S.M.C. Rewa (M.P.)

2. Coronary artery disease
• It is impairment of the function of the heart due
to inadequate blood flow to the myocardium as a
result of obstruction in the coronary circulation
• CAD is manifested in any of the following
.Angina pectoris of effort.
.myocardial infarction.
.Irregularities of the heart.
.Cardiac failure.
.Sudden death.

3. • CAD is the leading cause of death in developed
countries accounting for 25 to 30 % of total death
• In India increases the incidences of CAD because
of changes in the life –style and behavior pattern
of the people.
• Incidence is 2-3 times greater in urban areas than
rural areas.
• CAD is one and half times more among men then
women.
• Incidence is maximum in the age group of 50 to
60 years.

4. The Prevalence of Coronary Heart
Disease (CHD) “ HEART ATTACK” is rapidly
increasing in India
It has become an “ EPIDEMIC”.
It is a major contributor for mortality and
morbidity.

5. It is expected that deaths due to
HEART ATTACK will double in the next 10
years
The death rate due to heart attack
will be 295 per 1,00,000 population in
the year 2015.

6. • CAD is a local manifestation of progressive and
generalized disorders of the arteries namely
atherosclerosis.
• Disease is produced from the blockage of the
lumen of the coronary arteries.
• A plague is formed inside the arteries which
gradually grows to form a thrombus that fills
up the lumen and causes obstruction to the
flow of blood.

7. Angina
• Angina is a type of chest
discomfort caused by
poor blood flow
through the blood
vessels (coronary
vessels) of the heart
muscle (myocardium).

8. Predisposing Factors
• Non Modifiable
.Age –Incidences of CAD is high above 50 years
and maximum between 50 to 60 years of age
. Sex- More among men than women
.Family history – CAD has been seen to run in
families
.Genetic factors – play a role indirectly by
determining the total cholesterol and LDL levels

9. Modifiable Risk Factors
• Hypertension – increases the risk of CAD by accelerating
the atherosclerotic process
• Serum cholesterol- increase in cholesterol level increases
the risk of CAD . Threshold level is 220 mg/dl beyond which
the risk increases.
• Cholesterol is associated with the atherosclerosis of
peripheral vessels resulting in intermittent claudication
rather than CAD
• The ratio of LDL to HDL is more than 5 indicates the risk
• The level of plasma apolipoprotein –A1 (a fraction of HDL
protein)and apolipoprotein-B(a fraction of LDL protein
)are better predictors of CAD than HDL and LDL cholesterol

10. Smoking
major risk factor
• CO(Carbon Mono-Oxide), induces
atherogenesis
• Nicotine stimulates the release of adrenaline
resulting hypertension
• Nicotine also increases myocardial oxygen
demand and decrease HDL level
• Risk is directly proportional to No. of
cigarettes smoking per day and duration of
exposure.

11. • Serum homocystine –more than 15.5 mol/litre
damages the intima of the arteries thus causes
CAD.
• Diabetes mellitus –risk of CAD 2 to 3 times higher
than non diabetes.
• Obesity –increases CAD because of its association
with LDL cholesterol level HTN, and Diabetes.
• Hormones –hyper-estrogenemia favours
development of CAD. Means OC pills may causes
CAD.

12. • Type A personality –Chaterised by
competitive drive , restlessness
impatience, irritability, short temper ,sence of
urgency, overthinking etc are higher risk of
CAD than calmer type B personality people.
• Alcohol – CAD iscommon in heavy drinkers
• Soft water –incidence is higher than those
consuming hard water

13. • Noise –chronic exposure to noise over 110 db
increases serum cholesterol level thus the risk
of CAD.
• Drugs –misuse of fenfluramine and
phentermine used for weight reduction can be
damaging to the heart.

14. PATTERN OF CHD IN INDIANS :-
1. Heart attacks occur in Indians 10-15
years earlier than the western population
2. Malignant coronary artery disease
3.  Multivessel disease and left main
coronary artery disease
4. Smaller Coronary arteries?

15. Tests
• Many tests help diagnose CHD. Usually, your doctor will order more than
one test before making a definite diagnosis.
• Electrocardiogram (ECG)
• Exercise stress test
• Echocardiogram
• Nuclear scan
• Electron-beam computed tomography (EBCT) to look for calcium in the
lining of the arteries -- the more calcium, the higher your chance for CHD
• CT angiography -- a noninvasive way to perform coronary angiography
• Magnetic resonance angiography
• Coronary angiography/arteriography -- an invasive procedure designed to
evaluate the heart arteries under x-ray

16. Prevention
• Avoid or reduce stress as best as you can.
• Don't smoke.
• Eat well-balanced meals that are low in fat and cholesterol and include
several daily servings of fruits and vegetables.
• Get regular exercise. If your weight is considered normal, get at least 30
minutes of exercise every day. If you are overweight or obese, experts say
you should get 60 - 90 minutes of exercise every day.
• Keep your blood pressure below 130/80 mmHg if you have diabetes or
chronic kidney disease, and below 140/90 otherwise
• Keep your cholesterol and blood sugar under control.
• Moderate amounts of alcohol (one glass a day for women, two for men)
may reduce your risk of cardiovascular problems. However, drinking larger
amounts does more harm than good.

17. Diatery changes
• Consumption of saturated fats should be less
than 10% of total energy intake.
• Average intake of cholesterol should be less than
300mg/day/adult.
• Serum cholesterol level should be less than
200mg/dl
• Consumption of carbohydrates must be
proportionately increased.(vegetables, fruits
whole grains and legumes)
• Avoidance of alcohol consumption ; reduction of
salt intake to 5gm daily or less.

18. Key ways to help prevent heart
disease:
 Don’t smoke or use tobacco products
◦ Tobacco smoke contains more than 4,800 chemicals; many of which can
damage your heart and blood vessels
◦ The goal should be to achieve a smoke free society
◦ By effective information, educational activities ,legislative
restrictions,smoking cessation programmes.
 Get active
◦ Exercise
◦ Gardening
◦ Taking the stairs
 Eat a heart-healthy diet
◦ Research shows that fruits, vegetables, whole grains and low-fat dairy
products that can help protect your heart

19. Key ways to help prevent heart
disease:
• Maintain a healthy weight
– excess weight can lead to conditions that
increase your chances of heart
• Get regular health screenings
– Blood Pressure
– Cholesterol Levels
• Stress-free
– Relax
– Smile

20. Ways to Prevent Obesity
• Order off the children’s menu
• Limit the amount of time watching TV
• Have six small nutrient-dense meals a day.
• Changing up your orders at fast food
restaurants
• Reduce weight approx 10% from baseline.
Then reduce weight at a rate of about half to
one kg per week for 6 months.

21. HOW MUCH PHYSICAL ACTIVITY IS
ENOUGH?
30 to 60 minutes, on most
days of the week, at 50-80
percent of your maximum
capacity.

22. Blood pressure
• Even a small reduction in the BP of the whole
population by a mere 2 or 3 mm hg would
produce a large reduction in the incidence of
cardivascular complications.
It can be controlled by multifactorial approach
based on prudent diet (reduced salt intake
and avoidance of high alcohol intake ),regular
physical activity and weight control.

23. High risk strategy
• Identifying risk: by measuring BP, serum
cholesterol ,and taking ECG of high risk
patients
• Specific advice: those who have high BP
should be treated ,the patient should be
helped to break the smoking permanently –
nicotine chewing gum can be tried to wean
patients from smoking.

24. Treatment of CAD
• Aspirin. Taking a small (75 mg) daily dose of
aspirin makes your blood less likely to form
clots in your coronary arteries and reduces
your risk of having a heart attack.
M/A of asprin –inhibits the synthesis of
prostaglandins notably thrombaxane A2,a
potent vasoconstrictor and platelet activator .
• Statins. These drugs help to lower your
cholesterol levels and so slow down the
process of atherosclerosis.

25. • Beta-blockers. These drugs slow your heart
rate and reduce the pumping power of the
heart. This reduces your heart's demand for
oxygen. Beta-blockers also widen blood
vessels helping to lower blood pressure.
• ACE inhibitors. These drugs are often used in
people with heart failure or after a heart
attack. They lower your blood pressure.

26. Surgery
• Angioplasty (also known as percutaneous
coronary intervention or PCI). In this operation a
collapsed balloon is threaded through the blood
vessels until it reaches the arteries of the heart.
The balloon is inflated to widen the narrowed
coronary artery. A stent (flexible mesh tube) is
sometimes inserted to help keep the artery open
afterwards. The stent sometimes releases a drug
that helps to keep the blood vessel open. You
should be able to go home the day after the
operation.

27. • Coronary artery bypass graft (CABG). In this
operation, the surgeon takes a piece of blood
vessel from your leg or chest and uses it to
bypass the narrowed coronary arteries. The
bypass provides the heart with more blood.
This is open-heart surgery and requires a
longer stay in hospital.

28. Indications for coronary artery
revascularization
1. Pt .with unacceptable symptom despite medical
therapy to its tolerable limit.
2.pt. with left main coronary artery stenosis greater then
50% with or without symptom.
3.Pt. with three vessel disease with left ventricle
dysfunction (ejection fraction <50% or previous
transmural infraction).
4. Pt .with unstable angina who after symptom control by
medical therapy continue to exhibit ischemia on
exercise testing or monitoring .
5. Post myocardial infraction pt. with continuing angina or
sever ischemia on non invasive testing.