No discussion on the epidemiology of heart diseases will be complete willlout a look at the tremendous burden put by different heart diseases at vasious levels. In this the CAD occupies the prime place. In fact CAD is called greatest killer not only because of the absolute numbers of those affected but also for the strain it imposes on resources and disruption in economic and social fronts.
Healthcare Burden
CAD and its complications use up a substantial portion of the scarce healthcare resource of the country. It has been reported that CAD formed 5-20 per cent of all heart disease admissions in big hospitals in Delhi, Mumbai and sbinc other cities.In 1971-75 CAD was present in 16.5 per cent of all heart disease cases seen in AIIMS and that rose to 19.7 per cent in 1981-85. In tlle same years, proportion of CAD admissions rose from 20.8 per cent to 23.9 per cent respectively. Pooled data from the states of Assarn, Madhya Pradesh, Punjab, Kerala and Karnataka show that proportion of all cwdi.ac admissions to various government hospitals and incidence of CAD increased from 14 per cent in 1970 to 19 per cent in 1985.Admissions to a non-govei~ment tertiary care hospital in Vellore (South India) steadily increased from 4 per cent in 1960 to 33 per cent in 1989. Again, between 1966 to 1988 there has been a more than 20-fold increase in admissions for acute myocardial infarction in a single medical college hospital in Kerala. In Orissa,CAD admissions increased from 19.9 per cent in 1981-90 to 28 pel. cent in the next decade. There is definitely substantial regional variation in Cardio-vasculr~admissions and mortality in different parts of the country. However all these Istudies report an increasing burden from CAD on the healthcare system, especially on the urban hospitals.
The situation in the rural areas is also not much different. Though serial studies in rural areas alee not available, in one report lrom Rajasthan, CAD contributed to 8 per cent of patients attending a general medical clinic. Another report has shown that of a total of 1362 medical cases seen in a referral medical clinic, there were 110 CAD cases (roughly 9 per cent). If converted into absolule numbers, there are nill lions of patients with CAD scen all over India in hospitals, urban clinics and rural centres.No doubt burden on population and healthcare from CAD is very high.
Economic and Social Burden
Cardio-vascular diseases pose trcmendous ecoilomic strain on the populalion and the countries throughout the world. However Lhere is a disparity between the developing and the developcd nations. In the developed nations the incidence is risil~g but not alarmingly and the resources are available (though not equitably distributed) Lo tale suitable measures lor treatment and prevention. On the other hand, developing nations ase Pacing alrnost a silent epidenlic of CAD and access lo health care is severely restl-icled because of low availability ;lnd high cost.
Healthcare Burden
CAD and its complications use up a substantial portion of the scarce healthcare resource of the country. It has been reported that CAD formed 5-20 per cent of all heart disease admissions in big hospitals in Delhi, Mumbai and sbinc other cities.In 1971-75 CAD was present in 16.5 per cent of all heart disease cases seen in AIIMS and that rose to 19.7 per cent in 1981-85. In tlle same years, proportion of CAD admissions rose from 20.8 per cent to 23.9 per cent respectively. Pooled data from the states of Assarn, Madhya Pradesh, Punjab, Kerala and Karnataka show that proportion of all cwdi.ac admissions to various government hospitals and incidence of CAD increased from 14 per cent in 1970 to 19 per cent in 1985.Admissions to a non-govei~ment tertiary care hospital in Vellore (South India) steadily increased from 4 per cent in 1960 to 33 per cent in 1989. Again, between 1966 to 1988 there has been a more than 20-fold increase in admissions for acute myocardial infarction in a single medical college hospital in Kerala. In Orissa,CAD admissions increased from 19.9 per cent in 1981-90 to 28 pel. cent in the next decade. There is definitely substantial regional variation in Cardio-vasculr~admissions and mortality in different parts of the country. However all these Istudies report an increasing burden from CAD on the healthcare system, especially on the urban hospitals.
The situation in the rural areas is also not much different. Though serial studies in rural areas alee not available, in one report lrom Rajasthan, CAD contributed to 8 per cent of patients attending a general medical clinic. Another report has shown that of a total of 1362 medical cases seen in a referral medical clinic, there were 110 CAD cases (roughly 9 per cent). If converted into absolule numbers, there are nill lions of patients with CAD scen all over India in hospitals, urban clinics and rural centres.No doubt burden on population and healthcare from CAD is very high.
Economic and Social Burden
Cardio-vascular diseases pose trcmendous ecoilomic strain on the populalion and the countries throughout the world. However Lhere is a disparity between the developing and the developcd nations. In the developed nations the incidence is risil~g but not alarmingly and the resources are available (though not equitably distributed) Lo tale suitable measures lor treatment and prevention. On the other hand, developing nations ase Pacing alrnost a silent epidenlic of CAD and access lo health care is severely restl-icled because of low availability ;lnd high cost.
According to World Bank dollar-a-day estimates, of the 1.3 billio~~people living below the poverty line worldwide, 40 per cell1 (5 15 million) live in South Asin,and the gross nalioiial product per capita in that region is only US$393, conlpared with $1 250 for the rest of the developing wosld (Table 1.6).India spends about 5 per cenl o l ils gross domestic product (GDP) on health, ol' which direct private expenditure on health is about 82-83 per cent and the subsidized goveli~n~ent expenditure is 17-1 8 per cent. It is quite understandable that any disease that is as prevalent as CAD would appropriate a substanlial portion of that expenditure. Though no- rornlal calculalions exisl regasding the economic burden of CAD, in a study reported in Indian Hear1 Journal in 21105, the econoinic burden has been calculated as about Rs. 200 billion and that also as an underestimate. Considering that the annual GDP of India is about Rs. 25000 billion, the burden of CAD in India is about 0.8 per cent oS GDP. This is purely the direct cost o l tre&nent and does not include the cost in terms o l loss of man-hours and wages, w l ~ i c if l ~ added up would make llle total burden a colossal figure. This is nothing but an econonlic waste as almost 80 per cent of the heart attacks are preventable by appropriate management aild prevention strategies.
The social burden of CAD is also not difficult to comprehend. In Indians, acute coronary events occur at least 10 years earlier than ill Caucasian and Latin American countries and five years earlier than in China. This means that CAD affects Indians mostly in their productive years. Premature CAD therefore causes significant social burden in terms of loss of job and support for young children,woinen and the elderly. The exact cost to a family of such a catastrophe is again difficult to estimate but the DALY (disability adjusted life years) calculation include burden of premahre morbidity on the individual and clearly shows that CAD contributes to a large measure to it in India.
While CAD is definitely the major problem in the country, the two other conditions also require special mention and those are the burden iinposed by Hypertension and rheumatic heart disease.
The social burden of CAD is also not difficult to comprehend. In Indians, acute coronary events occur at least 10 years earlier than ill Caucasian and Latin American countries and five years earlier than in China. This means that CAD affects Indians mostly in their productive years. Premature CAD therefore causes significant social burden in terms of loss of job and support for young children,woinen and the elderly. The exact cost to a family of such a catastrophe is again difficult to estimate but the DALY (disability adjusted life years) calculation include burden of premahre morbidity on the individual and clearly shows that CAD contributes to a large measure to it in India.
While CAD is definitely the major problem in the country, the two other conditions also require special mention and those are the burden iinposed by Hypertension and rheumatic heart disease.
Burden of Hypertension
Since 1942, there have been several small and large population-based studies on Hypertension. A ineta-analysis showed an increase in the prevalence of Hypertension over the years, especially of systolic levels, more in urban than in rural areas. Recent studies using the criterion of 140/90 mmHg as the cut-off point for Hypertension have shown a prevalence of 10-30.9 per cent in urban areas,while earlier reports since 1950 showed a prevalence of 1-3 per ccnt.Tile reason for the increasing trend has been attributed to the same factors as those for CAD.
Hypertension appears to be the most important risk factor for the development of' CAD throughout India. In a study in Delhi involving 8000 subjects, the most important risk factor for CAD was Hypertension it1 over 50 per cent of subjects,young and old, followed by smoking and diabetes. This has also been seen at AIIMS, New Delhi and CMC, Vellore.
Burden of Rheumatic Heart Disease (RHD)
Although in the twenty-first century RHD has been eradicated in western countries, in India and other developing countries it continues to thrive and causc a high mortality among children and young adults. Thc nlost important source for the prevalence of RHD is the school surveys and the last scl~ool study done in primary school children 6-10 years of age has shown a prevalence of RHD of 3.911 000 and that is unacceptably high. Fu~lller proof of the continuing lasge reservoir of RHD cases is the large number of palieills in their teens and twenties coming in for the (relatively) new modality of balloon mitral valvotoiny. Paedialric clinics in large hospitals from various parts of India have reported several cases with acutc manifestations ol' RI-ID such as cmditis, chorea, nodules and polyarthritis.
Since 1942, there have been several small and large population-based studies on Hypertension. A ineta-analysis showed an increase in the prevalence of Hypertension over the years, especially of systolic levels, more in urban than in rural areas. Recent studies using the criterion of 140/90 mmHg as the cut-off point for Hypertension have shown a prevalence of 10-30.9 per cent in urban areas,while earlier reports since 1950 showed a prevalence of 1-3 per ccnt.Tile reason for the increasing trend has been attributed to the same factors as those for CAD.
Hypertension appears to be the most important risk factor for the development of' CAD throughout India. In a study in Delhi involving 8000 subjects, the most important risk factor for CAD was Hypertension it1 over 50 per cent of subjects,young and old, followed by smoking and diabetes. This has also been seen at AIIMS, New Delhi and CMC, Vellore.
Burden of Rheumatic Heart Disease (RHD)
Although in the twenty-first century RHD has been eradicated in western countries, in India and other developing countries it continues to thrive and causc a high mortality among children and young adults. Thc nlost important source for the prevalence of RHD is the school surveys and the last scl~ool study done in primary school children 6-10 years of age has shown a prevalence of RHD of 3.911 000 and that is unacceptably high. Fu~lller proof of the continuing lasge reservoir of RHD cases is the large number of palieills in their teens and twenties coming in for the (relatively) new modality of balloon mitral valvotoiny. Paedialric clinics in large hospitals from various parts of India have reported several cases with acutc manifestations ol' RI-ID such as cmditis, chorea, nodules and polyarthritis.
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