Dr. Hamzullah Khan, Postgraduate Medical Institute, Government Lady Reading Hospital Peshawar, Pakistan

ABSTRACT:

Coronary artery disease is major and growing contributors to morbidity, mortality and disability in the South Asian countries including Pakistan. Cardiovascular disease profile in Pakistan shows the presence of emerging and advancing diseases such as coronary artery diseases (CAD) and cerebrovascular accidents (CVA) and of established and receding diseases such as hypertension and diabetes, which are also risk factors for CAD and CVA. Unfortunately in most countries the response to CVD prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to respond to CVD epidemic is woefully inadequate.  While establishing a strategy for combating CVD there is need to offer multiple approaches on national, community and individual levels. Prevention programmes should be started based on cross-sectional surveys and case studies. Majority of the people have modifiable risk factors for cardiovascular disease that are easily preventable. Prevention efforts are required early in life, using strategies for behavioral modification and health promotion. Additionally, political, social, cultural, and economic issues need to be considered in prevention and control of these diseases, to identify and address key limitations.

INTRODUCTION:

The great increase in rates of cardiovascular disease in developing countries will probably have grave implications for south Asia, which houses nearly a quarter of the world’s population. Several factors might contribute to this effect, such as increased susceptibility of south Asian people to cardiovascular disease, unrecognized targets for preventive interventions, and restricted access to high-cost tertiary cardiovascular care for economically disadvantaged communities. Furthermore, prevention and control of cardiovascular disease does not feature prominently in the health care agendas of south Asian countries. To address these issues, therefore, a multifaceted approach is needed, which should include epidemiological studies to fill in the gaps in knowledge. Additionally, political, social, cultural, and economic issues need to be considered in prevention and control of these diseases, to identify and address key limitations and opportunities specific to the region. A set of recommendations outlining the approach is crucial .

Stroke is a clinical syndrome characterized by rapidly developing symptoms and/or signs of focal, and at times global (for patients in Coma), loss of cerebral functions, with symptoms lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin. According to World Health Organization report 2002, total mortality due to stroke in Pakistan was 78512.

BURDEN OF THE CARDIOVASCULAR DISEASES:

In 2000 more than half of the world deaths were due to coronary artery disease (CAD) in the developing counties. Coronary artery disease are major and growing contributors to morbidity, mortality and disability in the South Asian countries including Pakistan.. The total mortality due to cardiovascular disease in Pakistan during 2002 estimated by WHO were 154338.

RISK FACTORS OF CARDIOVASCULAR DISEASES:

Among non communicable diseases Cardiovascular Disease (CVD) is a leading cause of mortality and is responsible for one-third of all global deaths. Epidemiological data provide strong evidence that hypertension is one of the most important risk factors for the development of cardiovascular disease and kidney failure. Studies on migrant populations clearly demonstrate the enhanced susceptibility of South Asians to CVD compared to other ethnic groups.

High blood pressure (hypertension) is one of the most important preventable causes of premature death worldwide. In developing countries like Pakistan, the magnitude of the problem of uncontrolled hypertension is even greater. The National Health Survey of Pakistan reported that 21.5 per cent of the urban population over 15 years (one in every three persons the over age of 45) suffers from hypertension and only less than three per cent of the hypertensive had their blood pressure (BP) controlled to the conventional recommendations of under 140/90mmHg. The global estimate suggests that 8-18% of adults are hypertensive(defined as either taking antihypertensive drugs or having a systolic blood pressure equal to or more than 160mmHg and/or diastolic blood pressure equal to or more than 95mmHg) but by the same definition up to one half of the people 65 years and above have raised blood pressure. Hypertension is a well-established predisposing factor for cardiovascular diseases (CVD), such as left ventricular hypertrophy (LVH), left ventricular failure (LVF), atherosclerosis, ischemic heart disease (IHD) etc that have high mentality rates.

Diabetes is a risk factor for coronary artery diseases and stroke, and is the most common cause of amputation that is not the result of an accident. Worldwide only 10.15% of the cases are Type-1 diabetics and 85-90% are Type-2 diabetics. Type 1 diabetes causes nephropathy, proliferative retinopathy, renal failure and neuropathy. It usually follows a juvenile onset and the mortality, renal failure, and neuropathy chances increases in younger age i.e. 20 to 30 years^. According to WHO report 2004 the prevalence of diabetes in Pakistan and India is 5-9.9%, 10-14.9% in Greece, 15% or above in Qatar and below 5% in China. Type 1 diabetes is now known to be an autoimmune disease. For unknown reasons, the patient’s immune system destroys its own pancreatic insulin-producing beta cells. The hallmark of type-2 diabetes is insulin resistance, which may be mediated by one of a number of gene defects. At some point, the pancreatic beta cells are unable to compensate for the insulin resistance by increasing insulin secretion. Type 2 diabetes then appears. A sample sketch of prevalence of diabetes in Pakistan is shown in table.

Hyperlipidemia stands third important risk factor of coronary artery diseases. Hyperlipidemia can cause blockage of coronary arteries and increase incidence of ischemic heart diseases. The recommended levels in United State for total cholesterol in adult aged population is less than 240mg/dl, for LDL cholesterol less than160mg/dl, for HDL cholesterol less than 40mg/dl, and for triglycerides (fasting) is than 200mg/dl^.

Smoking is also a major risk to CAD. A local study from Pakistan reported that based on weighted estimates, the overall prevalence of cigarette smoking was 14.2% (95% CI: 13.6-14.8) in individuals aged >= 8 years and 19.4% (95% CI: 19.08-19.72) among those aged >= 15 years. The highest prevalence was seen in the province of Sindh (16.1%) and the lowest in North Western Frontier Province (7.1%). Nearly a quarter of males (25.4%) were smokers while only 3.5% of females smoked (p < 0.001). The smoking was slightly more prevalent in urban areas (15.2%) compared to rural areas (13.7%). This pattern was consistent in all provinces except the province of Sindh. The highest prevalence of cigarettes smoking among males (48.6%) was seen in those aged 25-44 years. After this age, there was a decline in smoking among males in Punjab and North Western Frontier Province, whereas the other two provinces, Sindh and Balochistan, did not show any such trend^.

Obesity is a moderate risk factor in our patients. In Pakistan average Basic Mass Index (BMI) of people aged 15 and above estimated is 23-24.9kg/m² for females and 18-22.9 for males, In India 23.24 for female and 18-22.9 for males, In Brazil – 25 – 26.9 female and 23-24.9 males and in USA and Canada it is above 27 for both females and males. In America, guidelines of the American Heart Association/American Stroke Association have shown new set of risk factors. It is aimed is to have a policy that covers all or nearly all risk factors to combat CVD. According to their report, non-modifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein (a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection.

Summarizing we can say that Hypertension, diabetes, hypercholestremia and smoking are major modifiable risk factors of coronary artery disease. Obesity coagulative disorders and history of use of oral contraceptives are minor risk factors to coronary artery disease.

PREVENTION STRATEGIES FOR CARDIOVASCULAR DISEASES

International scenario:

Unfortunately in most countries the response to CVD prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to respond to CVD epidemic is woefully inadequate. The gap between the need for CVD prevention, control and capacity to meet then will go even wider unless urgent steps are taken. As the CVD epidemic emerges in developing countries, it has an increasingly severe impact on men and women in their productive middle years, as well as on those who are older. The growing middle class of many developing countries is experiencing the first phase of the CVD epidemic, which for many is disrupting family stability and family income. This has consequences for society as a whole. The cost of treatment can also have a serious impact on a country’s health care expenditures and its economic development. For these reasons, development of effective approaches for CVD prevention and cost-effective management are urgent. Without effective prevention, the epidemic is predicted to expand, causing a profound impact on individuals and the country. There is a parallel opportunity for sharing knowledge on CVD prevention. Developed countries experienced an epidemic of CVD in the middle of this century and have since achieved a remarkable decline in cardiovascular mortality. Accomplishing this required major conceptual shifts in epidemiologic research (both observational and interventional), creation of a strong scientific database to guide policy and practice, and development of public information to discourage behaviors that predispose to CVD. As a similar epidemic of chronic diseases, especially CVD, emerges in developing countries, health professionals from developed countries are motivated to again share their experience of policies and approaches that have proven successful. International research on cardiovascular disease (CVD) has a history of four decades or more and includes the CVD Unit of the World Health Organization (WHO), the International Society and Federation of Cardiology (ISFC) with its scientific councils and Section on Epidemiology and Prevention, and specific efforts initiated in several developed countries over the same period.

WORLD HEART FEDERATION REPORT ON PAKISTAN.

To prevent cardiovascular disease, countries need adequate health systems. But adequate health systems do not just appear out of nowhere; they require a lot of inputs. One important prerequisite is adequate health information. In other words, countries first must know what is ailing their people. Are they too heavy? Are they too physically inactive? Do they smoke too much?

Endowed with a base of knowledge, countries can then begin to construct health systems that are suitable to their needs. Dr Sania Nishtar, President and Founder of Heartfile in Pakistan, puts the challenge succinctly: “What gets measured gets done”.

Sound health systems is ultimate goal

Dr Nishtar wants Pakistan to have adequate health systems, and not just ones able to prevent cardiovascular disease, which is the country’s biggest killer. She wants Pakistan to confront the range of grave communicable and noncommunicable diseases, from AIDS, cancer and diabetes to polio and tuberculosis.

That is why she wrote “Health Indicators of Pakistan,” the second in her Gateway Papers series. It is a collation of available health statistics in Pakistan. As such, it represents a first for her country. She hopes that it will serve as an evidence basis for health reform and as a template for periodic reports on health by Pakistan’s government.

Gateway Paper 2 was launched on 26 June 2007 in Islamabad with the participation of Prime Minister Shaukat Aziz, Health Minister M. Nasir Khan and Acting World Health Organization Representative Rayana Bouhaka.

Paper shows need to improve

The paper shows that there have been improvements in Pakistani health in many areas. For example, maternal and infant mortality have decreased over the last 60 years and immunization coverage has increased.

On the other hand, it also shows that Pakistan lags, even in comparison with other low-income countries. For example, it indicates that Pakistan has far to go toward the adequate testing for and treatment of tuberculosis, and that poliomyelitis continues to claim too many victims. In addition, it shows that Pakistan spends only 0.67% of its gross domestic product on health.

Of particular note, it shows that noncommunicable diseases account for 54.9% of deaths, as opposed to infectious diseases, which account for 26.9% of deaths. Nearly a quarter of its adults have high blood pressure. Forty-one per cent of its men and 6.9% of its women smoke. Twenty-eight per cent of urban and 23% of rural Pakistanis are overweight. The unmistakeable implication, she says, is that noncommunicable diseases, including heart disease and stroke, need more attention.

Substantial gains possible

“Aiming for further improvements will only be possible by making strategic choices and investments and by restructuring the mode of social service delivery, of which health is a part,”

“Health systems are critical to the entire discussion,” she added. “Prevention of cardiovascular disease cannot be delivered unless we talk in terms of strengthening health systems.”

The former Chairwoman of the World Heart Federation’s Foundations Advisory Board said that she chose the term “Gateway” for her papers to reflect her contributions to national health policy setting from outside the governmental sector.

Her first Gateway paper was entitled “Health Systems in Pakistan – A Way Forward”. It was intended be a road map for health reforms in Pakistan. The third will focus on specific recommendations to reform the health sector, she said.

HEARTFILE an established leader

Heart file is known for its innovative work to catalyze change in Pakistan’s health sector. The nongovernmental organization previously spearheaded Pakistan’s National Action Plan on Non-Communicable Diseases Prevention, Control and Health Promotion. Heartfile is a non-profit NGO health-sector think tank, recognized as a powerful and respected health policy voice within Pakistan and a unique model for replication in other developing countries.

The organization’s purpose is to catalyze change within the health sector in order to improve health and social outcomes

The organizations scope of work within Pakistan involves:

• Strengthening the evidence base of health reforms
• Spearheading Pakistan’s Health Policy Forum
• Reorienting health priorities in the wake of the epidemiological transition
• Performing public health research
• Publishing and disseminating original resource materials

Scope of work internationally, includes:

Developing innovations in the health sector and contributing to knowledge in the areas of health policy and public health planning for low resource settings Forming an empirical basis for health reforms in the area of non-communicable diseases.

WHO and International Clinical Epidemiology Network (INCLEN) efforts:

In addition to WHO and ISFC, national and international organizations engaged in CVD prevention and control include the International Clinical Epidemiology Network (INCLEN); United Nations Scientific, Educational and Cultural Organization (UNESCO); national and regional foundations; national academies of science and medicine in developed and in developing countries; medical schools and other academic centers of excellence; the World Bank; and donor agencies such as the Canadian International Development Centre and Swedish International Development Agency. Also, several networks have been established for the conduct of multinational randomized clinical trials in CVD, such as the International Studies of Infarct Survival (ISIS), Long Term Intervention with Pravastatin in Ischemic Disease (LIPID), and Global Utilization of Streptokinase and t-PA (tissue plasminogen activator) for Occluded Coronary Arteries (GUSTO), among others.

THE NATIONAL HEART, LUNG, AND BLOOD INSTITUTE REPORT 2001.

During the past 30 to 40 years, tremendous advances have been made in preventing cardiovascular disease (CVD). Since 1960, mortality from CVD has decreased more than 50 percent in the United States. This remarkable decline is a result of population-wide efforts to prevent CVD and advances in treating patients with CVD. Over the past four decades, dietary and smoking habits, treatment of hypertension and dyslipidemia, outpatient therapy for CVD, and inpatient treatment of acute CVD events have improved substantially. To identify fruitful areas of research for continuing the United States’ history of success in preventing CVD, the National Heart, Lung, and Blood Institute (NHLBI) established in January 2001 the Task Force on Research in Prevention of Cardiovascular Disease. Its members represented specific areas of prevention research. This report documents the deliberations and recommendations of the Task Force.

This document, therefore, reports key NCD risk factors. These include information on common lifestyle-related risks such as tobacco use, fruit and vegetable intake, Physical activity on the one hand, and biological risks inclusive of Diabetes, High Blood Pressure, Hypercholesterolemia and Obesity, on the other. In addition, data on Coronary Artery Disease, Stroke, Chronic Bronchitis, Cancer and Renal Diseases are also presented herewith.

These data suffer from several limitations. Firstly, incidence data is available for cancers only. Secondly, the nationally representative prevalence data for Diabetes, Renal Diseases and Chronic Bronchitis is more than 10 years old. Thirdly, there is the Issue of representativeness; prevalence data for Coronary Artery Disease has been reported from the results of a survey conducted in one city (Karachi) of the country, whereas data on prevalence of Stroke come from a survey carried out on a particular ethnic community within that city only.

LESSON FROM THE DEVELOPING COUNTRIES ON PREVENTION OF CARDIOVASCULAR DISEASES:

The increasing burden of CVD has important economic implications. CVD occurs typically at a younger age in developing than developed countries with important consequences such as loss of revenue at household level and loss of productivity at macroeconomic level. From a health system perspective, huge resources are needed for providing health care to large numbers of chronic patients for decades and for sustaining increasingly sophisticated equipment and more skilled and harder-to-replace workforce. There are two approaches to reduce the burden of CVD . The population strategy, that includes community-based programs and health promoting policies, recognizes that several modifiable CVD risk factors are widely distributed in the population and that small change in CVD risk among large numbers of people can reduce largely the incidence of CVD in the population. The alternative is to target “high risk” people, i.e. risk factors are screened in the population and persons with high risk of CVD are treated. These alternative strategies, “population” and “high risk”, can of course be considered as complementary.

PREVENTION OF CARDIOVASCULAR DISEASE: A PAKISTANI PERSPECTIVE:

In Pakistan the National Action Plan for Non-Communicable Disease Prevention (NAP-NCD) incorporates prevention and control of cardiovascular diseases (CVD) as part of a comprehensive and integrated non-communicable Disease (NCD) prevention effort. In this programme revision of the current policy on diet and nutrition to expand its focus on under-nutrition; the development of a physical activity policy; strategies to limit the production of, and access to, ghee as a medium for cooking and agricultural and fiscal policies that increase the demand for, and make healthy food more accessible.¹⁵

Heart-file in Pakistan has started a programme that focuses on cardiovascular disease prevention and health promotion, includes several initiatives that encompass building policy, reorienting health services, and developing community interventions that utilize the print and electronic media and outreach at the grass-root level to incorporate social marketing approaches.

NATIONAL/COMMUNITY LEVEL APPROACHES TOWARDS CARDIOVASCULAR DISEASE PREVENTION: COMMENTS OF THE PHYSICIANS

World health organization further reinforces the national approaches to combat cardiovascular diseases that framework convention on tobacco control (FCTC) is ratified in the country. Tobacco control legislation are enacted and enforced. Multi-sartorial actions are required to reduce fat intake, reduce salt and promote fruit and vegetable consumption. Include stakeholders in the policy formulation and service planning. Capacity for health research is built within countries by encouraging research studies on CVD.

CONCLUSION:

In short we can summarize that while establishing a strategy for combating CVD there is need to offer multiple approaches on national, community and individual levels. Prevention programmes should be started based on cross-sectional surveys and case studies. Majority of the people have modifiable risk factors for cardiovascular disease that are easily preventable. Prevention efforts are required early in life, using strategies for behavioral modification and health promotion. There is need for further actions, more collaboration, leadership, community involvement, UN assistance and government support to improve the quality of life people living with heart diseases.