CHD

Dr.Trinath Sarkar
Assistant Professor
Department of Community Medicine
SPECIAL FEATURE OF IHD
AMONG SOUTH ASIANS
 Occur in early age, mean age of onset a decade
earlier
 F>M as compared to developed countries
 Higher case fatality
 IHD occurs even in presence of normal or near
normal levels of “conventional” risk factors as
BMI,TC & smoking; on the other hand high level
of “unconventional” risk factors (increased
central obesity in face of normal BMI, low
HDL/high TG in the face of normal TC levels) as
occurs in metabolic syndrome ‘X’ may play an
important role.
RISK FACTORS OF CHD

Risk factors of CHD

Modifiable N on modifiable

Well established Emerging/Being Researched Age, Sex, Fami ly H/O, Rac e/genet ic
NON MODIFIABLE RISK
FACTORS
 Age - >45 yrs in M, >55 yrs in F
 Sex- M>F …but after 55 yrs M=F
 Family H/O- H/O definite MI or sudden death
in father or 1st degree male relative <45 yrs
age or in mother or 1st degree female
relative <55 years of age.
 Race/ Genetic makeup- some race more
predisposed, eg. South Asian at higher risk
(“thrifty gene”), Japanese are at lower risk,
finnish population are at higher risk.
MODIFIABLE CORONARY RISK
FACTORS

Modifiable risk factors

Well es tabli shed Emerging /being resear ched

Lipid Non -lipid Lipid

Non-lipid
MODIFIABLE WELL ESTABLISHED
LIPID FACTORS
 Raised TC
 Raised LDL-C
 Raised TG
 Low HDL (<40 mg/dl in M, <50 mg/dl in F)
 Metabolic syndrome (syndrome X)- a
clustering of low HDL, raised TG, HTN, IGT
and obesity
METABOLIC SYNDROME
 Postulated that once such clustering occurs …
major risk factor for development of IHD & T2DM.
 WHO criteria-
 Diabetes/IFG/IGT or evidence of insulin
resistance PLUS any two of the following:
 Obesity as defined BMI >30 or WHR >0.9 for M or
>0.85 for F (>0.8 for Indian F)
 HTN defined as SBP >140 or DBP>90
 Dyslipidaemia as manifested by TG>150 mg/dl or
HDL<35 mf/dl for M or <40 mg/dl for F
 Microalbuminuria defined as albumin excretion
>20 µg/mt.
MODIFIABLE WELL ESTABLISHED
NON LIPID FACTORS
 Tobacco use
 HTN
 T2 DM/IGT
 Obesity (generalized /central)
 Physical inactivity
 Atherogenic diet (high in total calories, total
fat,saturated fats,cholesterol,salt & refined
sugar; low in whole grains,cereal,
legumes,fruits,vegetables,vitamins,fibre
&omega3 FA)
 Mental stress & personality (“type A”)
MODIFIABLE EMERGING LIPID
FACTORS
 Raised TC: HDL-C (>4.5)
 “Lipid Triad” (concomitant presence of
raised TG,sd-LDLparticles, low HDL)
 Raised Apolipoprotein-B
 Low Apolipoprotein A1
 Small dense LDL particles
 Raised Non-HDL choleterol ( calculated by
TC-HDL & is actually VLDL+LDL)
MODIFIABLE EMERGING NON-
LIPID FACTORS
 Inflammatory markers-
 raised total WBC count
 raised CRP
 Prothrombotic factors-
 Platelet –hyperaggregability
 Raised fibrinogen
 Raised PAI-1
 Low tPA
 Others
 Raised serum homocysteine
 Microalbuminuria
 Raised resting pulse rate
RISK FACTORS & LEVELS OF
NCD PREVENTION (NPCDCS)
Behavioural risk Biological risk Disease outcome
factors factors
Tobacco Overweight,obesity Heart disease
Alcohol Raised BP Diabetes
Physical inactivity Raised Blood glucose Stroke
Diet Raised cholesterol Cancer
Chronic respiratory
distress

Tertiary
Primary Secondary prevention
prevention prevention (early (Disability
(Health diagnosis & limitation &
Promotion) management) rehabilitation)
PREVENTIVE STRATEGIES FOR
IHD
 Primordial prevention
 Primary prevention
A. Population strategy
 Mass approach
 Targeted group approach
B. Targeted high risk individual strategy
 Secondary prevention
 Tertiary prevention
PREVENTIVE STRATEGIES FOR
IHD
 Primordial prevention
 Primary prevention
A. Population strategy
 Mass approach
 Targeted group approach
B. Targeted high risk individual strategy
 Secondary prevention
 Tertiary prevention
KEY MESSAGE FOR IEC :DIET
 Just sufficient in calories –no more no less
 Total fats provide <30% of calories need
 Saturated fats provide <10% of calorie need
 Trans-fatty acids to be eliminated from diet
 Most dietary fat should be PUFA (up to 10% of
calories) or MUFA (10-15% of calories)
 Refined sugars provide <10% of calorie need
 Salt consumption (all sources) <5 g/day
 Cholesterol <200 mg/day
 Low in fried, creamed and sugared food stuffs
 Plenty of whole grains,cereals, legumes, beans &
pulses
 400-500g fresh fruits & vegetables
 Low fat dairy product
KEY MESSAGE FOR IEC
:PHYSICAL ACTIVITY
 Undertake BRISK walk every day, covering 2
miles (3.2 km) in 30-35 min daily , if you can
exercise longer or at higher intensity, the
better is
 Supplement aerobic exercise (walking,
running, cycling, sports) with light weight
training and stretching exercises as yoga
KEY MESSAGE FOR IEC
:TOBACCO & ALCOHOL
 NO TOBACCO. If you don’t use tobacco ,
don’t start; if you do ,stop.
 Avoid alcohol. If you must drink, not more
than 3 small drinks a day for men ( not more
than 2 small drinks a day for women). Do not
drive after drinks, after MI; try not to drink
daily.
KEY MESSAGE FOR IEC: MENTAL
STRESS
 Pray,meditate
 Spend quality time with family
 Yoga
 Manage your finances well
 Exercise regularly
 Look after health of yourself & family
members
KEY MESSAGE FOR IEC: BODY
WEIGHT & OBESITY
 Regularly check your body weight .
 Measure your waist & Hip circumference.
 BMI Should be kept at <25 (preferably <23)
and
 Waist <90 cm or WHR <0.9 for males & waist
<80 cm or WHR <0.8 for females.
KEY MESSAGE FOR IEC: REGULAR
FOLLOW UP & WHEN TO REPORT
 Undergo periodic /annual medical
examinations seriously. Take precautions as
told by your doctor.
 If you have any symptoms of chest pain ,
fatigueability, palpitation or breathlessness,
seek medical attention.
PREVENTIVE STRATEGIES FOR
IHD
 Primordial prevention
 Primary prevention
A. Population strategy
 Mass approach
 Targeted group approach
B. Targeted high risk individual strategy
 Secondary prevention
 Tertiary prevention
WHO INDIVIDUAL RISK PREDICTION CHART
PREVENTIVE STRATEGIES FOR
IHD
 Primordial prevention
 Primary prevention
A. Population strategy
 Mass approach
 Targeted group approach
B. Targeted high risk individual strategy
 Secondary prevention
 Tertiary prevention
SECONDARY PREVENTION
 Resting ECG
 Resting ECG+ effort angina
 Exercise(stress) ECG± Echocardiography
 Dobutamine stress test with 201thallium scan
PREVENTIVE STRATEGIES FOR
IHD
 Primordial prevention
 Primary prevention
A. Population strategy
 Mass approach
 Targeted group approach
B. Targeted high risk individual strategy
 Secondary prevention
 Tertiary prevention
CARDIAC REHABILITATION
 Physical rehabilitation- graded exercise
therapy.
 Psychological rehabilitation- insecurity,
anxiety, depression, education of disease,
social and familial support.
CARDIAC REHABILITATION:
PHYSICAL
 1st week- repetitive movement of large muscle group.
Starts with active & passive range of movements of all
extremities in the bed (CCU).eg. Ankle plantar &
dorsiflexion repeating hourly, when awake on 2 nd or 3
rd day. Gradually it is extended to sitting on a bed
side chair , using bedside commode and slow walking.
 2nd week- strolling in the street, light household
work , but not lifting weights.
 3rd & 4th week- daily walk, starting half a mile /day,
gradually increasing up to 2 miles/day.
 5th week onwards- resumption of full activity , but
always avoiding undue tiredness, breathlessness or
chest pain.
CARDIAC REHABILITATION:
PHYSICAL
 Sexual intercourse may be started after 3 rd
week but it may be wise to wait about 5th
weeks.
 Rule of thumb- when (s)he is able to go up a
flight of 20 stairs rapidly without chest pain
or breathlessness, (s)he is unlikely to have
problems.
thank
you