- Email: [email protected]
Prevention of coronary artery disease: the south Asian paradox
CORRESPONDENCE
Thrombolysis remains a valuable and cost-effective reperfusion technique for patients around the world. For countries or regions with a well established network of interventional centres, however, outcomes can be further improved by modifying ambulance triage patterns to transport patients with acute myocardial infarction to regional chest-pain centres that are able to do primary angioplasty quickly 24 h a day, 7 days a week, similar to the trauma centre model. Finally, although the sun may be setting on the “primary angioplasty versus thrombolysis wars”, we should not lose sight of the even more critical issue that a large proportion of patients eligible for reperfusion therapy are not receiving either of these life-saving treatments.5 Gregg W Stone Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York City, NY 10022, USA (e-mail: [email protected]) 1
2
3
4
5
Stone GW. Primary angioplasty versus “earlier“ thrombolysis—time for a wake-up call. Lancet 2002; 360: 814–16. Ellis SG, Da Silva ER, Spaulding CM, et al. Review of immediate angioplasty after fibrinolytic therapy for acute myocardial infarction: insights from the RESCUE I, RESCUE II, and other contemporary clinical experiences. Am Heart J 2000; 139: 1046–53. Morrison LJ, Verbeek PR, McDonald AC, et al. Mortality and prehospital thrombolysis for acute myocardial infarction: a metaanalysis. JAMA 2000; 283: 2686–92. Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Suryapranata H. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory: the PRAGUE study. Eur Heart J 2000; 21: 823–31. Eagle KA, Goodman SG, Avezum A, et al. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 2002; 359: 373–77.
Prevention of coronary artery disease: the south Asian paradox Sir—The most interesting part of the Review by Sania Nishtar (Sept 28, p 1015)1 is its new information on socioeconomic, political, cultural, and religious issues underlying the pathogenesis of the epidemic of coronary artery disease (CAD) in south Asia. However, several issues have not been addressed. The differences between healthrelated behaviours in the West and in south Asians need further emphasis. Health education seems to have little effect on health-related behaviour in
Western populations, but it could be of benefit among south Asians because the poor diet and lifestyle habits we currently see among these individuals are of recent origin, and therefore might be easier to reverse. In the USA and Europe, guidelines for desirable serum cholesterol concentrations have been changed from 250 mg/dL to 200 mg/dL, and more emphasis is being put on LDL cholesterol concentrations. Since most investigators agree that people of south Asian origin have a higher susceptibility to CAD than white individuals, the existing guidelines should take this difference into account for the prevention of CAD among south Asians. The risk of metabolic syndrome in Chinese and south Asians begins to increase above a body-mass index (BMI) of 23 kg/m2, and the optimum BMI is about 21 kg/m2.2,3 Similar observations have been made for waist-hip ratios and waist circumference. A study among women from five Indian cities showed that the prevalence of risk factors in relation to BMI began to increase significantly above 23 kg/m2, and showed a graded increase with increase in BMI.4 Similar associations were seen when waist circumference began to increase above 80 cm. In view of above effects of modest increases in weight, new obesity guidelines for Asian populations have been proposed by WHO with lower BMI levels of more than 23 kg/m2 or more than 25 kg/m2 used to define overweight and obesity, respectively.3 These new guidelines mean that a third of the south Asian adult population is now classified as obese, and 50% as overweight.2–4 Similarly, for total cholesterol (<170 mg/dL), LDL cholesterol (<90 mg/dL), triglycerides (<150 mg/dL), HDL cholesterol (>40 mg/dL), and blood glucose (<110 mg/dL), lower limits have been recommended by the International College of Nutrition and International College of Cardiology. These lipidrelated guidelines mean that a third to half of the adult population of south Asia is at high risk of developing CAD for which drug treatment as well as diet and lifestyle changes might be indicated. The gradient in risk of CAD in lowrisk rural populations, compared with urban and immigrant south Asians, indicates that increased physical activity would be the most important single measure for prevention of CAD in south Asians. Additionally, a study from south Asia has shown that eating 400–500 g/day of whole grains and another 400–500 g/day of seasonal vegetables and fruits in conjunction with 25–30 g/day of mustard or soya bean oil
THE LANCET • Vol 361 • January 4, 2003 • www.thelancet.com
can prevent cardiac events among highrisk individuals.5 Prevention of CAD in south Asians might also be slightly different to that in white individuals owing to the presence of metabolic syndrome and new risk factors such as higher lipoprotein (a) concentrations. Daniel Pella, Neil Thomas, Brian Tomlinson, *Ram B Singh *Subharti Medical College, Medical Hospital and Research Centre, Civil Lines, Moradabad 10, Uttar Pradesh 244001, India (RBS); Safaric University, Kosice, Slovakia (DP); and Prince of Wales Hospital, Hong Kong (NT, BT) (e-mail: [email protected]) 1 Nishtar S.Prevention of coronary heart disease in South Asia. Lancet 2002; 360: 1015–18. 2 Singh RB,Tomlinson B,Thomas GN, Sharma R. Coronary artery disease and coronary risk factors: the South Asian paradox. J Nutr Environ Med 2001; 11: 43–51. 3 World Health Organization.The Asia-Pacific perspective: redefining obesity and its treatment. Geneva: WHO, 2000. 4 Singh RB, Begom R, Mehta AS, et al. Waist circumference and risk of coronary risk factors in urban Indian women with low rates of obesity: the five city study. J Am Coll Nutr (in press). 5 Singh RB, Gal D, Niaz MA, et al.The effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients: the Indo-Mediterrnean diet heart study. Lancet 2002; 360: 1455–61.
Sir—Sania Nishtar1 provides a set of recommendations for the prevention of CAD in Asian people. Nishtar suggests risk factor modification such as diabetes control and weight reduction, reduction of tobacco use (smoking and chewing), and lipid lowering. In Brunei Darussalam—a small country in southeast Asia with a large south Asian population—a leading cause of morbidity and mortality is cardiovascular disease, and there is a high prevalence of cardiovascular risk factors such as smoking, hypertension, hyperlipidaemia, obesity, and diabetes. By using audit as an educational tool, the Brunei Project (a Master’s level diploma in general practice organised and run by our department in Brunei) aims to encourage good, evidence-based practice among the general practice registrars attending the course. These individuals then help to disseminate this information to their colleagues throughout the country. As part of the course, the registrars in two consecutive years gathered data on their patients, according to a standard protocol, ahead of the module on coronary heart disease. They reviewed 224 patients (mean age 60 years [SD 13]) in 2000, and 132 patients (62 years [10]) in 2001. This study formed the basis of the audit, which examined the diagnosis, monitoring, and treatment of patients with coronary heart disease. Results between the 2 years were
79
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Thrombolysis remains a valuable and cost-effective reperfusion technique for patients around the world. For countries or regions with a well established network of interventional centres, however, outcomes can be further improved by modifying ambulance triage patterns to transport patients with acute myocardial infarction to regional chest-pain centres that are able to do primary angioplasty quickly 24 h a day, 7 days a week, similar to the trauma centre model. Finally, although the sun may be setting on the “primary angioplasty versus thrombolysis wars”, we should not lose sight of the even more critical issue that a large proportion of patients eligible for reperfusion therapy are not receiving either of these life-saving treatments.5 Gregg W Stone Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York City, NY 10022, USA (e-mail: [email protected]) 1
2
3
4
5
Stone GW. Primary angioplasty versus “earlier“ thrombolysis—time for a wake-up call. Lancet 2002; 360: 814–16. Ellis SG, Da Silva ER, Spaulding CM, et al. Review of immediate angioplasty after fibrinolytic therapy for acute myocardial infarction: insights from the RESCUE I, RESCUE II, and other contemporary clinical experiences. Am Heart J 2000; 139: 1046–53. Morrison LJ, Verbeek PR, McDonald AC, et al. Mortality and prehospital thrombolysis for acute myocardial infarction: a metaanalysis. JAMA 2000; 283: 2686–92. Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Suryapranata H. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory: the PRAGUE study. Eur Heart J 2000; 21: 823–31. Eagle KA, Goodman SG, Avezum A, et al. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 2002; 359: 373–77.
Prevention of coronary artery disease: the south Asian paradox Sir—The most interesting part of the Review by Sania Nishtar (Sept 28, p 1015)1 is its new information on socioeconomic, political, cultural, and religious issues underlying the pathogenesis of the epidemic of coronary artery disease (CAD) in south Asia. However, several issues have not been addressed. The differences between healthrelated behaviours in the West and in south Asians need further emphasis. Health education seems to have little effect on health-related behaviour in
Western populations, but it could be of benefit among south Asians because the poor diet and lifestyle habits we currently see among these individuals are of recent origin, and therefore might be easier to reverse. In the USA and Europe, guidelines for desirable serum cholesterol concentrations have been changed from 250 mg/dL to 200 mg/dL, and more emphasis is being put on LDL cholesterol concentrations. Since most investigators agree that people of south Asian origin have a higher susceptibility to CAD than white individuals, the existing guidelines should take this difference into account for the prevention of CAD among south Asians. The risk of metabolic syndrome in Chinese and south Asians begins to increase above a body-mass index (BMI) of 23 kg/m2, and the optimum BMI is about 21 kg/m2.2,3 Similar observations have been made for waist-hip ratios and waist circumference. A study among women from five Indian cities showed that the prevalence of risk factors in relation to BMI began to increase significantly above 23 kg/m2, and showed a graded increase with increase in BMI.4 Similar associations were seen when waist circumference began to increase above 80 cm. In view of above effects of modest increases in weight, new obesity guidelines for Asian populations have been proposed by WHO with lower BMI levels of more than 23 kg/m2 or more than 25 kg/m2 used to define overweight and obesity, respectively.3 These new guidelines mean that a third of the south Asian adult population is now classified as obese, and 50% as overweight.2–4 Similarly, for total cholesterol (<170 mg/dL), LDL cholesterol (<90 mg/dL), triglycerides (<150 mg/dL), HDL cholesterol (>40 mg/dL), and blood glucose (<110 mg/dL), lower limits have been recommended by the International College of Nutrition and International College of Cardiology. These lipidrelated guidelines mean that a third to half of the adult population of south Asia is at high risk of developing CAD for which drug treatment as well as diet and lifestyle changes might be indicated. The gradient in risk of CAD in lowrisk rural populations, compared with urban and immigrant south Asians, indicates that increased physical activity would be the most important single measure for prevention of CAD in south Asians. Additionally, a study from south Asia has shown that eating 400–500 g/day of whole grains and another 400–500 g/day of seasonal vegetables and fruits in conjunction with 25–30 g/day of mustard or soya bean oil
THE LANCET • Vol 361 • January 4, 2003 • www.thelancet.com
can prevent cardiac events among highrisk individuals.5 Prevention of CAD in south Asians might also be slightly different to that in white individuals owing to the presence of metabolic syndrome and new risk factors such as higher lipoprotein (a) concentrations. Daniel Pella, Neil Thomas, Brian Tomlinson, *Ram B Singh *Subharti Medical College, Medical Hospital and Research Centre, Civil Lines, Moradabad 10, Uttar Pradesh 244001, India (RBS); Safaric University, Kosice, Slovakia (DP); and Prince of Wales Hospital, Hong Kong (NT, BT) (e-mail: [email protected]) 1 Nishtar S.Prevention of coronary heart disease in South Asia. Lancet 2002; 360: 1015–18. 2 Singh RB,Tomlinson B,Thomas GN, Sharma R. Coronary artery disease and coronary risk factors: the South Asian paradox. J Nutr Environ Med 2001; 11: 43–51. 3 World Health Organization.The Asia-Pacific perspective: redefining obesity and its treatment. Geneva: WHO, 2000. 4 Singh RB, Begom R, Mehta AS, et al. Waist circumference and risk of coronary risk factors in urban Indian women with low rates of obesity: the five city study. J Am Coll Nutr (in press). 5 Singh RB, Gal D, Niaz MA, et al.The effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients: the Indo-Mediterrnean diet heart study. Lancet 2002; 360: 1455–61.
Sir—Sania Nishtar1 provides a set of recommendations for the prevention of CAD in Asian people. Nishtar suggests risk factor modification such as diabetes control and weight reduction, reduction of tobacco use (smoking and chewing), and lipid lowering. In Brunei Darussalam—a small country in southeast Asia with a large south Asian population—a leading cause of morbidity and mortality is cardiovascular disease, and there is a high prevalence of cardiovascular risk factors such as smoking, hypertension, hyperlipidaemia, obesity, and diabetes. By using audit as an educational tool, the Brunei Project (a Master’s level diploma in general practice organised and run by our department in Brunei) aims to encourage good, evidence-based practice among the general practice registrars attending the course. These individuals then help to disseminate this information to their colleagues throughout the country. As part of the course, the registrars in two consecutive years gathered data on their patients, according to a standard protocol, ahead of the module on coronary heart disease. They reviewed 224 patients (mean age 60 years [SD 13]) in 2000, and 132 patients (62 years [10]) in 2001. This study formed the basis of the audit, which examined the diagnosis, monitoring, and treatment of patients with coronary heart disease. Results between the 2 years were
79
For personal use. Only reproduce with permission from The Lancet Publishing Group.