- Email: [email protected]
Reducing Clinical Inertia in Diabetes Management: An observational study
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 6 1 e2 6 3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Original Article
Reducing Clinical Inertia in Diabetes Management: An observational study K. Swaminathan* Consultant Endocrinologist, Kovai Medical Center & Hospital, Coimbatore, India
article info
abstract
Article history:
Background: Patients with diabetes are at high risk of vascular events. Aggressive treatment
Received 1 August 2014
of hyperglycemia, hyperlipidemia and hypertension are cornerstones of diabetes man-
Accepted 6 November 2014
agement in an effort to reduce risk of vascular disease. Our aim was to get a snapshot of
Available online 27 November 2014
diabetes management in the community in terms of the above three risk factors, so that deficient areas can be targeted to educate physicians and diabetologists.
Keywords:
Methods: All consecutive patients with known history of diabetes managed in the com-
Diabetes
munity who had enrolled for a diabetes master health check over a one year period from
Cardiovascular disease
Jan 2013 to December 2013 at Apollo Speciality Hospital, Madurai were included in this
Microvascular
study. Local Ethics Committee approval was obtained. Variables were collected and analyzed using Microsoft Excel 2007. Results: Data from one hundred and one patients were analyzed. Mean age of patients was 53.8 years with an average duration of diabetes of 3.5 years. Mean glycosylated hemoglobin was 8.6%. About 90% of patients had a blood pressure within the target range. Nearly twothirds of patients were not on a statin. The rates of newly detected neuropathy, retinopathy and microalbuminuria were 40%, 30% and 35% respectively. Conclusion: Physicians should adopt a more holistic approach to microvascular and cardiovascular risk factors in patients with diabetes, adhering to evidence based guidelines with personalized targets. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
There is data to suggest that diabetes patients without a previous myocardial infarction have as high a risk of such an event as nondiabetic patients with a history of myocardial infarction, thereby elevating diabetes as a Coronary Heart Disease equivalent.1 It is therefore often quoted that “Diabetes is not only a metabolic disorder but a vascular disease as well”.
The evidence for atherogenic risk factors in diabetes is strongest for hypertension, lipids, smoking and hyperglycemia.2 Aggressive risk factor reduction based on established national and international guidelines is vital in reducing the risk of both micro and macrovascular complications in diabetes. However, many health care professionals find it difficult to follow evidence based guidelines due to a variety of reasons ranging from clinical inertia, uncertainty of real life scenarios against guideline based management and the ever
* Tel.: þ91 8526421150; fax: þ91 422 2627782. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.apme.2014.11.002 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
262
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 6 1 e2 6 3
present argument of experience based medicine versus evidence based medicine. Data from a large Indian study recently has shown that glycemic control is extremely poor in India with a high prevalence of micro and macrovascular complications.3 Our aim was to get a snapshot of a real world risk factor management in patients with diabetes from the South Indian city of Madurai.
2.
Methods
All consecutive patients attending a diabetes master health check at Apollo Speciality Hospitals, Madurai were included in this study. All the participants were managed in the community for their diabetes and were “first timers” for the comprehensive check at our institution. Local Ethical Committee approval was obtained. A waiver of consent was given as this was a retrospective observational study. Data was prospectively collected and analyzed on Microsoft Excel 2007. The following variables were collected from our patients; age, sex, waist circumference, body mass index, blood pressure, fasting glucose, post-prandial glucose, glycosylated hemoglobin (HbA1c), fasting lipid profile, urinary microalbumin, retinopathy graded by an ophthalmologist and neuropathy grades using a biothesiometer. All patients underwent a detailed counseling session by a dedicated diabetes educator highlighting the importance of diet, lifestyle and risk factor management in diabetes.
3.
Results
A total of one hundred and one patients were analyzed. Mean age of patients was 53.8 years with a predominance of type 2 diabetes (98%). Most of the patients (95%) had no history of cardiovascular disease. The mean duration of diabetes was 3.5 years. Mean glycosylated hemoglobin was 8.6% with a fasting glucose of 175 mg/dl and a 2 h post-prandial of 289.7 mg/dl. Details of all other variables are tabulated in Table 1. Approximately 65% of patients were not on a statin. Blood pressure goals of 130/80 mm Hg was documented in 90% of patients, with predominant use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Some degree of neuropathy was present in 40% of the patients, with severe neuropathy documented in 15%. Nearly 30% had retinopathy with 3% needing urgent assessment for proliferative
Table 1 e Characteristics of study population {Mean (SD)}. Total number of patients (n) Mean age (years) Male:Female (n) Type 2 diabetes:type 1 diabetes (n) Mean duration of diabetes (years) Mean body mass index (kg/m2) Mean glycosylated hemoglobin (%) Mean systolic blood pressure (mm Hg) Mean diastolic blood pressure (mm Hg) Mean LDL-C (mg/dl) Mean HDL-C (mg/dl) Mean triglycerides (mg/dl)
101 53.8 years (10.2) 61:40 98:3 3.5 years (2.01) 27 (4.43) 8.6% (2.07) 128 mm Hg (16.6) 75.3 mm Hg (8.5) 104.2 mg/dl (33.9) 39.3 mg/dl (10.2) 156 mg/dl (93.7)
diabetic retinopathy. In patients with less than three years duration of diabetes, the mean glycosylated hemoglobin was 8.7% and nearly 67% of these patients were not on statins.
4.
Discussion
Our study highlights the presence of clinical inertia especially early in the course of type 2 diabetes, precisely when health care professionals should be aggressive in treating cardiovascular risk factors. The mean glycosylated hemoglobin (HbA1c) in our study was 8.6%. Hyperglycemia is an important risk factor in microvascular disease.4 In a recent large meta-analysis of 34,912 participants with type 2 diabetes, there was a significant reduction in the risk of microvascular complications in the intensive compared to standard glycemic control group.5 The rates of newly detected microvascular complications in our study were significantly high ranging from 30 to 40 % for retinopathy, microalbuminuria and neuropathy. High prevalence of microvascular complications early in the course of type 2 diabetes has been reported by few other Indian studies as well.3,6 The link between hyperglycemia and macrovascular disease is less straightforward. However, the concept of “legacy effect”, where a sustained period of glycemic control early in the course of diabetes has a long term benefit in reducing cardiovascular mortality7 may be very relevant in the way we approach glycemic targets in the first few years of type 2 diabetes. Most of our patients were free of macrovascular disease and were early in the course of type 2 diabetes. This should be an added incentive for physicians to treat glycemic targets aggressively with early combination therapy of medications with low side effect profiles. Nearly two-thirds of our patients were not prescribed a statin, even though the beneficial effects of statins in diabetes have been established by landmark clinical trials.8e10 This is of particular concern in India where the burden of coronary artery disease is high.11 Interestingly, as of January 2010, there were 259 distinct statin products available to the Indian consumers and nevertheless only a fraction of those eligible for statin therapy appeared to receive this therapy.12 Unlike some of their diabetes counterparts like gliptins, statins are not costly and are available at less than two rupees in combination with aspirin or anywhere between three and ten rupees depending on the strength of statin. The reasons for low usage of statin in India are probably multi-factorial. Data from the INTERHEART study showed that LDL-C (low density lipoprotein) from South Asians are lower, with a significant proportion of participants with acute myocardial infarction and controls having a baseline LDL-C < 100 mg/dl.13 Physicians often erroneously feel that the low density lipoprotein levels (LDL-C) are normal and fail to prescribe a statin on those grounds. However, Indians have a more atherogenic dyslipidemic profile compared to Western counterparts.14 Unless there is a reason not to, all patients with diabetes >40 years of age (probably lower) in India should be receiving a statin, based on current evidence. It is important to educate physicians and patients to increase appropriate statin use in diabetes to prevent the rising burden of cardiovascular disease.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 6 1 e2 6 3
The one silver lining in our study was excellent control of hypertension. Blood pressure targets of 130/80 mm Hg were documented in nearly 90% of patients. Prevalence of hypertension in India is high with some recent estimates showing values as high as 33% in urban India and 25% in rural India.15 Anecdotally, we see physicians and general practitioners more liberal in prescribing fixed dose antihypertensives and at least patients in our study seem to be compliant in taking medications for hypertension. We have inherent limitations in this study. There was no attempt to minimize bias based on demographics or socioeconomic status, as consecutive patients were selected in a single hospital study. Therefore results should be interpreted with caution. In conclusion, our study highlights the need for physicians to pursue evidence based glycemic and blood pressure targets especially early in the course of diabetes. Physicians need to be educated on the need to increase statin use in the appropriate clinical context to reduce the burden of macrovascular disease. A strong revalidation program, mandatory continuing professional development schemes and diabetes nurse specialist teams as in western countries can be adopted in India to update and ease the burden on physicians treating diabetes. A more holistic approach to assessment and management of microvascular and macrovascular risk factors is the urgent need of the hour.
Conflicts of interest The author has none to declare.
Acknowledgments Dr KS was formerly Consultant Endocrinologist at Apollo Speciality Hospital, Madurai and wishes to acknowledge Apollo Speciality Hospital Ethical Committee and staff for their help with this study.
references
€ nnemaa T, Pyo € ra € la € K. Laakso mortality 1. Haffner SM, Lehto S, Ro from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998 Jul 23;339:229e234.
263
2. Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ. 1998 Mar 14; 316:823-828. 3. Mohan V, Shah S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: data from the A1chieve study. J Assoc Physicians India. 2013 Jan;61(suppl l):12e15. 4. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Relationship of hyperglycemia to the long-term incidence and progression of diabetic retinopathy. Arch Intern Med. 1994 Oct 10;154:2169e2178. 5. Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycemic control versus targeting conventional glycemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2013 Nov 11;11:CD008143. http://dx.doi.org/10.1002/ 14651858.CD008143.pub3. 6. Gupta A, Gupta AK, Singh TP. Occurrence of complications in newly diagnosed type 2 diabetes patients: a hospital based study. J Indian Med Assoc. 2013 Apr;111:245e247. 7. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008 Oct 9;359:1577e1589. 8. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6;360:7e22. 9. Colhoun HM, Betteridge DJ, Durrington PN, et al, CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004 Aug 2127;364:685e696. 10. Nakamura H, Arakawa K, Itakura H, et al, MEGA Study Group. Primary prevention of cardiovascular disease with pravastatin in Japan (MEGA Study): a prospective randomised controlled trial. Lancet. 2006 Sep 30;368:1155e1163. 11. Gupta R. Burden of coronary heart disease in India. Indian Heart J. 2005 Nov-Dec;57:632e638. 12. Choudhry NK, Dugani S, Shrank WH, et al. Despite increased use and sales of statins in India, per capita prescriptionrates remain far below high-income countries. Health Aff (Millwood). 2014 Feb;33:273e282. 13. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART Study. J Am Coll Cardiol. 2009 Jan 20;53:244e253. 14. Manjunath CN, Rawal JR, Irani PM, Madhu K. Atherogenic dyslipidemia. Indian J Endocrinol Metab. 2013 Nov;17:969e976. 15. Anchala R, Kannuri NK, Pant H, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014 Jun;32:1170e1177.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Original Article
Reducing Clinical Inertia in Diabetes Management: An observational study K. Swaminathan* Consultant Endocrinologist, Kovai Medical Center & Hospital, Coimbatore, India
article info
abstract
Article history:
Background: Patients with diabetes are at high risk of vascular events. Aggressive treatment
Received 1 August 2014
of hyperglycemia, hyperlipidemia and hypertension are cornerstones of diabetes man-
Accepted 6 November 2014
agement in an effort to reduce risk of vascular disease. Our aim was to get a snapshot of
Available online 27 November 2014
diabetes management in the community in terms of the above three risk factors, so that deficient areas can be targeted to educate physicians and diabetologists.
Keywords:
Methods: All consecutive patients with known history of diabetes managed in the com-
Diabetes
munity who had enrolled for a diabetes master health check over a one year period from
Cardiovascular disease
Jan 2013 to December 2013 at Apollo Speciality Hospital, Madurai were included in this
Microvascular
study. Local Ethics Committee approval was obtained. Variables were collected and analyzed using Microsoft Excel 2007. Results: Data from one hundred and one patients were analyzed. Mean age of patients was 53.8 years with an average duration of diabetes of 3.5 years. Mean glycosylated hemoglobin was 8.6%. About 90% of patients had a blood pressure within the target range. Nearly twothirds of patients were not on a statin. The rates of newly detected neuropathy, retinopathy and microalbuminuria were 40%, 30% and 35% respectively. Conclusion: Physicians should adopt a more holistic approach to microvascular and cardiovascular risk factors in patients with diabetes, adhering to evidence based guidelines with personalized targets. Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
There is data to suggest that diabetes patients without a previous myocardial infarction have as high a risk of such an event as nondiabetic patients with a history of myocardial infarction, thereby elevating diabetes as a Coronary Heart Disease equivalent.1 It is therefore often quoted that “Diabetes is not only a metabolic disorder but a vascular disease as well”.
The evidence for atherogenic risk factors in diabetes is strongest for hypertension, lipids, smoking and hyperglycemia.2 Aggressive risk factor reduction based on established national and international guidelines is vital in reducing the risk of both micro and macrovascular complications in diabetes. However, many health care professionals find it difficult to follow evidence based guidelines due to a variety of reasons ranging from clinical inertia, uncertainty of real life scenarios against guideline based management and the ever
* Tel.: þ91 8526421150; fax: þ91 422 2627782. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.apme.2014.11.002 0976-0016/Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
262
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 6 1 e2 6 3
present argument of experience based medicine versus evidence based medicine. Data from a large Indian study recently has shown that glycemic control is extremely poor in India with a high prevalence of micro and macrovascular complications.3 Our aim was to get a snapshot of a real world risk factor management in patients with diabetes from the South Indian city of Madurai.
2.
Methods
All consecutive patients attending a diabetes master health check at Apollo Speciality Hospitals, Madurai were included in this study. All the participants were managed in the community for their diabetes and were “first timers” for the comprehensive check at our institution. Local Ethical Committee approval was obtained. A waiver of consent was given as this was a retrospective observational study. Data was prospectively collected and analyzed on Microsoft Excel 2007. The following variables were collected from our patients; age, sex, waist circumference, body mass index, blood pressure, fasting glucose, post-prandial glucose, glycosylated hemoglobin (HbA1c), fasting lipid profile, urinary microalbumin, retinopathy graded by an ophthalmologist and neuropathy grades using a biothesiometer. All patients underwent a detailed counseling session by a dedicated diabetes educator highlighting the importance of diet, lifestyle and risk factor management in diabetes.
3.
Results
A total of one hundred and one patients were analyzed. Mean age of patients was 53.8 years with a predominance of type 2 diabetes (98%). Most of the patients (95%) had no history of cardiovascular disease. The mean duration of diabetes was 3.5 years. Mean glycosylated hemoglobin was 8.6% with a fasting glucose of 175 mg/dl and a 2 h post-prandial of 289.7 mg/dl. Details of all other variables are tabulated in Table 1. Approximately 65% of patients were not on a statin. Blood pressure goals of 130/80 mm Hg was documented in 90% of patients, with predominant use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Some degree of neuropathy was present in 40% of the patients, with severe neuropathy documented in 15%. Nearly 30% had retinopathy with 3% needing urgent assessment for proliferative
Table 1 e Characteristics of study population {Mean (SD)}. Total number of patients (n) Mean age (years) Male:Female (n) Type 2 diabetes:type 1 diabetes (n) Mean duration of diabetes (years) Mean body mass index (kg/m2) Mean glycosylated hemoglobin (%) Mean systolic blood pressure (mm Hg) Mean diastolic blood pressure (mm Hg) Mean LDL-C (mg/dl) Mean HDL-C (mg/dl) Mean triglycerides (mg/dl)
101 53.8 years (10.2) 61:40 98:3 3.5 years (2.01) 27 (4.43) 8.6% (2.07) 128 mm Hg (16.6) 75.3 mm Hg (8.5) 104.2 mg/dl (33.9) 39.3 mg/dl (10.2) 156 mg/dl (93.7)
diabetic retinopathy. In patients with less than three years duration of diabetes, the mean glycosylated hemoglobin was 8.7% and nearly 67% of these patients were not on statins.
4.
Discussion
Our study highlights the presence of clinical inertia especially early in the course of type 2 diabetes, precisely when health care professionals should be aggressive in treating cardiovascular risk factors. The mean glycosylated hemoglobin (HbA1c) in our study was 8.6%. Hyperglycemia is an important risk factor in microvascular disease.4 In a recent large meta-analysis of 34,912 participants with type 2 diabetes, there was a significant reduction in the risk of microvascular complications in the intensive compared to standard glycemic control group.5 The rates of newly detected microvascular complications in our study were significantly high ranging from 30 to 40 % for retinopathy, microalbuminuria and neuropathy. High prevalence of microvascular complications early in the course of type 2 diabetes has been reported by few other Indian studies as well.3,6 The link between hyperglycemia and macrovascular disease is less straightforward. However, the concept of “legacy effect”, where a sustained period of glycemic control early in the course of diabetes has a long term benefit in reducing cardiovascular mortality7 may be very relevant in the way we approach glycemic targets in the first few years of type 2 diabetes. Most of our patients were free of macrovascular disease and were early in the course of type 2 diabetes. This should be an added incentive for physicians to treat glycemic targets aggressively with early combination therapy of medications with low side effect profiles. Nearly two-thirds of our patients were not prescribed a statin, even though the beneficial effects of statins in diabetes have been established by landmark clinical trials.8e10 This is of particular concern in India where the burden of coronary artery disease is high.11 Interestingly, as of January 2010, there were 259 distinct statin products available to the Indian consumers and nevertheless only a fraction of those eligible for statin therapy appeared to receive this therapy.12 Unlike some of their diabetes counterparts like gliptins, statins are not costly and are available at less than two rupees in combination with aspirin or anywhere between three and ten rupees depending on the strength of statin. The reasons for low usage of statin in India are probably multi-factorial. Data from the INTERHEART study showed that LDL-C (low density lipoprotein) from South Asians are lower, with a significant proportion of participants with acute myocardial infarction and controls having a baseline LDL-C < 100 mg/dl.13 Physicians often erroneously feel that the low density lipoprotein levels (LDL-C) are normal and fail to prescribe a statin on those grounds. However, Indians have a more atherogenic dyslipidemic profile compared to Western counterparts.14 Unless there is a reason not to, all patients with diabetes >40 years of age (probably lower) in India should be receiving a statin, based on current evidence. It is important to educate physicians and patients to increase appropriate statin use in diabetes to prevent the rising burden of cardiovascular disease.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 6 1 e2 6 3
The one silver lining in our study was excellent control of hypertension. Blood pressure targets of 130/80 mm Hg were documented in nearly 90% of patients. Prevalence of hypertension in India is high with some recent estimates showing values as high as 33% in urban India and 25% in rural India.15 Anecdotally, we see physicians and general practitioners more liberal in prescribing fixed dose antihypertensives and at least patients in our study seem to be compliant in taking medications for hypertension. We have inherent limitations in this study. There was no attempt to minimize bias based on demographics or socioeconomic status, as consecutive patients were selected in a single hospital study. Therefore results should be interpreted with caution. In conclusion, our study highlights the need for physicians to pursue evidence based glycemic and blood pressure targets especially early in the course of diabetes. Physicians need to be educated on the need to increase statin use in the appropriate clinical context to reduce the burden of macrovascular disease. A strong revalidation program, mandatory continuing professional development schemes and diabetes nurse specialist teams as in western countries can be adopted in India to update and ease the burden on physicians treating diabetes. A more holistic approach to assessment and management of microvascular and macrovascular risk factors is the urgent need of the hour.
Conflicts of interest The author has none to declare.
Acknowledgments Dr KS was formerly Consultant Endocrinologist at Apollo Speciality Hospital, Madurai and wishes to acknowledge Apollo Speciality Hospital Ethical Committee and staff for their help with this study.
references
€ nnemaa T, Pyo € ra € la € K. Laakso mortality 1. Haffner SM, Lehto S, Ro from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998 Jul 23;339:229e234.
263
2. Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ. 1998 Mar 14; 316:823-828. 3. Mohan V, Shah S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: data from the A1chieve study. J Assoc Physicians India. 2013 Jan;61(suppl l):12e15. 4. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Relationship of hyperglycemia to the long-term incidence and progression of diabetic retinopathy. Arch Intern Med. 1994 Oct 10;154:2169e2178. 5. Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensive glycemic control versus targeting conventional glycemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2013 Nov 11;11:CD008143. http://dx.doi.org/10.1002/ 14651858.CD008143.pub3. 6. Gupta A, Gupta AK, Singh TP. Occurrence of complications in newly diagnosed type 2 diabetes patients: a hospital based study. J Indian Med Assoc. 2013 Apr;111:245e247. 7. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008 Oct 9;359:1577e1589. 8. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6;360:7e22. 9. Colhoun HM, Betteridge DJ, Durrington PN, et al, CARDS Investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004 Aug 2127;364:685e696. 10. Nakamura H, Arakawa K, Itakura H, et al, MEGA Study Group. Primary prevention of cardiovascular disease with pravastatin in Japan (MEGA Study): a prospective randomised controlled trial. Lancet. 2006 Sep 30;368:1155e1163. 11. Gupta R. Burden of coronary heart disease in India. Indian Heart J. 2005 Nov-Dec;57:632e638. 12. Choudhry NK, Dugani S, Shrank WH, et al. Despite increased use and sales of statins in India, per capita prescriptionrates remain far below high-income countries. Health Aff (Millwood). 2014 Feb;33:273e282. 13. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART Study. J Am Coll Cardiol. 2009 Jan 20;53:244e253. 14. Manjunath CN, Rawal JR, Irani PM, Madhu K. Atherogenic dyslipidemia. Indian J Endocrinol Metab. 2013 Nov;17:969e976. 15. Anchala R, Kannuri NK, Pant H, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014 Jun;32:1170e1177.