DECLARATION OF CONFLICT OF INTEREST. None

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1 DECLARATION OF CONFLICT OF INTEREST None

2 BURDEN OF CORONARY ARTERY DISEASE IN DIABETES IN INDIA Amal Kumar Banerjee MD, DM,FACC,FESC,FACP,FAPSC,FICC President Association of Physicians of India SAARC Cardiac Society Immediate Past President Cardiological Society of India Senior Consultant & Intervention Cardiologist AMRI Hospital, Salt Lake, Kolkata Formerly Cardiology Division, Institute of Cardiovascular Sciences IPGME&R, SSKM Hospital Kolkata

3 PROLOGUE In India, diabetes and other NCDs are relatively overshadowed by the continued burden of communicable and nutrition-related diseases. While these health threats are still present, the rise of NCDs has been rather rapid

4 PROLOGUE C O N T D According to the World Health Report 2005, NCDs already contribute to 52 per cent of the total mortality in India and these figures are expected to increase to 69 per cent by the year 2030

5 EPIDEMIOLOGIC TRANSITION Indian J Med Res 2011;133:

6 Asian Indians are more prone to type 2 diabetes at a younger age and premature cardiovascular disease. There is a growing body of evidence to support the concept of the Asian Indian Phenotype J Assoc Physicians India 2003; 51 : Type 2 diabetes in South Asians: Epidemiology, risk factors and prevention. New Delhi: Jaypee Brothers Medical Publishers,2006;138-52

7 WHY ARE INDIANS MORE PRONE TO TYPE 2 DIABETES AND CAD? Greater ethnic susceptibility and genetic familial aggregation of type 2 diabetes Lower age at onset of Type 2 diabetes Low birth weight thin fat Indian Inflammatory markers; CRP Abdominal obesity and visceral fat Levels of adiponectin ASIAN INDIAN PHENOTYPE Lower threshold for BMI for diabetes Serum insulin levels/ insulin resistance Characteristic dyslipidemia: HDL cholesterol triglycerides & small dense LDL Increased prevalence of type 2 diabetes / premature CAD Indian J Endocrinol Metab. 2005;7:72 85

8 Among Asian Indians who are known to have high risk of premature coronary artery disease and diabetes, a significant association exists between insulin resistance with cardiovascular risk factors even among NGT subjects C U R E S - 66: J Assoc Physicians India 2011;59:

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10 The Challenge of Cardiovascular Disease in Developing Countries New York, NY: Columbia University, 2005

11 RISK FACTORS FOR CAD IN INDIANS LOW BIRTH WEIGHT Lp(a) Genetic / ethnic susceptibility GLUCOSE INTOLERANCE (DM + IGT) / INSULIN RESISTANCE OBESITY (Central Body) Modest elevation of LDL tpa, PAI-1 Atherothrombogenic profile Low HDL, High TC/HDL ratio?triglycerides CRP, Fibrinogen Platelet activation CAD

12 EPIDEMIOLOGY OF CORONARY ARTERY DISEASE IN INDIANS India is predicted to bear the greatest CAD burden, according to the estimates from the Global Burden of Disease Study The overall cardiovascular mortality in Indians is predicted to rise by 103% in men and 90% in women between 1985 and 2015 A matter of serious concern is that 52% of the CAD deaths in India occurred in people aged below 70 years, while the same was just 22% in developed countries

13 EPIDEMIOLOGY OF DIABETES IN INDIANS India leads the world with 50.8 million people in diabetes in 2010 Moreover, it is projected that, by the year 2030, 87 million will have diabetes in India Prevalence of diabetes in urban Indians has steadily increased from 2.1% in the 1970s to 8.2% in the 1980s, later climbing to 12 16%

14 DIABETES & MORTALITY IN INDIA J Assoc Physicians India 2006; 54 : 113-7

15 P R E VA L E N C E O F C A D Overall (n=1175) 11.0% NGT 9.1% IGT 14.9% Diabetes 21.4% Mohan V et al,.j Am Coll Cardiol. 2001; 38;

16 PREVALENCE OF CAD IN SOUTH INDIAN SUBJECTS WITH AND WITHOUT GLUCOSE INTOLERANCE SUBJECTS NGT IGT Diabetes Documented MI (%) 0.9% 3.4% Overall Q waves (%) 1.2% 1.4% 8.2% ST-segment depression (%) T-wave abnormalities (%) Total CAD prevalence (%) J Diabetes Sci Technol 2010;4(1): % 5.4% 2.8% 6.6% 8.1% 9.0% 9.1% 14.9% 21.4%

17 R I S K F O R C A D I N I N D I A N S 25 CAD PREVALENCE % additional risk due to IGT NON-DIABETIC SUBJECTS IMPAIRED GLUCOSE TOLERANCE DIABETES Mohan V et al, J Am Coll Cardiol. 2001; 38;

18 RISK FOR CAD AMONG SUBJECTS WITH DIABETES 25 CAD PREVALENCE % additional risk due to diabetes 0 NON-DIABETIC SUBJECTS IMPAIRED GLUCOSE TOLERANCE DIABETES Mohan et al,.j Am Coll Cardiol. 2001; 38;

19 PREVALENCE OF DIABETES WITH CAD IN INDIA Author Year Clinic/population based study City/State Prev alence % Chaddha et al 1990 Population New Delhi 9.7 Raman Kutty et 1993 Population Kerala 7.4 al Mohan et al 1995 Clinic Chennai 17.8 Gupta et al 1995 Population Uttar 7.9 Pradesh Ramachandran 1998 Population Chennai 14.3 et al Ramachandran 1999 Clinic Chennai 11.4 et al Mohan et al 2001 Population Chennai 21.4 Gupta et al 2002 Population Rajasthan 8.2

20 PREVALENCE OF CAD IN DIABETES IN INDIA

21 CREATE REGISTRY DATA 20, 468 patients with ACS 89 centres from 10 regions and 50 cities in India Known Diabetic Total % STEMI % NSTEMI % p < Lancet 2008;371: OASIS REGISTRY 1 & 2 DATA Patients with non-st elevation ACS Diabetes at admission in India : highest, age-adjusted prevalence 39.1% Indian Heart J 2005 ;57(3):217-25

22 CORONARY VESSEL INVOLVEMENT BY ANGIOGRAPHY Mishra, Routray, Das, Behera, Satpathy & Pattnaik, Cuttack, 2003

23 Relative odds ratio of CAD Relative odds ratio of CAD Relative odds ratio for CAD by quartiles of Fasting plasma glucose p = Reference <= >=91 Fasting blood sugar (mg/dl) Relative odds ratio for CAD by quartiles of 2 hour post plasma glucose Mohan V et al, Current Science, 2002, 83: Reference P < P < <= >=123 2 hr Post Prandial blood sugar (mg/dl)

24 Carotid IMT (mm) CAROTID IMT VALUES IN DIFFERENT STAGES OF GLUCOSE INTOLERANCE Chennai Urban Rural Epidemiology Study [CURES] # 0.8 * 0.75 * * p < 0.01 compared to NGT, # p < compared to IGT, NDD 0.6 Normal glucose tolerance Impaired glucose tolerance Newly detected diabetes Known diabetes Diabetic Medicine, 2006, 23:

25 Mean Oxidized LDL [U/L] MEAN OXIDIZED LDL VALUES IN SUBJECTS WITH DIFFERENT GRADES OF GLUCOSE TOLERANCE 60 * #@ 50 *@ NGT IGT Diabetes * p < compared to Normal subjects # p<0.001 compared to IGT p<0.001 compared to NGT after adjusting for age. Metabolism Clinical and Experimental 2007;56:

26 MEAN LEVELS OF SMALL DENSE LDL : CURES J Assoc Physicians India. 2005;53:95 100

27 Hs C-REACTIVE PROTEIN (HsCRP) IN SUBJECTS WITH CAD Mean CRP values(mg/l) No Diabetes & No CAD Diabetic subjects without CAD Diabetic subjects with CAD Diabetic Medicine. 2005;22:

28 PREVALENCE OF CAD WITH MULTIPLE RISK FACTORS Indian J Med Res. 2002;116:163 76

29 ODDS RATIO OF CAD WITH DIABETES AND HYPERTENSION : CUPS J Am Coll Cardiol. 2001;38(3):682 7

30 C O N C L U S I O N Prevalence of CAD is very high in Indians compared to other ethnic groups Among Indian diabetics it is even more striking Indians with pre-diabetes also tend to have high risk for CAD Atherosclerotic changes starts during the prediabetic stage itself Preventing CAD in Indian diabetics would require a multi-pronged approach with control of blood sugar, blood pressure, hyperlipidemia and life style modification

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