The Heart Failure Epidemic in India!
WORLD HEART DAY
The Heart Failure Epidemic in India!
Dr. Pranab Bhattacharyya
Heart failure is a condition caused by different underlying diseases rather than being a specific disease itself.
It may be described as the culmination of different types of untreated or sub-optimally treated heart diseases or due to progressive exposure to various cardiovascular risk factors. This condition carries high morbidity and mortality and accounts for many repeated hospitalizations.
Traditionally, HF has been defined as a condition where there is a reduced ability of the heart to pump and/or fill with blood, resulting in an inadequate cardiac output caused by a structural or functional abnormality of the organ.
The body’s needs for blood and oxygen are not met. Despite its name, heart failure does not mean the heart has completely failed. However, it may be life threatening if left untreated.
Those diagnosed with heart failure may experience shortness of breath either during activity (most commonly) or at rest. Sometimes it comes on suddenly at night and makes one sit up to make breathing easier. Persistent cough or wheezing, swelling in the feet, ankles and legs, weight gain, tiredness and fatigue, lack of appetite, nausea and increased heart rate may be noticed.
The magnitude of the problem is of serious concern as Heart failure is a rapidly growing public health issue with an estimated prevalence of 64 million people globally. The prevalence is increasing due to the ageing of the population, improved survival after heart attack and improved treatment and survival of patients with heart failure.
Yet, Heart Failure remains associated with high mortality and morbidity, poor quality of life and functional capacity, and confers a substantial burden to the healthcare system. In many South Asian countries including India, there are limited data regarding exact prevalence or incidence of heart failure.
Moreover, countries like India, experience a ‘double burden’ of heart failure cases. This refers to the increase in non-communicable diseases (NCDs), such as hypertension, diabetes and coronary heart disease contributing to heart failure, alongside the persistence of ‘traditional’ infective heart diseases, such as rheumatic heart disease causing heart valve abnormalities leading to heart failure over time.
Although heart failure is predominantly thought of as a disease of the elderly, Indians present almost 10 years earlier in age compared to other ethnic counterparts, with a mean age of 61 years.
Four major conditions which are contributors to the majority of HF burden globally are important in the perspective of primary prevention. They are ischemic coronary heart disease or ischemic heart disease, hypertension, diabetes and rheumatic heart disease.
Ischemic coronary heart disease is responsible for more than 70 % of the burden of heart failure in India. Delay in seeking/ getting treatment is the most important reason for the development of heart failure in ischemic heart disease. Increasing awareness among the public and quality improvement initiatives to reduce time of patient contact to starting treatment can help especially primary angioplasty and stent implantation for heart attack.
Affordability issues are a significant barrier to timely treatment. However, with Government of India’s Flagship Public Health Insurance/Assurance Scheme Called “Ayushman Bharat Pradhan Mantri Jan Arogya Yojana” currently in force, all eligible patients are receiving coronary angioplasty and stent implantation for heart attacks free of cost.
Diabetes is also on the rise in India. The prevalence in India now stands at 11.4 per cent. Screening and early detection of diabetes will prevent the development of complications like heart failure.
Hypertension is often referred to as the silent killer, poses a significant health challenge. According to a recent survey, 35 per cent of the adult population in India is hypertensive and among them only one third are really controlled. Those with uncontrolled blood pressure go on to develop heart failure. Preventive measures play a crucial role in reducing blood pressure and mitigating its associated risks.
These measures include reducing dietary salt intake, improving physical activity levels, and increasing the consumption of fruits and vegetables.
Rheumatic heart disease is still a persisting problem in India contributing to the increasing burden of heart failure patients. There are several time points where actions can be taken to halt the progression from streptococcal throat infection to rheumatic fever, and subsequently to established rheumatic heart disease and heart failure.
Public health initiatives aimed at preventing and treating streptococcal infections are important, including timely administration of antibiotics to children with streptococcal sore throat and long-term penicillin prophylaxis. These measures will prevent repeated episodes of acute rheumatic fever, thereby reducing the risk of progressive valve damage and the development of severe complications such as heart failure.
Other Key Lifestyle Contributors to heart failure risk in Indians include use of tobacco products (not only cigarettes, but also bidis and chewable tobacco), abdominal obesity, air pollution and pesticides and general obesity.
Adoption of healthy lifestyle practices is of utmost importance – avoidance of smoking and tobacco products, weight management, eating healthy diet including fresh fruits and vegetables, limiting salt and alcohol intake, staying active with moderate exercise, reducing stress levels and getting adequate sleep. Medical opinion may be sought regarding recommended vaccinations especially influenza and pneumonia.
Costs incurred by heart failure care include direct costs (expenditure on hospital and physician services, drugs, and follow-up) and indirect costs (due to lost productivity, sickness benefit, and welfare support). When comparing overall contribution to global heart failure spending, the United States ranks at the top, while South Asian countries including India, ranking the lowest in the world.
Although appropriate use of medications for heart failure have shown to improve morbidity and mortality, however, only 30% patients with heart failure take regular medicines as prescribed. Lack of education on heart failure, need for multiple medicines and a high pill burden and medication costs were cited as some of the major reasons for this non-compliance in an important study.
In appropriately selected patients, Device therapy, specifically CRT/ICD, has also been shown to improve mortality and reduce hospitalizations in patients with a diagnosis of heart failure. Scientific data have shown a clear superiority of CRT over optimal medical therapy in the improvement of heart failure symptoms. Despite this, only a quarter of patients accept implantation of a CRT device, with financial constraints being the main reason for refusing implantation of this device.
Factors, such as ageing and rising populations, in many South Asian countries including India, alongside an increased prevalence of Non-Communicable Diseases’, point towards an impending epidemic of heart failure. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines may be helpful in overall management of this important health issue.
Keeping in mind the high cost of treatment of the burgeoning population of heart failure patients, the main focus must be on prescribing appropriate cost-effective medicines by physicians, medical adherence to prescribed medicines by patients and to adopt urgent steps for lifestyle changes.
Dr. Pranab Bhattacharyya, Professor of Cardiology, Cardiothoracic & Neuroscience Centre, Gauhati Medical College & Hospital. Ph. 9435555572
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