Our activity of going to all the 20 districts of Jammu and Kashmir continues un-interrupted. After Kupwara and Machil followed by Khan Sahab, District Budgam, we went to the community health centre (CHC), Rajpora in district Pulwama on 27th November for a camp. This camp was under the banner of Gauri Healthy Heart Project (GHHP). The activity received full support by the district health authorities headed by the CMO Dr Haseena Mir, who had deputed Dr Javed Ahmed Bhat, BMO to coordinate the health camp along with a well-knit team. The program has the blessings of the financial commissioner Mr Atal Dulloo and the Director Health services Dr Samir Muttoo.
The CHC Rajpora is a very well-maintained, spacious, multi-speciality hospital, it has facility for dialysis for chronic kidney disease patients. At present all the dialysis facilities of the district have been shifted here with 5 machines, since the district hospital has been converted into a COVID centre. The hospital was in news after a hysterectomy was done successfully in a patient with intractable bleeding because of multiple uterine fibroids. Such efficiency in sub-district hospitals is unusual and is exemplary.
The treatment to targets for high Blood Pressure (BP), diabetes with or without heart disease is essential. In order to emphasize it the medical team of GHHP along with doctors of the district evaluated pre-screened patients with these problems and optimized the drug treatment and also counselled for life style management.
All the patients underwent a complete evaluation as per a pre formed questionnaire. Measurement of body mass index, BP using a calibrated instrument, random blood sugar and serum lipid estimation by point of care instruments. Additionally, an electrocardiogram (ECG) was taken for all by a special ECG machines capable of transmitting the high-quality tracing reported through I cloud on an App downloaded with the doctors. One of the special features was that we also had an access to echocardiography for evaluating the cardiac status for patients with suspected but un-diagnosed cardiac problems.
We saw a total of 127 individuals, with 61% between ages of 40 to 65 years. All of them were Kashmiri speaking with 62% females with 45% of their families earning less than Rs 50,000 annually but all had a house to stay and enough land for growing paddy and a few cattle for milk. 65% patients were either overweight or obese. Majority of them were however physically quite active with their daily chores. Smoking was not a problem with 85% non-smokers.
The problem of uncontrolled Hypertension (HT) despite being treated:
Out of 86 patients (67%) with high BP and on drugs, 41% had uncontrolled HT with BP more than 140/90 mms Hg 8 (9.3%) out of them had diabetes also. This combination called a deadly duo leads to a very high possibility of getting a heart attack, brain stroke or chronic kidney disease. Although most of the HT patients were on at least 2 drugs, there compliance was poor and they were not aware of the targets. Our OPD booklet had clearly mentioned the targets of BP control , blood sugar and cholesterol levels for everybody. The list of drugs dispensed at the health centres needs to be reviewed from time to time. For example, it is high time RAAS inhibitors (like Enalapril / Ramipril) are added to amlodipine in health centres of the district. Likewise, water pills (Diuretics – thiazides) need to be encouraged in this high salt intake population. All these molecules are fairly cheap.
Uncontrolled HT was seen in more than one third of high BP patients in all the 3 districts visited by us. This finding needs to be recognized and treatment strategies made more aggressive.
A high intake of salt by way of “Noon Chai” which was consumed by 96% of the individuals is an important factor. Excessive salt intake, a part of Kashmiri food habits, is an important cause of difficult to treat hypertension and needs besides counselling addition of a water pill (diuretic) in the treatment.
Diabetes was present in 25 patients (19 %) but it was invariably controlled with post meal sugars of < 180 mgs/dl in 83% patients. The newer agents, SGLT2 inhibitors which improve survival and reduce heart failure were being taken by 5 of these patients. Three agents from this group are available (canagliflozin, dapagliflozin and empagliflozin). This was contrary to our experience in Kupwara and Budgam districts, where these agents were not even available with private chemists. We recommended these in all of them and gave them starter kits which had been brought by us. Fortunately dapagliflozin has recently become generic with a significant cost reduction.
Electrocardiography:
Of the 118 ECG’s done 31 were abnormal. Left bundle branch block being seen in 11 (9%) patients, 5 of these had very poorly functioning hearts. Atrial fibrillation (AF) a disorder of rhythm was seen in 6 (5%) patients. This abnormality with a very fast and irregular heart rate predisposes patients to brain strokes and needs lifelong blood thinners (anti coagulants). Aspirin which is an anti-platelet drug does not work in this situation. The treatment of all the patients with poor heart function and AF was suitably optimized after counselling.
Echocardiography:
We did 11 echocardiographic studies on selected patients needing it. A multi-purpose ultrasound machine based in the CHC was utilized. Dr Gowhar from Pulwama district hospital joined us for this activity.
We diagnosed a 23-year-old man with chest pain who had clinical findings suggesting inflammation of the outer layer of the heart called pericardium. He was found to have a massive collection of fluid in this space which could have been life threatening. He was immediately shifted to the tertiary centre of SKIMS after contacting the HOD cardiology. He is currently admitted there and is progressing well. Besides this we found 3 patients with very poorly functioning hearts needing aggressive medical therapy, which was started forthwith.
Lipid Abnormalities:
Like in the other 2 districts, high post meal triglyceride more than 200 mgs/dl was seen in 46% individuals evaluated and low levels of HDL cholesterol was seen in 75% and one third of them had high triglycerides. Most of them were overweight and had high BP. This combination of dyslipidaemia, obesity and HT is called “Metabolic Syndrome”. This syndrome is associated with high risk of developing cardio vascular disease and diabetes. Life style modification is the key to prevent these problems. Regular exercise and consuming more fruits and fresh vegetables which fortunately are available throughout the year now, is the key along with reducing the amount of rice in the meals.
High LDL cholesterol levels were seen in relatively lower percentage of patients 22%. These patients need statin group of drugs (atorvastatin or Rosuvastatin). Our analysis showed that statins were being prescribed more frequently in deserving patients in this district as compared to Kupwara and Budgam. Excessive rice intake along with hypothyroidism, which is seen in up to 18% population in rural Kashmir and obesity are important causes of high triglycerides. This coupled with low levels of exercise, high mutton and low vegetable intake adds to the risk. Medicines are very important when LDL cholesterol levels are high especially in high risk patients with other risk factors. Atorvastatin is a cost-effective medicine and need to be used in high doses (40 mgs or more) in such individuals. These reduce the heart attacks and strokes by more than one third. Using pure triglyceride lowering medicines (fenofibrates) unless it is more than 500 mgs/dl is of no clinical benefit. Very high triglycerides usually more than 1000 mgs can lead to serious diseases like pancreatitis which if not treated in time can be fatal.
Holistic Treatment:
Besides controlling High BP and blood sugar the cholesterol levels need to be kept very low. Keeping BP close to 130/80 mms Hg pays the most dividends at a low cost. Life style measures are very important adjuncts in everybody with or without high risk. We can postpone serious vascular events like heart attacks, strokes and kidney failure by at least one decade.
Lesson learnt:
Pulwama district which is close to the capital city Srinagar, has a significant problem of non-communicable diseases. Uncontrolled hypertension is a major problem. Overweight and obesity are major issue which gets compounded by high BP and elevated triglycerides leading to “Metabolic Syndrome”. Life style measures and public education programs in the district by medical professionals including health workers is the key to success. This along with judicious use of cost-effective drugs with proper counselling is the need of the day. The district doctors need to promote these important measures along with public awareness programs from the administration.
Acknowledgements:
The Team:
Dr’s Haseena Mir, Javed Ahmad Bhat, Gowhar, Zubair Saleem, and doctors of the District along with the team of the Academics and Research Batra Hospital and Medical Research Centre lead by Ms Priyadarshini Arambam.
Pharmaceutical industry for facilitating the investigations and giving starter kit of drugs.
CEO, GHHP Ajaz Rashid
The staff of the CHC Rajpora deserves a special thanks