On the spot observations

Challenges in treating High BP and Diabetes in District Kupwara including Machil Sector
On the spot observations

Heart diseases remains the predominant causes of mortality in at least a quarter of our population for more than 2 decades and is clearly showing an alarming trend all over India including Jammu and Kashmir. This is actually fuelled by a high prevalence of high blood pressure (Hypertension) and diabetes mellitus (DM) which are the two important and preventable risk factors. Other important risk factors being smoking, high levels of blood cholesterol, obesity, physical inactivity and low consumption of fruits and vegetables.

The estimates in J and K of high blood pressure would be around 42% of the population which would mean a figure of around 5 million people with hypertension (HT). Diabetes mellitus (DM) would be present in around 1.5 million people. The combination of HT and DM also called a "deadly duo" in 0.9 million people.  This population is at an even higher risk. Recognition of these problems and early adequate treatment is necessary to reduce the high cardio vascular mortality predominantly because of heart attacks, strokes and kidney failure

The treatment standards for common problems like HT and DM are very variable. This is especially true for peripheral and remote locations of Jammu and Kashmir. This is despite a well-structured health care system consisting of District and Sub district Hospitals, Primary health centres (PHCs), New type PHCs, Wellness centres and Sub centres. Running these is a challenge due to limited resources, shortage of staff and connectivity with the major towns and the main cities. Winter months starting from November to March increase these challenges due to obvious reasons.

In our endeavour through the Gauri Heart Health project (GHHP) which has started to move around sequentially to all the 20 districts of the Union territory, it has been decided to evaluate a minimum of 100 patients identified by the district health authorities with an equal representation from all the blocks. The focus will be on patients already undergoing medical treatment for HT, DM or established heart disease to review the strategies and optimize their management as per the current National guidelines. All patients would have a BP measurement with a calibrated and internationally approved instrument to get correct readings.

In case patients are not on new drug classes which have been introduced in the last few years to improve the outcomes especially of patients with DM and associated problems these would be recommended. In addition, everybody would be counselled for having a healthy life style.

We started with Kupwara District after a virtual inauguration by the Financial Commissioner Mr Atal Dulloo on 29th September the World Heart Day. The logistics were arranged by the DC and the CMO. The Army supported us for travelling to Machil sector.

Our group consisting of 3 doctors and 3 Research Coordinators along with paramedics of the hospitals, evaluated 105 pre-selected patients (61% males with 20% more than 65 years of age). Forty seven percent patients had HT and 13% had DM. The general impression was that half of the patients with HT had BP levels more than the target of 140/90 mms Hg including some with alarmingly high levels of more than 200 mms Hg. At least 20 percent were taking medicines only when they felt it was high. Medicines prescribed were of acceptable groups and very often in combination forms. A noteworthy feature was medicines which were more expensive had higher prescriptions: Like Olmesartan was used more often than Telmisartan.

The population habitually has a very high salt intake with "Noon Chai" (salted tea) low consumption of fruits and vegetables other than haakh (collard green) and very little consumption of raw salads coupled with high intake of rice, potatoes and red meat cooked as a curry. Very economical drugs like diuretics (water pills) which would be very effective, in a high salt intake population had been used very sparingly.

In the group of patients with DM (13%), very few patients were checking their sugar levels using the point of care devices. All of them were on acceptable combinations of Metformin and sulfonyl urea's. DPP4 agents (Gliptins) and insulin injections were also used in some. The checking of the level of control by tests like glycosylated haemoglobin (HbA1c) was very rare.

The newer agents which in diabetics, significantly reduce problems like heart and kidney failure, were not seen in any of the prescriptions. These are agents like canagliflozin, dapagliflozin and empagliflozin. Starter kits which we had carried were given to them and pharmacies of the area through drug companies were advised to stock them.

These drugs being expensive, all patients were counselled to take them after explaining to them the long-term benefits. The patients of valley are known for their health consciousness and accepting new drugs without hesitation.

Another important observation was lack of emphasis on estimating cholesterol levels and a low prescription rates of statins (atorvastatin, rosuvastatin etc). These agents which reduce heart attacks and strokes by around 30% were either not prescribed or in very low doses.  High or very high triglycerides was also an observation. The common cause of this being a very high intake of carbohydrates esp. rice, unrecognized DM and thyroid problems.

Aspirin for prevention in patients without a previous vascular event was needlessly used in a large majority of patients. The guidelines for its use which have changed in the last few years have not penetrated effectively to physicians of the region. This can result in un necessary bleeding episodes without any net protective value. Its use is advocated only if there has been a heart attack, stroke or angioplasty/ bypass surgery.

Learnings from the Dudi, Machil Sector:

The population of this area is around 17,000. During the winter months only around 6,000 to 7,000 remain there. This population is scattered in small cluster of around 9 villages spread over a large area. It is an area close to the line of control with poor communication facilities with Kupwara and rest of the UT. This area where 35 pre-selected patients were seen had issues in management in common with those seen at Kupwara hospital.

The major issue here is that during the winter months, between November and March, it is totally cut off from Kupwara and neighbouring areas. With the cooperation of Indian Army, an existent small memorial building made in the honour of a martyred Indian Army officer Mr Sahai, could be converted into a small health centre with Telemedicine. The Army officials readily accepted to provide the networking. The DC Kupwara also has agreed to support it with funding. A blue print for this will be ready very soon and the plan is to make it operational, before Machil gets cut off by the road link, at the earliest.

The patients requiring acute surgical interventions which would be in small numbers would be airlifted by helicopter service of the army. One such lady with a complication during labour was airlifted in year 2019 to Kupwara, where she was operated upon successfully.

In our interaction with the doctors working at the levels of PHCs, block medical officers, physicians posted in various hospitals across the districts, district health officers and the CMO of the district, the observations made during the camp were shared. The use of cost-effective drug combinations in treating HT with an emphasis on using diuretics to treat HT was advocated strongly. In addition, adding newer agents to manage DM and use of statins in appropriate high doses and not aspirin, unless dealing with an old heart attack or a stroke. Life style management should always be an important adjunct to the management in all cases.

We plan to have a regular communication and follow up with them and take a feedback periodically. Our next district in the project is Khan Sahib in Budgam district on 31st of October.

Author Is a Cardiologist recipient of Padma Shri and Dr B C Roy Award   and Founder Director Gauri Healthy Heart project

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