After Kupwara as planned under the banner of Gauri Healthy Heart Project (GHHP) we went to the community health centre (CHC), Krimshore , near Khan Sahib in Budgam district. The activity received full support by the district health authorities headed by the CMO Dr Tajamul Hussain khan, who had deputed Dr’s Yasir Wani and Riaz Ahmad to coordinatalong the health camp along with their well-knit team. The Deputy Commissioner, Budgam, Mr Shahbaz Ahmad Mirza also extended all the help and inaugurated the CME on Diabetes and High BP a deadly duo in his complex at Budgam on the 2nd of November. The program had the blessings of the financial commissioner Mr Atal Dulloo.
It has been my experience that the treatment to targets which is very important in these conditions is inadequate in the peripheral areas of our homeland. This leads to increasing occurrence of heart attacks, strokes, chronic kidney disease which can largely be prevented by aggressive treatment approaches. These approaches are a combination of healthy life style measures and administration of cost-effective medicines, in order to emphasize it the medical team of GHHP along with doctors of the district evaluated pre-screened patients with high BP, diabetes with or without stable heart disease.
All the patients underwent a complete evaluation as per a pre formed questionnaire. Measurement of body mass index, Blood pressure using a calibrated instrument, random blood sugar and serum lipid estimation by point of care instruments. Additionally, an ECG was taken for all.
We saw a total of 117 individuals, with 69% between ages of 40 to 65 years. Nearly 95% were Kashmiri speaking with 70% males. Half of them by definition were overweight and 20% obese despite majority of them being physically very active and spending at least 45 to 60 minutes on walks and even climbing up hill. Despite warnings written on cigarette boxes nearly half of them were cigarette smokers.
Uncontrolled BP and Blood Sugar Levels Already on Treatment:
Out of 70 patients with high BP and on medicines which constituted 82% of the patients seen,42% were uncontrolled and one third of them were diabetics. This combination called a deadly duo leads to a very high possibility of getting a heart attack, brain stroke or chronic kidney disease ultimately requiring long term dialysis or a kidney transplantation. Although most of high BP patients were on at least 2 drugs, there compliance was poor and were not aware of the targets. Our OPD booklet had clearly mentioned the targets of BP , blood sugar and cholesterol levels for everybody.
A high intake of salt by way of “Noon Chai” which was consumed by 86% of the individuals and more than 4 cups a day by one quarter of them is an important factor. Excessive salt intake is an important cause of difficult to treat hypertension and needs besides counselling addition of a water pill (diuretic) in the treatment.
As per the projections diabetes is present in around 10% of our population. We saw 26 diabetics on drug treatment and uncontrolled diabetes (random sugars > 180mgs/dl) was seen in more than half of them (68%) which is a striking finding. None of them were on newer agents which improve survival and reduce heart failure, possibly because of not being prescribed or high cost, which is always a limitation and needs pondering over by the authorities.
High Fat Content in Blood:
One of the glaring findings was raised random (Post meal) triglyceride (ugly cholesterol) levels more than 280 mgs/dl, in a very large percentage of patients (45%). This is usually related to high carbohydrate intake and serves a good estimator of abnormal apo-B concentrations, which makes it a useful marker of cardiovascular disease. Out of these more than half (56%) were diabetics on treatment. The bad cholesterol ( LDLc ) levels > 130 mgs/dl were seen in 60% patients who had blood tests.
The high level of bad and ugly cholesterol predisposes to vascular events especially when associated with high BP and diabetes. Excessive rice intake especially polished one along with hypo-thyroidism, obesity and kidney disease are important causes. This coupled with high mutton and low vegetable intake adds to the problem. Medicines are very important when LDLc 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. Patients seen by us had either stopped their prescribed statins or were on very low doses.
Additional Observations;
ECG abnormalities suggesting disease of the conduction system (equivalent of electrical wires of the heart) which supply current for heart muscle contraction were seen in around 15% patients in this selected group. Three of them were in need of a permanent pacemaker. One of them a young man was walking around with a heart rate of just 20/minute with weakness as the only symptom. He was immediately sent to SMHS hospital in an ambulance after informing a cardiologist friend. Other two were counselled and again referred.
Lesson learnt:
This district which is close to the capital city Srinagar, has a significant problem of non-communicable diseases. Hypertension and diabetes despite drug treatment are often uncontrolled. Obesity and high blood contents of ugly and bad cholesterol in spite of the availability of good treatment are seen in large numbers. Life style measures and public education programs in the district by medical professionals including health workers along with judicious use of cost-effective drugs with proper counselling is the need of the day.
Author is a Cardiologist, Past President of Cardiological Society of India. Recipient of Dr B C Roy Award and Padma Shri. Founder Director Gauri Healthy Heart Project.