Prevention of Coronary Artery Disease

Healthy Lifestyle- The Panacea- Lifestyle Trumps Genetics

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Pak Army

Ischemic heart disease is a major cause of mortality in the world. It is estimated that annually 17.2 million people died worldwide making it one of the biggest killers. In the United States of America 3,65,000 people die of coronary heart disease annually. The treatment of coronary heart disease is lifelong and very expensive. There is also an inestimable cost of enormous sufferings. The real answer of this dreadful problem is in adopting preventive measures. Surely prevention is not only better than cure. In fact it is the only cure, the real cure. Developed countries like the European Union, Nordic, Canada, Australia, New Zealand, Japan etc. practicing Universal welfare, national Health Care Systems have considerably reduced the incidence of coronary artery disease by adopting preventive measures at National and also at individual health care levels. Likewise, many developing countries like Sri Lanka, Cuba etc. have enormously reduced the burden of ischemic heart disease. Pathetically the burden of ischemic heart disease is progressively increasing in Pakistan.

Prof. Mahmud Ahmad Akhtar

In a recent study published in the Pakistan Armed Forces Medical Journal the authors concluded that the incidence of the metabolic syndrome- the precursor of coronary heart disease is higher amongst the soldiers of Pakistan Armed Forces than the Saudi Arabian, Jordanian and the Indians. Surely it is alarming. It is due to poor lifestyle, having poor quality, calorie rich diet, lack of activity and physical exercise, increased consumption of tobacco, neglect of health and education in the national priorities.

The risk factors are defined as modifiable like life-style ones and un-modifiable the inherited genetics. Adopting lifestyle measures like avoiding obesity particularly central/ abdominal (abdominal girth midway between lower costal margin and upper iliac crest less than) 35 ½ in males and less than 31 ½ inches in females by taking diet consisting of at least five portions of vegetables/fruits (one portion is one cup of leafy vegetable, 1/2 cup of solid vegetables, a small fruit), whole grains, pulses/legumes (beans, lentils, peas) nuts, seeds (90% plant based) rich fibre both soluble and insoluble, low-fat dairy products,  fatty fish,  white meat- low saturated fats and red meat, and low salt and low sugar diet, avoiding processed-food/ junk food,  trans fatty acids. Adequate sleep of eight hours following circadian Rhythm, avoid smoking, pollutions, undue stresses, taking regular exercises (stretching, aerobics, muscle strengthening, relaxation) More importantly five minutes’ exercise hourly, avoiding sitting more than 40 minutes. These measures are highly preventive.

South Asians are considered genetically more prone to coronary artery disease. For prevention, European males are recommended to have abdominal girth less than 40 inch (South Asian less than 35 ½ inch) European females less than 35 inch (South Asian less than 31 ½). South Asian individuals/ patients should be encouraged, educated and motivated to adopt healthy lifestyle measures. Dedicated prevention entails the whole hearted health care.

Recent study has shown that by adopting above-mentioned preventive measures people can temper down even the worst genetic fifty genes involved in the causation of coronary artery disease. These have been identified each playing its specific role. A new analysis of data from more than 50000 people in the USA has provided an answer. Dr. Sekar Kathresan, the Director of the centre for human genetic research at Massachusetts. General Hospital in Boston says that you have control over this problem even if you have been dealt a bad genetic hand. It was published recently (Nov 13, 2016) in the New England Journal of Medicine to coincide with the presentation of the results at the annual meeting of the American Heart Association.

The investigators found risk of heart disease, but a good life style cut, in it half just as important they found, a terrible lifestyle erases about half of the benefits of good genetics. The lifestyle can work both ways. It has predominant role found in another study that group analyses involved black and white American aged 45-64.

A good lifestyle with the people having highest genetic risk cut the 10 years’ likelihood of the heart disease to 5.1% from 10.7%. Another study involved 21,222 American Woman aged 45 and older who were health professional, their 10 year risk fell to 2% from 4.6% in the high-risk group if they also had a healthy lifestyle. Exercise improves heart rate, blood pressure and cholesterol but those account only for half of the benefits. Recent experimental studies of animals carried out at the Maryland University, USA have shown that a single physical work out affects gene activity within the cardiac cells producing proteins which prolongs the length of telomers a sign of healthy and longer living cells thus prolonging the life of the cardiac cells. It needed repeated exercises to maintain healthy cardiac cells. Aerobic exercise is more effective.

In another study, Swedish participants aged 44 to 73 had a 10-year risk reduction to 5.3% from 8.2%. In another American study of Americans aged 55 - 80, those with a genetic risk but a healthy lifestyle had significantly less calcium, a sign of disease in the heart coronary arteries. These Studies have been widely reported in the medical journals.

For effectively adopting preventive measures, there is a need to develop a change in attitude and the system of healthcare. In the better developed Healthcare Systems, the prevention starts at the Primary Health Care level. The GPs counsel patients during the initial primary consultation, like wise consultants spend considerable time with patients advising/ counselling on preventive aspects and also preventive medicine given the importance, it deserves. In Pakistan, there is not only lack of knowledge due to poor medical education as a result of mushrooming of substandard medical institutions and massive mal-practice. Even many cardiologists just spend a few minutes with the patient avoiding listening/ talking to patients even not touching a patient.

A patient who gets a heart attack, for successful management the patient should reach the coronary care unit within a short period. The expensive, non-cost effective free standing cardiac institutes are being setup neglecting primary/ emergency cardiac care. As an example in ISB/RWP area there are two cardiac institutes loaded with all sort of patients even minor hypertension, anxiety states, ordinary chest pain etc. reporting directly without referrals. There are many cardiac departments at the public and private hospitals not having properly equipped/ staffed coronary care units.

From Rawalpindi to Lahore there is not a single coronary care unit worth the name. There is a need to have network of acute coronary care units all over the country, part of the cardiac departments at tehsil/ district hospital levels so that heart attacks are treated in time and lives are saved. Same is the situation for the patients suffering from strokes.

The developed countries first established the network of acute coronary Care unit all over the country part of their cardiac departments of the General hospitals. Cardiac Institutes emerged much later that too an occasional one for high class research purpose. In Pakistan, the situation is in the reverse direction for vote caching and to fulfil the needs of elites, neglecting the common 95% of people who live in rural and backward areas.

In conclusion, lifestyle measures of keeping ideal weight, avoiding central obesity by taking healthy diet, 90% plant-based diet, good sleep, regular regime of exercises, even people with bad genetic history and risk factor like obesity etc, can derive benefits while those with good genetic history, having bad lifestyle can be affected adversely. This shows the overall importance of healthy life-style. It trumps even the bad genetics while bad life style loose the benefits of good genetics. It is also cost effective. It should be adopted and promoted at National level through every means-media, academics, religious leaders and political leader’s exemplary life.