Supported by an Unrestricted
Educational Grant from
Professor of Medicine, Director- Cardiovascular Imaging Program
Mount Sinai Hospital, New York
Head of the Department of Cardiology
All India Institute of Medical Sciences, New Delhi
President, Cardiological Society of India
</b> This is a really great pleasure not indeed for me this afternoon on the occasion of CSI Cardiac Prevent. He is a president of CSI, I am Dr. H K Chopra. I feel highly privileged to have with me the world authorities in cardiology. To my right is Dr. Srinath S. Reddy, known all the world, he has been the president of World Heart Federation and he is also the president of public health foundation who had tremendous contribution in the field of cardiology in making it noble strategies how to prevent the CAD. To my left is Dr. Jagat Narula, you will feel very privileged and proud as an Indian that Jagat Narula have received a very big heights, he is the trusty of American College of Cardiology, a pioneer and a legend. I am very privileged. I think I will interact with Dr. Reddy.
</b> Dr. Reddy, we just heard your lecture and the power of your lecture, I have no words to express.They are so beautiful, very informative and I am sure we are moving in a very right direction and I would like to ask your input, as to what is the future dimension by which, we can control the CAD. I agree, the way you mentioned tobacco control will renew heart, the rising menace of coronary artery disease to the large extent. What else, we should do in CSI or in the Indian government, we need to have your suggestions.
</b> I believe, there are important pathways by which we can reduce premature mortality due to cardiovascular disease in India. Tobacco, high blood pressure, diabetes are among the three major risk factors that we should be addressing in our country, particularly, from what we know as the major contributors to premature mortality in the Indian population. At the same time, people who are already at a high risk of getting a major cardiovascular event in the next 10 years either because of a combination of multiple risk factors, which they have already acquired or because they have already suffered an event and are candidates for recurrence of another event, should be protected with adequate coverage of life saving evidence based drug therapies. We now have tools at our hand, by which, we can effectively reduce the risk of people, even in people at high risk by using at least four simple drugs and these are not expensive in the Indian context, where generic drugs are also available. However, not many of these candidates at high risk are currently receiving the treatment they should be getting. So improving our health system performance in terms of access and affordability, but more importantly in terms of right prescription practices and improved adherence to these therapies are important. While definitely pushing the pulse pedal on tobacco control by a wide variety of tobacco control measures, whether it is increase taxes, whether it is making public spaces and work places smoke free or having better and more effective pictorial warnings. Those are all important measures. Similarly, acting in the area of trying to reduce the trans-fat content and the sugar content of processed foods these are again important policy measures, encouraging physical activity among Indians, who are particularly prone to insulin resistance because of low physical activity that is also important. However, in the next 15 years the health systems will have to really prioritize apart from all of these the protection of people at high risk by appropriate strategies for early detection and effective risk reduction.
</b> I think, Dr. Reddy you brought many important point that we need to change the mindset of people to have an acceptance of an appropriate restriction and you also mentioned very categorically and empathically that we have to make sure that there is proper adherence or compliance. The issue is at times, the mindset of patient is such that the compliance is not adequate and the second thing, which we see here, that even the prescription is quite variable. You see from a physician level to a super specialist physician level and to a cardiologist level there is lot of variability. How we can address this issue in masses so that our doctor colleague, our primary physician colleague as well as a public at large get educated.
</b> I think, one of the important measures is to prepare standard management guidelines. The science is very clear about what needs to be given to what kind of patients, but we need to cornify that in to simplified what we can call clinical protocols in terms of standard management guidelines. Those would have to be disseminated widely, but now there is an opportunity particularly, with central and state funded health insurance scheme, the Rashtriya Swastha Bhima Yogana as well as many others and whole idea of universal health coverage coming in to have these as a part of an essential health package, which will fit in to this overall insurance program of RSBY or any other universal health coverage program. So once that becomes mandatory then people will understand how this protocols will have to be applied, but also physician education is important and we ought to do it particularly our physician’s in primary care, well we should not have patients receiving the best advice in advanced care institutions and getting lost in the maze of primary care where all kinds of wrong practices are then followed, but education of patience is also important along with education of families, because a well informed patient can be not only a wonderful alley in the whole in the whole health care, actually there is a partnership process that is built in and there I think informing the patients properly even helping using digital technology for education for monitoring, for prescription revision, all of these can actually transform India, we do not have to entirely physician available dependent, but we can actually use technology to bridge some of these gaps, but improving patient education is also absolutely critical component.
</b> Thank you very much Dr. Reddy, I think the point is very well taken Dr. Reddy, has given a very very important point. He said that we have to transform the relationship between the doctors and the patient and education is very important.When we give a solution,the solution is we have to go in a digital way. We have to grow education by print media, electronic media, more communitization and protocolization is the need of the hour. I am sure, things will definitely change with the new module and the new technology we are going to reach masses in a very short span of time and we will definitely improve in the years to come. Dr. Reddy, I think your inputs were enormous valuable and I am sure it has to be implemented, executed with the help of government and non governmental organization, definitely we will work very hard with public health foundation and CSI in a joint venture to combat this menace of rising coronary artery disease in India.
</b> Thank you.
</b> I have with me Dr. Jagat Narula, we are very privileged that he is from India and he has created a huge impact on the globe and representing American College of Cardiology as a trusty.He is a man who has got a lot of contribution in the imaging as a pioneer. I would like to ask Dr. Jagat Narula, do you think that imaging has huge potential if the screening is done, so that we can see the occult CAD or occult or hidden coronary artery disease in the patient who are suffering from obesity, because just now Dr. Reddy spoke that hypertension is a very menace. If you control hypertension and control obesity to control the CAD. We need a tool clinically is fine, there is no doubt about it, but sometimes hidden manifestation takes time and it is a veinal problem or a cardiac problem, what is a potential of imaging as a screening technique, screening tool from your view point, Dr. Jagat Narula.
</b> It’s a very good question, Dr. Chopra imaging essentially is going to be at the forefront, there is no doubt about it. The examination would be done with the imaging tools. For example, you will have the handheld ultrasound with you, you will be able to look at the carotids, you will be able to look at the heart, you will be able to look at anything else. So imaging our stethoscope now. I think the days of stethoscope are numbered or its probably gone and imaging would do very well. When it comes to looking at the high risk groups or it comes to looking at the people who are likely to develop because of the risk factors. Certainly for the screening purposes imaging does make sense. You can have again the carotid ultrasound or coronary calcium scores, which probably would have to come down in their price so that we can use it more commonly in the high risk population. However, when you look at it philosophically, I do not think that we have to depend upon imaging. I think we have got to go after the risk factors.I think it has got to be an approach, which has to be a universal approach. Dr. Reddy, whatever he was telling us is all very practical, it is all policy and it is always going to be much more cost effective when we will be looking at the secondary prevention, where the people have already suffered from the disease or we know that they have the disease, but I think in parallel what we would need and as I said I am going more philosophically here that we would like to have a parallel track where we need to reach out to the public the education has to be to the public not to the patient alone. The education has to be from us and that is something where we do not need the imaging or any other tool for the screening, we have got to go after the risk factors, we have to identify the risk factors, we have to let people know that they have to even prevent their risk factors from happening. The so called primordial and other types of risk factors and the risk factor training or health education has to start at the level of the children. The most important thing that we really need to do is that we reach out to children, we develop the programs were and I know Dr. Reddy had done, lots of program going on for last about 20 years or so like Hriday and other where we have talked about these things, because by the time we become adult, I think it becomes very difficult to change our practices, so most important thing in my opinion would be going after the risk factors and if we take the communicable disease examples, which have been the true success stories for example, Polio it was all, we are not looking at the people who are genetically susceptible or not looking at the strange or other things we went with the universal vaccinations. Similarly, we have got to go with the universal programs here that the risk factor reduction is the most important thing and essentially we have got to get away from these issues that there is genetics involved in there or there is age involved in tbere or anything else. So focus has to be risk factor, risk factors and risk factors.
</b> I think, Dr. Jagat Narula is a really very forceful in saying imaging as a very limited role, no doubt it is powerful tool in the emergencies,but is not the screening tool of that way importance. He says control the risk factors, risk factors should not happen and I think the message very rightly given by Dr. Jagat Narula, he is here to create lot of heart protection corridors right from the childhood and he has quoted the data by “Hriday” I think this is a very powerful data and a very powerful organization, who started school healthy heart initiatives for the first time in India, for which we feel very proud and I think time has come we need to focus that the risk factors should not be born and number two what we call the primodal prevention, or a primary prevention or a secondary prevention and now since the disease is so overt we have to focus on secondary prevention to control the risk factors and he said repeatedly three time control the risk factor, risk factor and risk factor. I think it is a very important message Dr. Narula. I just have to ask you ,since you are on such an important position now in United States and you say universal policy, so I would like to ask you as American College of Cardiology in what way you are going to have an alliance with the public health foundation or CSI to create an impact of the universal policy to control the risk factors.
</b> Although in the way I was trying to say the universal was that our approach has to be universal in the sense that we go after the risk factors in everybody in all the pupils and not essentially the patients, but as far as the role of the as American College of Cardiology and the collaboration with the Cardiology Society of India is concerned I think there are mammoth possibilities. There are immense possibilities here and I do know that you are working very closely with the American College of Cardiology trying to start the educational focus here and again more importantly with World Heart Federation also that we are trying to go to the primary care level not only the cardiologist so that the education could be dispensed and we could promote the awareness about the risk factors in the country for the prevention of non communicable diseases and the most important thing that here we have to look for also is that these risk factors which we commonly talk about cardiology they basically may be the risk factor for almost everything. The same behavioral and dietary problems are the bases of most of the non communicable diseases, be it cancers, be it cardiovascular diseases, be degenerative brain disease, Alzheimer’s disease, respiratory diseases and all other thing. So essentially it is a dietary and the behavioral problem which we will need to attack so as to have the healthy living for the entire nation.
</b> I think the point is very well taken Dr. Jagat, I think you are very very empathic in saying it is not only behavioral pattern but also the dietary pattern and the metabolic factors which are very very important and Dr. Reddy only pointed out this morning that if you control one risk factors we will see the influence on many other risk factors and he used the word, I heard it very carefully pre-Alzheimer’s or Alzheimer’s can be taken care of. So I think the risk factor control is the need of the hour, if you really want to create a well being. Dr. Reddy was very very categoric this morning, He said we need to have paradigm shift from illness to wellness. Well he used the word well-being. Dr. Reddy, I would like to ask you a final word what exactly you mean by well-being?
</b>Well-being of course implies that one has to enjoy good health so that is a prime requisite, but for that health, not only to be manifest in terms of freedom from disease, but the ability to draw upon physical, emotional and spiritual resources to find fulfillment in any activity that one undertakes without impediment either from personal factors or from societal factors that would be the state of well-being and well-being is not purely an individual attribute one has to be a part and parcel of a healthy and happy society and that actually will ultimately provide the well being that is required. We can not be feeling well if somebody else in our family is dropping death from a heart attack, so not only, personal health but everybody else’s health matters a lot.
</b> Fantastic, I think it is a very very nice opinion that he said it is not the individual well-being the well-being of society is the well-being of an individual. A well-being of a globe is a well-being of an individual and in the same way the well-being of an individual is a well-being of a globe in other words one individual is a hologram of the whole universe and the whole universe is a hologram of what the individual is. Very beautifully said, I think Dr. Reddy. I think it was a very nice interpretation, I really want to compliment both the legends of cardiology Dr. Reddy and Dr. Jagat Narula and this is going to go in a big way and I am sure the individuals from the rightdoctors.com, disseminate this information all over the world how we can control the rising menace of CVD. Thank you very much Dr. Reddy and Thank you very much Dr. Jagat Narula.