The Arterial Time Bomb

IN JANUARY, AFTER Indian cricket star Sourav Ganguly suffered a heart attack and had to undergo a procedure to remove blockage in coronary arteries, two runners in their late 40s, like Ganguly, met at a café in Gurugram city. “I cannot believe that someone as fit as Ganguly has had not one but three blockages in his heart,” said one. His friend nodded gravely and said that he wondered if they should go for a check-up.

A week later, the man had been put on statins (cholesterol-lowering drugs), as a CT angiogram (an imaging test that looks at the arteries supplying blood to the heart) had detected calcification in his arteries; it could have become severe over time, increasing the danger of a heart attack like Ganguly suffered. But a timely check-up helped a cardiologist put him on medication, significantly reducing his risk.

The runner was lucky. In Mumbai, around the same time, a 42-year-old man had been playing cricket with some close friends and relatives when he suddenly developed an intense pain in his chest. He collapsed in the car on his way to the hospital. By the time he reached the emergency ward, the doctors attending on him found no sign of life in him, though only eight minutes had passed since he had complained about discomfort in his chest. “He had been practically dead for about two or three minutes,” recalls Dr Praveen Kulkarni, a senior cardiologist who works at the city’s Global Hospital.

The patient had suffered a massive heart attack. After about 20 minutes of CPR (cardiopulmonary resuscitation), the rhythm in his heart returned. An angioplasty was done soon after. In the next few days, the man began to recover. By the fourth day, he was off the ventilator. Fortuitously, he had also suffered no brain injury (which can occur when the heart stops pumping blood into the brain). And just last week, after having come so close to death, the patient returned home.

Cardiologists across India say they are increasingly encountering cases of younger people with coronary heart disease. “Forget 50s and 40s, I have done so many procedures on young people who are in their 30s, sometimes even late 20s. The list is endless,” says Dr Surinder Bazaz, senior director of cardiac surgery at Gurugram’s Medanta Hospital.

According to the Indian Heart Association (IHA), India accounts for nearly 60 per cent of the world’s heart disease burden. In India, it is now striking people at a younger age—almost 33 per cent earlier, according to IHA statistics—than other demographics. Fifty per cent of heart attacks in Indian men occur under 50 years of age, while 25 per cent occur to those under 40.

“If I am seeing a patient in his 40s, I know his disease is going to be severe,” says Dr Bazaz. “The younger the person, the more problematic his disease is.”

There is a string of factors responsible for the heart disease epidemic among Indians. As more and more people become affluent, their lifestyle has undergone a change. This essentially means they are eating more food, becoming sedentary, and they lead more stressful lives. Coupled with increasing levels of pollution in Indian cities, it becomes a recipe for disaster.

Dr Brajesh Kunwar, the director of interventional cardiology in Mumbai’s Fortis Hiranandani Hospital recalls how, till about a decade or more ago, if a patient below 30 came complaining of chest pain, doctors would never consider an electrocardiogram (ECG) test which can detect heart abnormalities. “But now your body may be that of a 25-year-old, but your heart looks much older,” he says.

“One of the big factors is stress. We get lots of people in their 30s getting heart disease because this is the time when many people are trying to establish themselves in their professions and businesses. And the stress levels because of the cutthroat competition in these
industries are insane. No wonder we get patients in the age group of 30s and 40s,” says Dr Kunwar.

Experts point out that the rapid socio-economic change India has gone through over the last few decades has played a significant role. “We suddenly began to consume more calories and refined food that has a lot of carbohydrates,” says Dr Sujay Shad, senior cardiac surgeon at Delhi’s Sir Ganga Ram Hospital. Since carbs do not satiate us like the unrefined food older generations used to eat, we are always foraging for food. “The problem is sugar content. Every time the body senses sugar, it sends insulin to control it. The sugar comes down, but the insulin results in the inflammation of the body, including the arteries, precipitating the heart disease” says Dr Shad.

“We are also the diabetes capital of the world. And with diabetes, one can often end up with heart disease, not to forget hypertension,” says Dr Kulkarni. He points to studies that say one in three adults in urban India has hypertension and many of them never end up monitoring their blood pressure and glucose levels, leading to heart disease. “If left undetected, this then results in a heart attack,” he says.

In September last year, when Mumbai’s municipal body (the Brihanmumbai Municipal Corporation) released its figures for the number of deaths that had occurred in the city between March 1st and July 31st, it surprised many. A total of 49,040 people had died as opposed to 35,982 for the same period in the preceding year. Covid-19 had spread rapidly through this period, virtually bringing the city’s healthcare system to its knees. But over 13,000 more people had died in this period in 2020, of which Covid accounted for only 6,395 deaths. Also, this significant increase in number was despite the fact that because of the lockdown, deaths occurring from road accidents and communicable diseases had been negligible.

DOCTORS BELIEVE THAT a majority of these deaths occurred because people chose to stay away from hospitals. Of these, they say, a large chunk would have been of people dying from heart disease.

In Mumbai, the 42-year-old man who almost died while playing cricket could not believe that he had such a crisis. How had a man in his early 40s, who appeared fit and led an active lifestyle, even playing sports like cricket regularly, developed a severe heart condition that led to such a massive heart attack?

Doctors however aren’t surprised. This age bracket of people in their mid-30s and early 40s now commonly get wheeled into hospitals in Indian cities with a cardiac issue.

“After a bit of digging, I found that there was some (high) cholesterol issue (in the patient). He’d also been recently diagnosed with hypertension and advised medicines which he had not been taking regularly,” says Dr Kulkarni about the man he saved. “So while he looked healthy, these small telltale signs were there.”

Another such patient Dr Kulkarni treated in the past was Saurabh Maphuskar, a 21-year-old college student. A resident of the central Mumbai suburb of Parel, he came to the hospital complaining of breathlessness, only to learn that three of his arteries were blocked.

Had there been a blockage in just one or even two of his arteries, perhaps an angioplasty procedure would have sufficed. But with blockages in three major blood vessels of the heart, or what is known as critical triple vessel disease, the doctors had no option but to cut him open for a CABG (coronary artery bypass grafting) procedure.

The doctors found that there was a history of high cholesterol in the family. Although this factor probably played a big role in Maphuskar’s poor heart condition, what had exacerbated the issue was his incredibly poor lifestyle. “He was someone who consumed a lot of junk food. It was just so shocking to see someone so young with such an issue,” says Dr Kulkarni.

But on some occasions, there are no explanatory reasons. Dr Kulkarni talks of patients who have no family history of heart disease leading perfectly healthy lives and are physically active, and yet get heart attacks. “One female patient of mine is just 31 years old. She takes care of her health, is lean and fit. And yet she got a heart attack. Perhaps someday, down the line, science will progress enough for us to learn of some element that might explain all this,” he says.

Towards the end of last year, Mohit (name changed upon request), a 27-year-old IT professional based in Navi Mumbai, began to feel some discomfort in his chest. Having had consumed a meal ordered from a restaurant earlier in the day, Mohit put the discomfort down to a mild form of acidity. By the next morning, he was suffering from breathlessness and had to be rushed to the hospital.

The young man hadn’t had a mild acid attack the night before. He had got a heart attack.

The reasons were the same. A sedentary lifestyle made worse with the demands of a stressful job. “The work from home scenario had made it only more difficult for him,” says Dr Kunwar who performed an angioplasty for Mohit. “He would be in his chair all day, hardly moving about, even in the house. In the office set-up, at least you walk around a bit to chat with your colleagues, or have to move a bit to commute to work.”

In the two months since his discharge, Mohit has tried to change his lifestyle. He exercises regularly, has cut out poor food habits and even stopped smoking.

“When he first came to the hospital, I was quite shocked since he was only in his 20s,” Dr Kunwar says. “But then on second thought, maybe not.”

In Kashmir, doctors recently expressed concern over the sharply rising cases of heart attacks among relatively younger people. “It demands immediate attention so that many lives at risk can be saved by timely awareness programmes, preventive and diagnostic interventions,” noted a spokesperson for the Doctor’s Association.

Dr Deepak Krishnamurthy, a senior interventional cardiologist at Bengalaru’s Sakra World Hospital, says at least 25-30 per cent of heart attack cases coming to him are of people below 40. “We must keep a lookout for cholesterol, obesity, sugar levels, blood pressure, especially among those who have a family history,” he says.

Doctors like Krishnamurthy are now recommending that campaigns against fast food and smoking be run from school days itself. “We have to change the way our children look at things like chocolate or ice-cream as reward,” says Dr Shad. “The brain senses the reward and wants to constantly binge on it.”

WHAT ABOUT PREVENTION? Doctors recommend that we lead an active lifestyle, take up exercise encourage children to engage in physical activity as well. “Do not take things like high cholesterol and borderline diabetes and hypertension lightly,” says Dr Krishnamurthy. Particular care must be taken by people who have a combination of factors like diabetes, obesity, hypertension, a history of smoking and a family history of heart disease. For those in the high-risk category, doctors recommend keeping a watch on these things and go for detection tests like CT angiogram.

There has been quite a debate on the use of statins as well. Many have accused the health industry of pushing these for profit. “They are not for everyone. But if your risk is high, because of a combination of factors, the doctor will most likely recommend them,” says Dr Shad. Many who take statins complain about the side-effects, such as muscle pain. But Dr Shad points to a recent study by Imperial College London which suggests that most symptoms from taking statins could be due to ‘nocebo effect’—where people get symptoms because they expect to experience negative side-effects. “I know of four doctors who were unable to tolerate statins earlier, but can take them very well after they got stents in angioplasty procedure to open up their arteries,” he says.

But a better option is to avoid all risk factors. “You cannot do anything about genetics. But it would be foolish if you have a family history and you also choose to smoke,” says Dr Bazaz.

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