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Written By THT Editorial Team

Dr. Prajjwal Pyakurel

Reviewed by Dr. Prajjwal Pyakurel , Cardiovascular Epidemiologist and Community Physician, MD

What is CHD?

Coronary Heart Disease (CHD) is a health condition that involves the constriction or obstruction of the coronary arteries, which are responsible for delivering oxygenated blood to the heart muscle. This constriction or obstruction is caused by the accumulation of fatty substances known as plaques on the inner lining of the arteries, a condition referred to as atherosclerosis. There are several types of plaques and some of the plaques are less likely to rupture because they have a thick fibrous cap with a small lipid core (LC) area . While unstable and vulnerable plaques have been characterized by several studies which indicate that they have a thin fibrous cap (< 65 µm) and its LC is substantial . If plaque ruptures in the carotid artery, it will either block the oxygenated blood from reaching the brain or bleed, which will lead the brain cells to die.[11] Over time, these plaques can limit the flow of blood to the heart, resulting in various symptoms such as angina (chest pain), breathlessness, and in severe instances, myocardial infarction (heart attack) [1].

CHD is a progressive disease that develops over several years, often due to a combination of factors, including genetic predisposition, lifestyle habits, and pre-existing health conditions. Risk factors for CHD encompass age, gender (men are generally at a higher risk, particularly before menopause), family history of heart disease, smoking, hypertension, hypercholesterolemia, diabetes, obesity, sedentary lifestyle, unhealthy diet, and chronic stress [2].

Why is CHD a Pandemic?CHD has escalated to pandemic levels due to a multitude of interconnected factors, ranging from lifestyle habits to global health disparities. Here’s an explanation of why CHD has attained pandemic status, supported by citations:

Global Prevalence: As individuals age, their arteries tend to stiffen and become more susceptible to damage, thereby increasing the risk of CHD [2].

Comparing CVD-related incidence, prevalence, death and DALYs between countries and region.[12]

Age standardized Rates per 100,000 populations
IncidenceDeathsPrevalenceDALYs
Nepal717.8 (748.6–689.7)260.8 (292.3–227.6)5679.8 (5954.0–5437.6)5242.2 (5901.8–4512.9)
Global922.3 (954.3–893.1)233.1 (236.4–229.7)6081.6 (6320.8–5860.8)4597.9 (4734.2–4463.7)
South Asia698.7 (724.8–674.4)294.6 (305.4–279.1)5432.7 (5674.0–5213.3)6006.7 (6222.4–5746.4)
Bangladesh729.1 (757.1–703.8)298.0 (326.2–269.6)6296.3 (6576.5–6037.1)5975.2 (6534.7–5415.7)
India679.2 (705.5–655.3)282.3 (293.3–265.0)5214.2 (5447.6–5000.4)5804.3 (6015.2–5532.3)
Pakistan858.4 (888.4–829.7)423.0 (483.8–364.8)6566.2 (6877.5–6285.0)8222.9 (9506.4–7003.7)
Bhutan644.6 (670.4–621.3)217.1 (255.0–182.5)5506.8 (5760.8–5261.6)4285.0 (5000.9–3544.3)
Sri Lanka720.2 (750–690.9)197.1 (220.2–171.6)5600.3 (5904.0–5326.7)3717.4 (4204.1–3246.3)
Maldives689.4 (719.7–662.8)164.9 (175.6–154.3)5615.6 (5873.0–5366.5)3162.2 (3371.4–2924.0)
USA1588.2 (1637.0–1537.7)151.1 (153.9–148.1)7275.8 (7565.4–7012.2)3029.7 (3168.0–2900.9)

Increasing Burden in Developing Countries: Low- and middle-income countries (LMICs) shoulder a significant burden of CHD, with over three-quarters of cardiovascular disease (CVD) deaths occurring in these regions [2]. Rapid urbanization, the adoption of unhealthy western lifestyles, and limited healthcare access contribute to the rising prevalence of CHD in LMICs.

Common Risk Factors: Shared risk factors such as tobacco use, unhealthy diet, physical inactivity, obesity, hypertension, and diabetes contribute to the global spread of CHD [3]. These risk factors are common across various populations and contribute to the worldwide proliferation of CHD.

Distribution of CVD risk factors by age groups (n = 314).

 

Age group (years)40–49 (n = 94)50–59 (n = 83)60–69 (n = 93)70 and above (n = 44)Total (n = 314)p Value
n (%)n (%)n (%)n (%)n (%)
Gender
Male40 (42.5)42 (50.6)51 (54.8)27 (61.4)160 (51.0)0.16
Female54 (57.5)41 (49.4)42 (45.2)17 (38.6)154 (49.0)
Smoking tobacco16 (17.0)23 (27.7)16 (17.20)13 (29.50)68 (21.7)0.12
Alcohol use9 (9.6)23 (27.7)13 (13.9)9 (20.4)54 (17.2)0.01
Overweight12 (12.7)14 (16.8)21 (22.5)10 (22.7)57 (18.2)0.61
Obese61 (64.9)50 (60.2)46 (49.4)21 (47.7)178 (56.7)0.61
Hypertension43 (45.7)54 (65.1)59 (63.4)36 (81.8)192 (61.1)<0.01
Diabetes23 (24.4)37 (44.6)39 (41.9)13 (29.5)112 (35.7)0.02
      • Abbreviation: CVD, cardiovascular disease.

Figure 2 shows the gender-wise distribution of 10-year CVD risk. Moderate–high CVD risk is significantly higher (p < 0.01) among males compared to females. Cardiovascular risk according to the age group is shown in Table 3. Very high and high cardiovascular risk (>20%) was seen mostly among people aged 70 years and above. 49.4% of participants in the 60–69 years age group, and 63.6% of participants above 70 years had moderate cardiovascular risk (10%–20%).[13]

Economic and Healthcare Systems Impact: CHD imposes a substantial economic burden on societies, encompassing direct medical costs, lost productivity, and social welfare losses. The World Heart Federation estimates the annual cost of CHD to be in the billions of dollars, with projections indicating a further increase in costs over time [4].

Health Inequities: Disparities in access to healthcare and preventive services exacerbate the impact of CHD, particularly in underserved communities and marginalized populations. Limited access to affordable healthcare, preventive interventions, and treatment modalities perpetuates the cycle of CHD burden in vulnerable populations [5].

Environmental and Social Determinants: Environmental factors such as air pollution, noise pollution ,inadequate urban planning, and exposure to toxins contribute to the development of CHD. Social determinants of health, including poverty, education level, and social support networks, also play a significant role in shaping CHD risk [6].

Globalization of Unhealthy Lifestyles: Globalization has facilitated the spread of unhealthy lifestyles characterized by sedentary behavior, poor dietary choices, and increased stress levels. These lifestyle factors contribute to the rising incidence of CHD worldwide, transcending geographical boundaries [7].

Current Status of CHD in Nepal

Coronary Heart Disease (CHD) in Nepal currently poses a significant public health challenge, underscored by increasing prevalence rates and associated risk factors. As per data from the World Health Organization (WHO), CHD contributes to a considerable portion of Nepal’s disease burden, accounting for approximately 12.26% of total deaths, with an age-adjusted death rate of 102.19 per 100,000 population [1].

Emerging epidemiological data suggests a worrying trend of rising CHD prevalence in Nepal. A study conducted in urban Kathmandu revealed a prevalence of 5.9%, indicating a significant burden of cardiovascular diseases in urban areas [2]. Moreover, recent findings indicate that the prevalence of smoking, hypertension, diabetes, and dyslipidemia among the population aged 40 to 80 years in rural Nepal was 27.8%, 34.4%, 6.9%, and 38.5%, respectively, highlighting the multifactorial nature of CHD risk factors in the Nepalese population [3].

Furthermore, the shift towards sedentary lifestyles, urbanization, and dietary changes exacerbates the prevalence of CHD. These factors, compounded by limited access to healthcare services, especially in rural regions, pose significant challenges to effective CHD management [4].

Addressing the Burden of CHD in Nepal

Addressing the burden of Coronary Heart Disease (CHD) in Nepal necessitates a comprehensive approach, drawing insights from strategies employed in both developed and developing nations. Here are some potential strategies for improvement, incorporating insights from global initiatives and interventions tailored for Nepal:

Health Education and Awareness Campaigns: The implementation of public health campaigns to raise awareness about CHD risk factors and promote healthy lifestyle choices is crucial. This strategy has proven effective in various contexts, including developed countries like the United States and Europe [1]. In Nepal, community-based health education programs can target both rural and urban populations, emphasizing the importance of quitting smoking, adopting healthy dietary habits, engaging in regular physical activity, and managing hypertension [2].

Access to Healthcare Services:  Due to fragmented health care systems in many LMICs(Low and Middle Income Countries), many patients are unaware of the disease and disease symptoms resulting in the delay of the care-seeking behavior. People from remote areas and limited access to advanced technology are more prone to suffer. The limited ambulance services in these parts also play a major role in the delay.Apart from the delay in reaching the primary care centers or hospitals, the lack of specialists and inadequate medical facilities hinder the delivery of proper and timely care. [10]Enhancing access to healthcare services, especially in rural areas, is vital for effective CHD management. Telemedicine facilities and mobile clinics can help bridge the gap in healthcare access, as demonstrated in countries like India and Bangladesh [3]. In Nepal, initiatives to establish primary healthcare clinics in remote regions and promote telemedicine consultations can enhance CHD diagnosis, treatment, and follow-up care [4].

Risk Factor Modification:  Early identification of pre-diabetic and pre-hypertensive condition and applying appropriate dietary and behavioural measures will be crucial .Encouraging lifestyle modifications to reduce CHD risk factors is paramount. Developed countries have implemented policies to regulate the availability of unhealthy foods and promote smoke-free environments [5]. In Nepal, advocating for tobacco control measures, promoting healthy dietary patterns rich in fruits, vegetables, and whole grains, and facilitating access to affordable medications for hypertension and dyslipidemia can help mitigate CHD risk [6].

Policy Interventions: Implementing policies to regulate unhealthy behaviors and strengthen healthcare infrastructure is vital. Examples include taxation on tobacco products, legislation on trans-fat content in foods, and investments in healthcare workforce training and facility development [7]. In Nepal, aligning with the Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (2014–2020) and integrating CHD prevention strategies into primary healthcare systems can drive sustainable improvements [8].

Early Detection and Management: Enhancing screening programs for early detection of CHD risk factors and ensuring timely management of the condition are critical. Evidence-based treatment protocols and risk-based management approaches, as outlined in global initiatives like the HEARTS Technical Package, can guide healthcare providers in Nepal [9]. Strengthening data collection systems and integrating cardiovascular risk assessment tools into routine clinical practice are also essential steps.

By integrating these strategies into a comprehensive national CHD prevention and control program, Nepal can make significant strides in reducing the burden of CHD and improving cardiovascular health outcomes across diverse populations.

REFERENCES

  1. World Health Organization. (2018). Noncommunicable diseases country profiles 2018. World Health Organization. Retrieved from:  https://www.who.int/publications/i/item/9789241514620
  2. Khanal, M. K., Ahmed, M. S. A. M., Moniruzzaman, M., Banik, P. C., Dhungana, R. R., Bhandari, P., Devkota, S., & Shayami, A. (2018). Prevalence and clustering of cardiovascular disease risk factors in rural Nepalese population aged 40–80 years. BMC Public Health, 18(677). https://doi.org/10.1186/s12889-018-5584-3
  3. Government of Nepal. (2014). Multisectoral action plan for the prevention and control of non communicable diseases (2014-2020). Retrieved from https://www.who.int/docs/default-source/nepal-documents/multisectoral-action-plan-for-prevention-and-control-of-ncds-(2014-2020).pdf).
  4. World Health Organization. (n.d.). Cardiovascular diseases. Retrieved from WHO(Original work published 2021)
  5. World Heart Federation. (2011). World heart report 2011.
  6. Mendis, S., Lindholm, L. H., Mancia, G., Whitworth, J., Alderman, M., Lim, S., & Heagerty, T. (2007). World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: Assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. Journal of Hypertension, 25(8), 1578-1582. https://doi.org/10.1097/hjh.0b013e3282861fd3
  7. World Health Organization. (2007). Prevention of cardiovascular disease: Guidelines for assessment and management of total cardiovascular risk. https://www.who.int/publications/i/item/9789241547178
  8. Rajan, S., Rathod, S. D., Luitel, N. P., Murphy, A., Roberts, T., & Jordans, M. J. D. (2020). Healthcare utilization and out-of-pocket expenditures associated with depression in adults: A cross-sectional analysis in Nepal. BMC Health Services Research, 20, Article 250. https://doi.org/10.1186/s12913-020-05094-9
  9. Aryal, A., Citrin, D., Halliday, S., Kumar, A., Nepal, P., Shrestha, A., Nugent, R., & Schwarz, D. (2020). Estimated cost for cardiovascular disease risk-based management at a primary healthcare center in Nepal. Global Health Research and Policy, 5, Article 2. https://doi.org/10.1186/s41256-020-0130-2
  10. Prajapati D, Bhandari N, Gautam P, Dhital R, Shrestha A. Coronary Artery Disease in Nepal: Current Perspective, Challenges, Need for National Practice Guidelines, and Potential Solutions. Kathmandu Univ Med J. 2022;80(4):505-13.
  11. Abdulsalam, J Feng. Distinguish the Stable and Unstable Plaques Based on Arterial Waveform Analysis. Procedia Structural Integrity 15 (2019) 2–7
  12. Bhattarai S, Aryal A, Pyakurel M, Bajracharya S, Baral P, Citrin D, Cox H, Dhimal M, Fitzpatrick A, Jha AK, Jha N, Karmacharya BM, Koju R, Maharjan R, Oli N, Pyakurel P, Sapkota BP, Shrestha R, Shrestha S, Spiegelman D, Vaidya A, Shrestha A. Cardiovascular disease trends in Nepal – An analysis of global burden of disease data 2017. Int J Cardiol Heart Vasc. 2020 Jul 31;30:100602. doi: 10.1016/j.ijcha.2020.100602. PMID: 32775605; PMCID: PMC7399110.
  13. Sitaula,D., Dhakal,A.,  Mandal,S.,  Bhattarai,N.,  Silwal,A., Adhikari,P., Gupta,S., Khatri,D., Lageju,N., Guragain,B.,(2023). Estimation of 10-year cardiovascular risk among adult population in western Nepal using nonlaboratory-based WHO/ISH chart, 2023: A cross-sectional study,VOL6,Issue (10). https://doi.org/10.1002/hsr2.1614
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