Polypharmacotherapy for primary prevention of cardiovascular disease.

India is likely to have the highest absolute burden of cardiovascular disease (CVD) related morbidity and mortality in the world. The prevalence of risk-factors (RFs) is high, particularly in the young, and a strategy to reduce RF prevalence in a large population needs to be developed. It is possible to modify risk factors at the individual level or at the population level. The latter is likely to have a greater impact. Current evidence shows that the reduction of risk factors such as BP or serum cholesterol from any level (rather than above a particular threshold) confers potential benefits. At present, lifestyle interventions have not demonstrated the benefits in reducing CVD related mortality and morbidity. A polypharmacotherapy strategy (2-3 BP lowering drugs, a statin, and aspirin) has promise to considerably reduce CVD-related mortality and morbidity. Such a therapy could target a large proportion of the population, intervene simultaneously on multiple RFs, and have wide acceptability. Cost and adherence are important issues for the success of this strategy. Adherence is suboptimal even for secondary prevention. A fixed-dose combination (FDC) of these drugs may improve adherence and reduce costs. But prior to recommending the wide-spread use of an FDC polypharmacotherapy strategy, studies are required to systematically evaluate its efficacy and safety and then determine the adherence, cost, and acceptability in the population. Studies are ongoing in India and other countries to determine the role of FDC polypharmacotherapy in the primary prevention of CVD. Such FDC therapy may reduce costs, improve adherence, and reduce CVD events at the population level; especially in developing countries such as India.

The burden of cardiovascular disease in the Indian subcontinent.

Ischaemic heart disease and stroke are among the most common causes of death and disability in the world. The Indian subcontinent (including India, Pakistan, Bangladesh, Sri Lanka, and Nepal) has among the highest rates of cardiovascular disease (CVD) globally. Previous reports have highlighted the high CVD rates among South Asian immigrants living in Western countries, but the enormous CVD burden within the Indian subcontinent itself has been underemphasized. In this review, we discuss the existing data on the prevalence of CVD and its risk factors in the Indian subcontinent. We also review recent evidence indicating that the burden of coronary heart disease in the Indian subcontinent is largely explained on the basis of traditional risk factors, which challenges the common thinking that South Asian ethnicity per se is a strong independent risk factor for coronary heart disease. Finally, we suggest measures to implement in policy, capacity building, and research to address the CVD epidemic in the Indian subcontinent.

Two-year outcomes in patients admitted with non-ST elevation acute coronary syndrome: results of the OASIS registry 1 and 2.

BACKGROUND: Acute coronary syndrome continues to have significant long-term morbidity and mortality. This study sought to compare baseline characteristics, practice patterns and clinical outcomes for patients with non-ST elevation acute coronary syndrome from a broad range of low-, middle- and high-income countries. METHODS AND RESULTS: We compared the data from a prospective registry of patients with non-ST elevation acute coronary syndrome involving 4615 patients from 65 centers in 8 low and middle income countries (OASIS registry 2) with those obtained from 7987 patients from 95 centers in 6 middle and high income countries (OASIS registry 1). Patients in the OASIS registry 2 were younger, were more often males and smokers, presented later to the hospital after symptom onset and had a lower prevalence of diabetes at admission [with the exception of India, which had the highest age-adjusted prevalence (39.1%)]. There were marked variations in the angiography and intervention rates during the hospital stay, but the uses of proven pharmacological therapies were comparable. The two-year mortality rates adjusted for baseline covariates ranged from 6.9% to 15%. Patients from China had the lowest two-year mortality rate (6.9%) and patients from India had the highest rate (15%). Combining the two registries, the covariate-adjusted rate of death or myocardial infarction did not differ across countries with in-hospital angiographic rates of > or = 50% (17.1%), 25-49% (16.7%) or < 25% (16.5%). However, the covariate-adjusted rates for subsequent myocardial infarction (7.6%, 9.2% and 10.8% respectively, p < 0.0001), refractory angina (21.3%, 27.7% and 35.4% respectively, p < 0.0001) and the composite of death, myocardial infarction or refractory angina (34.9%, 40.7% and 46.8% respectively, p < 0.0001) differed depending on the angiographic rates. CONCLUSIONS: Among the participating countries there was a marked heterogeneity in patient characteristics, coronary interventions, resulting in differences in the two-year composite rates of death, myocardial infarction and refractory angina among patients admitted with non-ST elevation acute coronary syndrome.