Mr.V had to fly down from Dubai straight to Calicut to undergo Bypass surgery as an emergency procedure couple of weeks ago. Today, he is back for his one-week review and is fit to fly back to resume his work. Though he has had a remarkable recovery he is still depressed and he is quite perplexed as to how a healthy person like him could have had a heart attack.

Mr.V is a 39 year old IT professional. He is a pure vegetarian, does not smoke or drink, jogs daily for half an hour. He does not have Diabetes or high blood pressure and his cholesterol was borderline. Mr.V did not have the well-established risk factors of smoking, diabetes, blood pressure and high cholesterol.  

After detailed investigations, it was found that he had a high Homocysteine and high Lipoprotein(a) [Lp(a)] level. These proteins have been discovered in the past few years and are known as new risk factors for heart disease. In studies conducted on Indians in UK and US, it has been observed that they have high levels of Lp(a) and Homocysteine and are therefore more prone for heart disease. Hence, it is therefore even more important to keep these risk factors under control.

 40 % of the coronary bypass surgeries performed at MIMS are on expatriates from Gulf, and the average age of these patients were around 42 years. Obesity had been seen only in 2% of these patients. But Hypertension in 70%, Diabetes in 56% and hypercholesterolemia in 70% were the common risk factors.  Smoking was a past history in 60% and only 10% of them were presently smoking. More than 80% had a family history of ischemic heart disease.

The fact that nearly 30% of these patients in the 40s age group had diffuse coronary artery disease had been the alarming fact that has made us really sit down and think about this unfortunate people. We had been investigating all our bypass surgery patients for elevated levels of Lp(a), Homocysteine and Hs-CRP (Highly Sensitive C-reactive Protein) levels. The early results definitely have shown an upward trend in these patients who have had diffuse coronary artery disease. Our full analysis and conclusion would be published after one year.

Though these results only give us an indication on what we have, not many studies have come from India telling us how to prevent this epidemic. But these patients with diffuse coronary artery disease (CAD) are now being treated surgically by reconstruction of their coronary arteries using internal mammary artery conduits. The gratifying results, with this type of coronary reconstruction, have been well accepted, and, are reproducible in this segment of population. 

Meanwhile the need to monitor these risk factors of coronary artery disease are to be stressed in evaluation and treatment of these patients at high risk. Looking forward to see more and more results on these risk factors to be published from our Indian population.

 Lp(a)

It is a lipoprotein particle found in the bloodstream. Lipoprotein (a) is a major and independent genetic risk factor for atherosclerosis and cardiovascular disease. Lipoprotein (a) is a variant of bad LDL attached to an extra protein particle. It prevents breakage of clots.

The concentration of Lp-a is race specific and is found to be high in Indians. Normal blood level of lipoprotein (a) is less than 30mg/dl. Evaluation of Lp(a) levels would be useful in dyslipidemics, patients with CAD at early age and in patients with family history of CAD.

Lp(a) is largely an inherited risk factor. In patients with high Lp(a) levels, maintaining a low LDL level would reduce the risk for CAD. At present, niacin and oestrogen replacement (in ladies) has been shown to reduce Lp(a) levels.

 Homocysteine

This is an aminoacid found in the blood. High levels of homocysteine are found in some patients with CAD at an early age. This is also associated with low levels of vitamin B6, B12 and folic acid.

Studies have shown that homocysteine may contribute to the build up of fatty substances in the arteries, increase clotting and make blood vessels less flexible, causing decreased vasodilatation. 

Normal blood level of homocysteine is 5-15 mmol/l. Homocysteine levels can be evaluated in patients with other risk factors for CAD or in patients with family history of CAD.

Patients with high levels homocysteine levels should increase their Vitamin B (folic acid, vitamin B12 and B6) intake. These vitamins can be found in fruits, green and leafy vegetables and grains.

High Sensitivity Assay For C-Reactive Protein (Hs-CRP)

CRP is short for "C-reactive protein," a protein found in the blood. It is what we call a marker for inflammation, meaning its presence indicates a heightened state of inflammation in the body. Inflammation is a normal response to many physical states including fever, injury and infection. Inflammation is now believed to play a role in the initiation and progression of cardiovascular disease.

High levels of Hs-CRP consistently predict new coronary events in patients with unstable angina and acute myocardial infarction (heart attack). Higher Hs-CRP levels also are associated with lower survival rate of these people.  Many studies suggested that after adjusting for other prognostic factors, Hs-CRP was still useful as a risk predictor.

Recent studies also suggest that higher levels of Hs-CRP may increase the risk that an artery will reclose after its been opened by balloon angioplasty.  High levels of Hs-CRP in the blood seem to predict prognosis and recurrent events in patients with stroke and peripheral arterial disease.

Most studies show that the higher the Hs-CRP levels, the higher the risk of developing heart attack. In fact, scientific studies have found that the risk for heart attack in people in the upper third of Hs-CRP levels is twice that of those whose Hs-CRP is in the lower third. These prospective studies include men, women and the elderly.

Recent studies also found an association between sudden cardiac death, peripheral arterial disease and Hs-CRP. However not all of the established cardiovascular risk factors were controlled for when the association was examined. The true independent association between Hs-CRP and new cardiovascular events hasnt yet been established.

People who have suffered a heart attack or stroke and those with at least one risk factor, such as family history, high blood pressure, high cholesterol, smoking or diabetes, should be tested. While the American Heart Association and Centers for Disease Control just recently recommended Hs-CRP testing as an option for those already at risk, The Cleveland Clinic has used the Hs-CRP test routinely for at-risk patients for over three years. Hs-CRP is a great test for people with one or two risk factors who wonder if they are really in jeopardy of a heart attack or a stroke. Its probably not useful for people without any risk factors.

• If Hs-CRP level is lower than 1.0 mg/L, a person has a low risk of developing cardiovascular disease.
• If Hs-CRP is between 1.0 and 3.0 mg/L, a person has an average risk.
• If Hs-CRP is higher than 3.0 mg/L, a person is at high risk.

Anyone over the age of 35 with any of the two proven risk factors of coronary artery disease need to be evaluated extensively to rule out critical coronary artery disease and take necessary steps to prevent heart attack. It is all the more important for us to understand that we as Indians as a race are more prone to coronary artery disease at a younger age than the rest of the world. Hence, modification of our lifestyle and intake of fruits and vegetables and timely evaluation would decrease the risk of developing early coronary artery disease.