ADDRESS AT THE THROMBOSIS RESEARCH INSTITUTE, BANGALORE
18-12-2006 : Bangalore
Mission towards Healthy Hearts
I am delighted to participate in the dedication of the Thrombosis Research Institute, Narayana Hrudayalaya, Bangalore. My greetings to the organizers, surgeons, doctors, medical scientists and technologists, pharmacologists, and distinguished guests.
Dear friends when I am in the midst of expert in the field of Thrombosis I am reminded of the famous statement by Norman Cousins in his book, 'Anatomy of the illness' "Patients are today reaching out to the doctor not just for medical help. They are reaching out for kindness, assurance and hope" I would also like to share with you a quote in the paper which I came across on the topic 'One World, one people, one surgery' by Dr.T.E.Udwadia which states: "The poorest of the poor have as much right as anyone to less pain after surgery, reduced medication, less morbidity, shorter hospitalization, and early return to home, family, and work. Minimal access surgery and the expensive technology it requires is advocated, not as homage or tribute to new technology, but in appreciation of the manifold benefits this new technology gives our patients and our people." This thought has to be the focus of the Thrombosis researchers of Narayana Hrudayalaya.
Characteristics of Indian Population
The mortality and morbidity resulting from cerebro and cardio vascular diseases are a major and increasing public health problem in India. In developed countries, stroke is a disorder, which occurs in the age group of 55 years and above and therefore is an age-related disorder. Stroke continues to be a common cause of death and disability in India. Recent community surveys from many regions of India show the crude prevalence rate of stroke to be 200 per 100,000 population. Stroke in the young is more common in India compared to the West. Various studies have reported that 18 to 32% of stroke occurs in individuals aged 40 years or less, compared to only 3% in the West. However, in India, stroke in patients aged 40 years and below accounts for 18-40% of all strokes. The prevalence varies between different regions in the country, for example in Southern states of India the prevalence of stroke in young is as high as 40%.
Understanding of Stroke Risk Factors
Apart from the dramatic consequences of stroke on a young patient, the burden can be extremely heavy on the family and society in general. The management of these young patients especially the prevention of recurrent strokes requires understanding the pathogenic mechanism and the diagnosis of its cause. Moreover, despite the strides in the recognition of the causes and consequences of ischemic stroke, there are still many unanswered questions regarding stroke risk factors.
Despite new diagnostic technologies, the cause remains unexplained in majority of these subjects. In the past few years several lines of evidence suggest that increased genetic susceptibility associated with environmental factors may play a role in the athero-thrombotic disease. The conventional risk factors like hypertension, diabetes and hyper-cholesterolemia are less frequent in this age group. There is dearth of information about the prognosis, morbidity and stroke recurrence in subjects with many of these genetic risk factors. Likewise, the role of nutritional deficiencies in individuals with a genetic predisposition to stroke is unclear. Until prospective epidemiologic studies further define the role of the various inherited and acquired risk factors in the pathogenesis of brain ischemia and infarction, important management issues are likely to remain perplexing. The importance of finding these defects has significant implications for therapy of the individual patient and institution of family studies to identify, inform and possibly treat others at risk.
Treatment of Thrombosis
The knowledge obtained through the new research is likely to impact positively specialties like Cardiology, Neurology, Peripheral Vascular Disease, Open-Heart Surgery, Coronary Vascular Interventions and Artificial Heart Valves. Congenital gene-linked disorders like Hemophilia may be benefited by new genomic medical technology. Availability of drugs like Heparin opened the door to operations such as open-heart surgery, cardiac catheterization and angiography. Thrombolytic drugs like Streptokinase have reduced ICCU mortality of acute heart attacks from 15% to 5%. Appropriate and early timely use of these drugs is saving lakhs of lives all over the world. Heparin and clot-buster drugs have contributed tremendously in saving patients with deep venous thrombosis and clot embolism to lungs. Recent contributions in the management of acute brain stroke is of great clinical significance. We need newer thrombolytic drugs more ideally suited for safe and effective use in acute heart attacks and brain strokes. They should not only be more effective, but they should have no systemic side effects and not have rebound thrombosis. One of the nano-technology applications ideally suited for this purpose is drug-mailing, where the injected drug will go to the site of the clot and be effective locally at that required site.
Resistance to drugs
Aspirin has been in use for more than 300 years. It has found new applications in the treatment of patients with coronary artery disease, cerebro-vascular disease, peripheral vascular disease and as a thrombosis-preventive drug in patients with stents in the blood vessels. But unfortunately, 25% of the populations has aspirin - resistance. The alternative drugs used for the same clinical indication has problem of resistance in 10% of the people. The clinical challenges confronting us are how to detect resistance to drugs and counter effectively through therapeutic strategies. Resistance to these drugs pose serious problems in patients with cardio-vascular disease and those who have coronary stents, particularly drug-eluting stents. Non-response to these drugs may mean complications and loss of life.
Strategies for Prevention
The major cause of is-chemic stroke is athero-thrombosis. Strategies of stroke prevention include control of known causal risk factors for athero-thrombosis such as hypertension, diabetes, smoking and possibly, hyper-cholesterolemia. However, despite their relative effectiveness, these strategies fail to prevent a substantial portion of recurrent strokes and other serious vascular events. One reason for this may be that other unrecognized risk factors for athero-thrombosis exist that escape control by these strategies. These need to be identified.
It is important to identify the major contributory factors for predisposition to stroke in the young is genetic or nutritional, or, most importantly, an additive effect of both. Thrombosis Research Institute of Narayana Hrudayalaya can collaborate with institutions like NIMHANS, Bangalore, AIIMS, New Delhi and other centres for unraveling these mysteries and help in developing better means to prevent carebro and cardio vascular thrombosis. This will involve research into the patho-physiology of thrombosis, thrombotic and hemorrhagic disorders along with development of new strategies and protocols for facilitating development of effective appropriate drugs.
Rheumatic Heart Disease
A large number of poor patients in India have Rheumatic Valvular Heart Disease requiring valve replacement. Prosthetic heart valves need life-long oral anti-coagulant therapy. But unfortunately, these patients need life long anti-coagulant monitoring also, as they may develop clotting of the prosthetic valve or bleeding disorders which can be potentially life-threatening. The above complications occur at the rate of 1% per patient per year. Monitoring of oral anti-coagulant regime means easy access to coagulation- profile assessment once in two months. Affordable, easy access to these investigations is difficult in the rural areas, leading to non-compliance of treatment which in turn may lead to higher mortality and morbidity. Poor economic conditions and lack of education contribute to the above problems.
Missions for Thrombosis Research Institute
I would suggest that Thrombosis Research Institute of Narayana Hrudayalaya can work in partnership with NIMHANS, AIIMS, CARE Foundation and other leading medical research institutions in the country and abroad in the following areas.
1. Developing a simple and cost effective test for identifying individuals most at risk of suffering from cardiovascular disease at an early age to allow intervention to prevent long-term disability.
2. Undertaking population genetics and gene expression studies in early onset of coronary artery disease in the Indian population to gain a deeper understanding of the inter - relationship between the genetic and environmental risk factors.
3. Developing a vaccine against heart disease or stroke. Ongoing studies in 3,500 patients and family members have already shown that in addition to cholesterol and other lipids, infection with certain viruses and bacteria cause changes in blood vessels that enhance areas of localized thickness called atheroma. The evidence is that infection happens very early in life, usually around the age of 2 to 3 years. There is a need to design a unique vaccine to prevent infection and changes in blood vessels.
4. Creating a centre of excellence for developing the human resource needed for advanced molecular biology of cardiovascular diseases through a multi-institutional joint post-graduate education programme.
Conclusion: Life Style Intervention
While I am with the cardiac community and thrombosis researchers, I would like to share a research results of successful life style intervention programme carried out by DRDO in partnership with Global Hospital and Research Centre, Mount Abu an institution of the Brahma Kumaris.
The life style given to these patients was very simple and rudimentary. In fact, they received a traditional Indian diet having lots of fibre, fruits and sprouts which I understand was a staple diet of every Indian family about five decades ago. The exercise given was simple; a brisk walk both in the morning and evening hours. The major component of the intervention was stress management through meditation. The main efforts were to empower patients with information and education on heart disease and how they themselves can control or reverse it.
The outcome on a sample of five hundred and twelve patients appears to be quite rewarding. Like any medical treatment a visibly marked improvement in cardiac health of these patients could be seen within seven days of the commencement of the intervention. Their requirement of drugs prescribed by their cardiologists decreased markedly. The symptoms of chest pain and uneasiness reduced. Their capacity to exercise improved dramatically. I understand that after six months of intervention some of the patients were even able to take to swimming. The so-called bad cholesterol, stress hormones profile improved noticeably. The psychological or mental health showed considerable improvement. I would suggest Thrombosis Research Institute to include life style intervention factor in their research for finding cost effective prevention and treatment to the needy patients.
With these worlds, I dedicate the Thrombosis Research Institute at Narayana Hrudayalaya to the nation. My best wishes to all the members of Thrombosis research success in their mission of developing new cost effective strategies of preventing and treating thrombosis.
May God bless you.