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South Asians face increased heart risk
Why are some otherwise healthy South Asians increasingly vulnerable to heart disease compared with other ethnic groups?
Dr. Subodh Verma checks up on Ashok Verma in the intensive care unit in the minutes following his cardiac operation
Ashok Verma never expected to be strapped to an operating table, with his chest cracked open and his beating heart in the hands of a surgeon.
If it were any other Tuesday morning, the active 39-year-old would be bundling his two young sons off to school before rushing to work in Brampton.
But, as for so many other South Asians, open-heart surgery is the only thing that will keep him alive past middle age.
His cardiac surgeon has spent the last hour readying his heart for a triple bypass – sawing his sternum down the middle, teasing the left mammary artery away from his chest, and cutting open the peritoneum with a sizzling cauterizer to reveal the fist-sized heart, slowly, steadily, beating.
Now, Dr. Subodh Verma peers into Ashok's open chest and points at pencil-thin arteries snaking over the heart.
"There are blockages here and here and here and here," he says, shaking his head. "There's diffuse plaque all through the heart. This is the most aggressive atherosclerosis I've seen in such a young patient."
Ashok's heart, though housed in a seemingly healthy 39-year-old body, is actually closer in age to that of an overweight septuagenarian. Many of his arteries are dangerously blocked, preventing blood from reaching parts of his heart. And the organ itself is covered with a slick of fat, as though it has been dunked in sticky yellow paint.
For Verma, a cardiac surgeon at St. Michael's Hospital and no relation to Ashok, this is an all too common sight.
Startling findings
South Asians, more than any other ethnic group, are at risk of dying from a heart attack at an early age. A massive international study, led by researchers at McMaster University and published last year in the Journal of the American Medical Association, has found people native to India, Pakistan, Bangladesh, Nepal and Sri Lanka can die from heart disease five to 10 years earlier than those from other ethnic groups. Most startling, this statistic holds true even when South Asians appear to be at a healthy weight.
Researchers now believe that just being South Asian may be an independent risk factor for heart disease, and there is increasing evidence that traditional risk factors, including obesity, high blood pressure, elevated cholesterol levels and diabetes, attack the cardiovascular system more aggressively in this population.
With more than one million people of South Asian descent in Canada – and with South Asians making up the fastest growing community in Toronto – understanding what makes them at elevated risk, and how to best prevent and treat risk factors, is crucial to preserve lives.
Experts know the interplay of genes with environment imparts increased risk, and a common phrase scientists use is, "Genes load the gun and environment pulls the trigger." But just how much, and by what mechanisms, a person's genetic make-up is influenced by their lifestyle – their eating habits, their propensity for physical activity, their nicotine addiction – is not yet known.
In recent years, Verma has watched a steady stream of young South Asian patients wheeled into his operating room. And he often sees the same thing when he cuts open their chests: smaller than average blood vessels, blockages spread throughout heart vessels and thick globs of fat coating the organ.
Early intervention key
Many of these patients are lucky; their disease has been caught in time. Others, who go for months or years without their symptoms being diagnosed, will die before they reach the operating table. Studies have shown the first symptom of heart disease for between 35 and 50 per cent of people will be a fatal heart attack.
But since heart disease can largely be prevented and treated, Verma and other cardiology experts say there is room to raise awareness and to take action in both the research and the health-care communities – and by South Asian patients themselves.
"High blood pressure or diabetes may age a South Asian's cardiovascular system much faster," says Verma, who also holds a Canada Research Chair in atherosclerosis. "But if (South Asian) patients are diagnosed earlier and managed earlier, we may be able to offset the problems before the first presentation of symptoms is a fatal heart attack."
ashok considers himself one of the lucky patients. His wife, Renu, talks about his bypass as a "second chance," something that few people get.
The first signs started last summer: a chest pain here and there, some shortness of breath after playing with his two sons, Akash, 10, and Akshay, 8, in the yard. At first, Ashok attributed the sharp twinges to muscle aches from overexerting himself. Heart disease, he recalls, never even crossed his mind.
It was only after three months of feeling ill that Ashok went to his family doctor. That's where he first heard he had heart disease.
"We were shocked," Ashok says. "It was something you didn't expect. It would be different if you are a lazy person, but I don't have time to even sit on the couch. I'm always running around."
The conundrum with Ashok, and others like him, is that he appears to be healthy, says Verma.
Ashok does not smoke, most days he eats well, and he keeps relatively active. Neither of his parents have a history of heart disease. And his only health problem is type 2 diabetes, something that was diagnosed eight years ago and which Ashok says he has kept under control since.
Diabetes, a well-known risk factor for heart disease, may have helped to accelerate the buildup of plaque in his coronary arteries. But if he were a white man of similar age and size with the same lifestyle characteristics, Verma says Ashok may not have needed a triple bypass operation at this young age.
"We are working in the area of finding reasons why being brown, for lack of a better word, imparts in an otherwise healthy person, like Ashok, who works out, who has a healthy lifestyle, and who at a young age is diagnosed with this devastating problem."
The bad fat link
The same yellow fat that hugs Ashok's heart also surrounds his other organs. This abdominal, or visceral fat, is much more active – and dangerous – than the fat found under your skin. It acts like a furnace to produce toxic fumes in the body, decreasing insulin sensitivity, reducing good cholesterol levels and raising blood pressure, all of which are risk factors for heart disease.
Sonia Anand, an associate professor of medicine at McMaster University and an international expert on the links between ethnicity and heart disease and diabetes, says South Asians are more likely to get visceral fat than any other ethnic group, even if they eat and exercise the same. People of South Asian descent are also more apt to have the same array of risk factors for heart disease as Caucasians, but at about 45 pounds lighter, she says.
It's not yet known what causes South Asians to accumulate more visceral fat, but Anand says research groups from around the world are trying to home in on the precise biological mechanisms. Although diet likely plays a role – South Asians tend to eat a diet high in carbohydrates, and low in fruits and vegetables, which can affect blood sugar levels – along with a general lack of physical activity, their genes are also a factor.
Experts say we are just beginning to untangle the complexities of the ethnic origins of disease. And though multiple predictions and hypotheses are being attacked around the world, scientists all agree that research in the field has to speed up.
Last month, the Heart and Stroke Foundation of Ontario announced it will dedicate $700,000 to ethnic-specific research in the form of $50,000 two-year grants. The foundation is also investing $150,000 to develop specific cardiovascular risk profiles of South Asian and Chinese Canadians that will help create ethnic-specific health promotion initiatives.
"We can't meet our mission of eliminating heart disease and stroke unless we meet the needs of the population, and that means meeting the needs of ethnic groups that have a very distinctive cardiovascular profile," says Marco Di Buono, the foundation's director of research.
Right now, many of the guidelines physicians use to prevent and treat heart disease come from the Framingham Heart Study, a 60-year trial undertaken by the U.S. National Institute of Health to investigate the causes of cardiovascular disease. Named for the town in Massachusetts where the study takes place, the majority of its subjects are white and most are men.
Di Buono says the study has provided groundbreaking results in predicting an individual's risk for heart disease. But, he adds, in today's society it does not go far enough.
"It's imperative that we don't just use a reference group of white men to figure out how to treat, prevent and eliminate heart disease and stroke in a diverse population."
Dr. Milan Gupta, a cardiologist at William Osler Health Centre, says upwards of 40 per cent of the Brampton hospital's heart patients are South Asian, a much larger proportion than one would expect from the patient catchment area.
The first step to reduce this number is to raise awareness in the community, says Gupta, who is also an assistant professor at McMaster University. Not enough South Asians know they are at increased risk of heart disease or know the signs of a heart attack, he says.
On top of that, one of Gupta's studies of heart patients in Brampton and Scarborough found South Asians in the throes of a heart attack went to the emergency room a full hour later than white patients, which meant their heart muscle was more likely to suffer permanent damage from the attack.
"Time is muscle, because the sooner you get to us in the setting of a heart attack, the higher the likelihood of survival," says Gupta, adding that it was not clear why South Asians delayed going to the ER.
Back in the operating room, Ashok's heart has been stopped for more than one hour. Only the steady swish of the heart-lung machine has kept blood swirling through his body and his vital organs alive.
In the final stage of the bypass, Verma is attaching a harvested vein to a two-millimetre hole in Ashok's immobile heart.
"This is his entire life right here," he says. "This vessel, this is everything for him and his family and his future."
His green-gloved hands pull suture as fine as baby hair through the tiny lip of vein. It is a tense moment: "Give me two minutes of silence in the room, please."
Minutes later, Ashok's heart is beating again – brought back to life by a quick jolt of electricity – and the steady beep beep beep of the monitors fill the room. All seems to be well.
Verma and his assistant, another cardiac surgeon, lace up Ashok's chest with 10 stainless steel wires, each as thick as the nib of a pen, by hooking them deep under each edge of his split sternum bone. When the wires are in place, the pair yank his chest closed with the same force used to tie a stiff hockey skate.
Ashok will rest in hospital for five days before being allowed to go home.
But his recovery does not stop here. Bypasses are meant to only last 15 to 20 years. Ashok will have to work hard to preserve his new veins and arteries and keep his heart muscle healthy.
And the rest of his family – his mother, father, his two brothers and his two sons – will all have to be screened for the deadly disease.
https://www.thestar.com/life/health...1/south_asians_face_increased_heart_risk.html
Why are some otherwise healthy South Asians increasingly vulnerable to heart disease compared with other ethnic groups?
Dr. Subodh Verma checks up on Ashok Verma in the intensive care unit in the minutes following his cardiac operation
Ashok Verma never expected to be strapped to an operating table, with his chest cracked open and his beating heart in the hands of a surgeon.
If it were any other Tuesday morning, the active 39-year-old would be bundling his two young sons off to school before rushing to work in Brampton.
But, as for so many other South Asians, open-heart surgery is the only thing that will keep him alive past middle age.
His cardiac surgeon has spent the last hour readying his heart for a triple bypass – sawing his sternum down the middle, teasing the left mammary artery away from his chest, and cutting open the peritoneum with a sizzling cauterizer to reveal the fist-sized heart, slowly, steadily, beating.
Now, Dr. Subodh Verma peers into Ashok's open chest and points at pencil-thin arteries snaking over the heart.
"There are blockages here and here and here and here," he says, shaking his head. "There's diffuse plaque all through the heart. This is the most aggressive atherosclerosis I've seen in such a young patient."
Ashok's heart, though housed in a seemingly healthy 39-year-old body, is actually closer in age to that of an overweight septuagenarian. Many of his arteries are dangerously blocked, preventing blood from reaching parts of his heart. And the organ itself is covered with a slick of fat, as though it has been dunked in sticky yellow paint.
For Verma, a cardiac surgeon at St. Michael's Hospital and no relation to Ashok, this is an all too common sight.
Startling findings
South Asians, more than any other ethnic group, are at risk of dying from a heart attack at an early age. A massive international study, led by researchers at McMaster University and published last year in the Journal of the American Medical Association, has found people native to India, Pakistan, Bangladesh, Nepal and Sri Lanka can die from heart disease five to 10 years earlier than those from other ethnic groups. Most startling, this statistic holds true even when South Asians appear to be at a healthy weight.
Researchers now believe that just being South Asian may be an independent risk factor for heart disease, and there is increasing evidence that traditional risk factors, including obesity, high blood pressure, elevated cholesterol levels and diabetes, attack the cardiovascular system more aggressively in this population.
With more than one million people of South Asian descent in Canada – and with South Asians making up the fastest growing community in Toronto – understanding what makes them at elevated risk, and how to best prevent and treat risk factors, is crucial to preserve lives.
Experts know the interplay of genes with environment imparts increased risk, and a common phrase scientists use is, "Genes load the gun and environment pulls the trigger." But just how much, and by what mechanisms, a person's genetic make-up is influenced by their lifestyle – their eating habits, their propensity for physical activity, their nicotine addiction – is not yet known.
In recent years, Verma has watched a steady stream of young South Asian patients wheeled into his operating room. And he often sees the same thing when he cuts open their chests: smaller than average blood vessels, blockages spread throughout heart vessels and thick globs of fat coating the organ.
Early intervention key
Many of these patients are lucky; their disease has been caught in time. Others, who go for months or years without their symptoms being diagnosed, will die before they reach the operating table. Studies have shown the first symptom of heart disease for between 35 and 50 per cent of people will be a fatal heart attack.
But since heart disease can largely be prevented and treated, Verma and other cardiology experts say there is room to raise awareness and to take action in both the research and the health-care communities – and by South Asian patients themselves.
"High blood pressure or diabetes may age a South Asian's cardiovascular system much faster," says Verma, who also holds a Canada Research Chair in atherosclerosis. "But if (South Asian) patients are diagnosed earlier and managed earlier, we may be able to offset the problems before the first presentation of symptoms is a fatal heart attack."
ashok considers himself one of the lucky patients. His wife, Renu, talks about his bypass as a "second chance," something that few people get.
The first signs started last summer: a chest pain here and there, some shortness of breath after playing with his two sons, Akash, 10, and Akshay, 8, in the yard. At first, Ashok attributed the sharp twinges to muscle aches from overexerting himself. Heart disease, he recalls, never even crossed his mind.
It was only after three months of feeling ill that Ashok went to his family doctor. That's where he first heard he had heart disease.
"We were shocked," Ashok says. "It was something you didn't expect. It would be different if you are a lazy person, but I don't have time to even sit on the couch. I'm always running around."
The conundrum with Ashok, and others like him, is that he appears to be healthy, says Verma.
Ashok does not smoke, most days he eats well, and he keeps relatively active. Neither of his parents have a history of heart disease. And his only health problem is type 2 diabetes, something that was diagnosed eight years ago and which Ashok says he has kept under control since.
Diabetes, a well-known risk factor for heart disease, may have helped to accelerate the buildup of plaque in his coronary arteries. But if he were a white man of similar age and size with the same lifestyle characteristics, Verma says Ashok may not have needed a triple bypass operation at this young age.
"We are working in the area of finding reasons why being brown, for lack of a better word, imparts in an otherwise healthy person, like Ashok, who works out, who has a healthy lifestyle, and who at a young age is diagnosed with this devastating problem."
The bad fat link
The same yellow fat that hugs Ashok's heart also surrounds his other organs. This abdominal, or visceral fat, is much more active – and dangerous – than the fat found under your skin. It acts like a furnace to produce toxic fumes in the body, decreasing insulin sensitivity, reducing good cholesterol levels and raising blood pressure, all of which are risk factors for heart disease.
Sonia Anand, an associate professor of medicine at McMaster University and an international expert on the links between ethnicity and heart disease and diabetes, says South Asians are more likely to get visceral fat than any other ethnic group, even if they eat and exercise the same. People of South Asian descent are also more apt to have the same array of risk factors for heart disease as Caucasians, but at about 45 pounds lighter, she says.
It's not yet known what causes South Asians to accumulate more visceral fat, but Anand says research groups from around the world are trying to home in on the precise biological mechanisms. Although diet likely plays a role – South Asians tend to eat a diet high in carbohydrates, and low in fruits and vegetables, which can affect blood sugar levels – along with a general lack of physical activity, their genes are also a factor.
Experts say we are just beginning to untangle the complexities of the ethnic origins of disease. And though multiple predictions and hypotheses are being attacked around the world, scientists all agree that research in the field has to speed up.
Last month, the Heart and Stroke Foundation of Ontario announced it will dedicate $700,000 to ethnic-specific research in the form of $50,000 two-year grants. The foundation is also investing $150,000 to develop specific cardiovascular risk profiles of South Asian and Chinese Canadians that will help create ethnic-specific health promotion initiatives.
"We can't meet our mission of eliminating heart disease and stroke unless we meet the needs of the population, and that means meeting the needs of ethnic groups that have a very distinctive cardiovascular profile," says Marco Di Buono, the foundation's director of research.
Right now, many of the guidelines physicians use to prevent and treat heart disease come from the Framingham Heart Study, a 60-year trial undertaken by the U.S. National Institute of Health to investigate the causes of cardiovascular disease. Named for the town in Massachusetts where the study takes place, the majority of its subjects are white and most are men.
Di Buono says the study has provided groundbreaking results in predicting an individual's risk for heart disease. But, he adds, in today's society it does not go far enough.
"It's imperative that we don't just use a reference group of white men to figure out how to treat, prevent and eliminate heart disease and stroke in a diverse population."
Dr. Milan Gupta, a cardiologist at William Osler Health Centre, says upwards of 40 per cent of the Brampton hospital's heart patients are South Asian, a much larger proportion than one would expect from the patient catchment area.
The first step to reduce this number is to raise awareness in the community, says Gupta, who is also an assistant professor at McMaster University. Not enough South Asians know they are at increased risk of heart disease or know the signs of a heart attack, he says.
On top of that, one of Gupta's studies of heart patients in Brampton and Scarborough found South Asians in the throes of a heart attack went to the emergency room a full hour later than white patients, which meant their heart muscle was more likely to suffer permanent damage from the attack.
"Time is muscle, because the sooner you get to us in the setting of a heart attack, the higher the likelihood of survival," says Gupta, adding that it was not clear why South Asians delayed going to the ER.
Back in the operating room, Ashok's heart has been stopped for more than one hour. Only the steady swish of the heart-lung machine has kept blood swirling through his body and his vital organs alive.
In the final stage of the bypass, Verma is attaching a harvested vein to a two-millimetre hole in Ashok's immobile heart.
"This is his entire life right here," he says. "This vessel, this is everything for him and his family and his future."
His green-gloved hands pull suture as fine as baby hair through the tiny lip of vein. It is a tense moment: "Give me two minutes of silence in the room, please."
Minutes later, Ashok's heart is beating again – brought back to life by a quick jolt of electricity – and the steady beep beep beep of the monitors fill the room. All seems to be well.
Verma and his assistant, another cardiac surgeon, lace up Ashok's chest with 10 stainless steel wires, each as thick as the nib of a pen, by hooking them deep under each edge of his split sternum bone. When the wires are in place, the pair yank his chest closed with the same force used to tie a stiff hockey skate.
Ashok will rest in hospital for five days before being allowed to go home.
But his recovery does not stop here. Bypasses are meant to only last 15 to 20 years. Ashok will have to work hard to preserve his new veins and arteries and keep his heart muscle healthy.
And the rest of his family – his mother, father, his two brothers and his two sons – will all have to be screened for the deadly disease.
https://www.thestar.com/life/health...1/south_asians_face_increased_heart_risk.html
