In Trinidad and Tobago (T&T), 25% of adult deaths are due to heart disease, specifically Coronary Artery Disease (CAD) or Ischemic Heart Disease (IHD) which leads to heart attack. If we add Cerebrovascular Events (CVE) or Stroke and cancers to the cause of death, we would have covered 60% of the causes of adult mortality in T&T. This, according to Dr. Naveen Seecheran, consultant cardiologist at the Eric Williams Medical Science Complex (EWMSC), are the figures from 2015 coming out of the Pan American Health Organization, the regional branch of the World Health Organization (WHO) for the Americas.
Dr. Seecheran laments these figures as both CAD and CVE are quite preventable when people make healthy choices and manage their conditions. He explained that both cardiovascular diseases are secondary to a systemic condition called Atherosclerosis. Atherosclerosis is a disease in which plaque builds up inside your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. This limits the flow of oxygen-rich blood to your organs and other parts of your body. Atherosclerosis that occurs in the blood vessels of the heart can lead to heart attack and those of the brain can lead to stroke. As seen in the data mentioned previously, both heart attack and stroke contribute significantly to the cause of death among Trinbagonians.
Dr. Seecheran mentioned that at the cardiac clinics in EWMSC, most patients presenting with CAD would have comorbidities of Diabetes Mellitus type II and Chronic Kidney Disease, two major risk factors for atherosclerosis and CAD. He added that, in addition to these two, other major risk factors include; high blood pressure, elevated blood cholesterol, pre-diabetes, overweight or obesity, smoking unhealthy diet and lack of physical activity. With new research into the socio-economic factors or social determinants of health, it was also found that being of lower economic means, worldwide, increases your risk of heart disease and stroke. A chronically stressful life, social isolation, anxiety and depression also increase the risk. These risk factors, he said, are modifiable as their effect on predisposition to CAD can be reduced by making healthy choices and management of these conditions.
However, he said that there are factors that are non-modifiable that related to one’s age, gender, ethnicity and genetics. After age 55, the risk of atherosclerosis and CAD doubles every decade. Men are at greater risk of CAD than a pre-menopausal woman. But once past menopause, a woman’s risk is similar to that in men. In fact, the gender issues where CAD is concerned is so unique that this month has been designated Heart Disease Awareness month among women in North America. Ethnicity has often been shown to play a significant role. There has been a drive to screen South Asians in Europe as studies have shown that this ethnic group shows a high incidence and prevalence for CAD. Some genetic factors have been attributed to these such as the higher incidence of high cholesterol among South Asians due to the inheritance of a certain genotype, as well as a relatively smaller caliber of the arteries supplying the heart that is also genetically determined. Such genetic associations have also been the culprit in the observation that if your first-degree male relative (e.g. father, brother) has suffered a heart attack before the age of 55, or if a first-degree female relative has suffered one before the age of 65, you are at greater risk of developing heart disease. If both parents have suffered from heart disease before the age of 55, your risk of developing heart disease can rise to 50% compared to the general population.
Dr. Seecheran said though, that these factors of age, genetic and ethnic associations were yielded from studies in Europe and North America. In T&T however, these factors may be more ubiquitous within the context of the local population owing to our unique dietary habits, lifestyle and culture. Thus, in T&T the established risk factors may interplay differently within our population. In his clinics he has noticed no specific ethnicity forming the majority of his patient group and he says this warrants further research within the T&T population that will aid in the proper and adequate treatment among T&T patients presenting with CAD.
Two noteworthy papers published by Dr. Seecheran and others, on a T&T population sample, demonstrated that there is a significantly poor adherence rate of CAD patients taking their medications and the need for more educational interventions to improve outcomes of patients with CAD. He says that this highlights much of the work to be done at a policy level to achieve any dent in the scourge of CAD in T&T. Dr. Seecheran went on to itemize what he believes should be key to dealing with CVD within the T&T context. He emphasized that CAD like all other diseases should be dealt with from a multidisciplinary team approach. This would involve not only the cardiologist, but many specialties including; the dietitian, the district health visitor, the community physician, the social worker, the psychiatrist, the internist and so on. He went on to point out that one of the most crucial departments in CAD prevention and management was the community clinic. The latter plays an important role in primary prevention of diabetes, high blood pressure, high cholesterol and obesity by health promotion to encourage healthy diets, increased physical activity and smoking cessation.
Within the context of empowering the community through community primary care clinics, adequate continuous medical education courses should be offered to the primary care physicians to become experts at cardiovascular risk assessment, proper screening for CAD within the community and appropriate referral to the hospitals for those suspected of having a medium to high risk of developing CAD and would require further evaluation and adequate follow-up. Also, a move to establish cardiac non-invasive investigations like exercise stress testing, and echocardiography as screening tools, within the context of chest pain centers in the community setting, will go a long way in reducing unnecessary referrals to hospital and the overcrowding of the cardiac outpatient clinics to simply rule out CAD. Such a system would result in efficient and cost-effective usage of the limited catheterization laboratories across the country and ultimately a reduction in the prevalence and incidence of CAD in T&T.
Indeed, such a focus on establishing policy and protocol to enable a multidisciplinary approach for CAD in T&T would see a reduction in heart attacks as a major cause of death in this part of the Caribbean.
Dr. Visham Bhimull, Family Physician
MBBS (UWI), Diploma in Family Medicine (UWI)