South AsiansSouth AsiansCardiovascular DiseaseCardiovascular Disease

Ashley MarionUniversity of Guelph-Humber

Brampton Civic Hospital Cardiac Rehabilitation

0671496

BackgroundBackground

GeographyGeography– locationlocation– ClimateClimate

CultureCulture– DietDiet– Views on exerciseViews on exercise– Prevention and awarenessPrevention and awareness

Physiological differencesPhysiological differences

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What puts South Asians at What puts South Asians at higher Risk?higher Risk?

INTERHEART case-control study, 52 INTERHEART case-control study, 52 countries, all ethnic groups, including countries, all ethnic groups, including South AsiansSouth Asians– 9 risk factors account for >90% of the 9 risk factors account for >90% of the

population’s noticeable higher risk of MIpopulation’s noticeable higher risk of MI smokingsmoking, raised , raised apolipoprotein apolipoprotein

B/apolipoprotein A1 ratio (),B/apolipoprotein A1 ratio (), hypertensionhypertension, , diabetes mellitusdiabetes mellitus, , abdominal obesityabdominal obesity, and , and psychosocial stresspsychosocial stress

Physiological DifferencesPhysiological Differences

PhenotypePhenotype

BiochemicalBiochemical

Differences in body Characteristics*Differences in body Characteristics*

Physiological Differences Physiological Differences Exp.Exp.

Arterial diameterArterial diameter Altered adipokine activity (leptin, Altered adipokine activity (leptin,

adiponectin)adiponectin)– Inflammation = biomarker of atherosclerosisInflammation = biomarker of atherosclerosis– Raji et al,Raji et al,

Adiponectin= improves insulin sensitivityAdiponectin= improves insulin sensitivitygoodgood Adiponectin levels lower in Asian Indians than in Adiponectin levels lower in Asian Indians than in

whiteswhitesincreased whole body insulin resistanceincreased whole body insulin resistance impaired fibrinolysis (process of preventing impaired fibrinolysis (process of preventing clots)clots)altered endothelial functionaltered endothelial function

AdipokinesAdipokinesinsulin resistanceinsulin resistance atherosclerosis atherosclerosis

Raji et al

Conditions to take note…Conditions to take note…

Ischemic Heart DiseaseIschemic Heart Disease

StrokeStroke

Peripheral vascular diseasePeripheral vascular disease

StrokeStroke

Adiponectin levels lower Adiponectin levels lower increased increased whole body insulin resistancewhole body insulin resistance impaired fibrinolysis+ Arterial impaired fibrinolysis+ Arterial diameter= Increased number of diameter= Increased number of strokesstrokes

http://www.cadiresearch.org/?page_id=442

Peripheral vascular diseasePeripheral vascular disease

What is PVD?What is PVD?– Condition of blood vesselsCondition of blood vessels

Leads to narrowing/hardening of arteriesLeads to narrowing/hardening of arteries Lower Limbs and feetLower Limbs and feet

– Caused by arthrosclerosisCaused by arthrosclerosis South Asians= increase in South Asians= increase in

atherosclerosisatherosclerosis

Ischemic Heart DiseaseIschemic Heart Disease

Aka. Myocardial IschemiaAka. Myocardial Ischemia– Heart muscle damage/inefficientHeart muscle damage/inefficient– Reduced blood supply to heartReduced blood supply to heart

– Reduced blood Reduced blood

flow=flow=ATHEROSCLEROSISATHEROSCLEROSIS– RisksRisks

Increases with ageIncreases with age SmokersSmokers DiabeticsDiabetics HPTHPT

BarriersBarriers

What are some of the barriers to What are some of the barriers to working with this population?working with this population?– LanguageLanguage– Culture and tradition Culture and tradition

tradition does not change over-nighttradition does not change over-night

RecapRecap

– AdipokinesAdipokinesinsulin resistanceinsulin resistance atherosclerosisatherosclerosis

– Insulin resistanceInsulin resistance diminished diminished adiponectin levelsadiponectin levels

Considerations for Considerations for Screening/DiagnosticsScreening/Diagnostics

What do physicians need to consider?What do physicians need to consider?– Aware of prevalence of metabolic Aware of prevalence of metabolic

syndrome and glucose intolerance in South syndrome and glucose intolerance in South AsiansAsians

– ScreenScreen waist circumference and waist-hip ratio, rather waist circumference and waist-hip ratio, rather

than BMI.than BMI. Assessment of fasting glucose and a complete Assessment of fasting glucose and a complete

lipid profilelipid profile a strong family history of diabetes, or impaired a strong family history of diabetes, or impaired

fasting glucose, an OGTT should be consideredfasting glucose, an OGTT should be considered

TreatmentTreatment

no evidence to suggest that treatment no evidence to suggest that treatment targets should differ between ethnic targets should differ between ethnic groups.groups.

– Exercise*Exercise*– Diet changeDiet change– Stress level changes…Stress level changes…

Not enough studies with regards to Not enough studies with regards to different responses to pharmaceuticsdifferent responses to pharmaceutics

Example Exercise programExample Exercise program

Start slowly with aerobics (3 x 30 min Start slowly with aerobics (3 x 30 min with 10 min warm-up and cool down)with 10 min warm-up and cool down)– Walking, swimmingWalking, swimming– Cycling for most obese, not as hard on Cycling for most obese, not as hard on

jointsjoints Strength trainingStrength training

– Lighter weights higher repsLighter weights higher reps– ContinuousContinuous– Breath, no max liftsBreath, no max lifts

Barriers to ExerciseBarriers to Exercise

DietDiet HR?HR?

– Beta blockers (HPT)Beta blockers (HPT)– RPERPE– Beware starting BPBeware starting BP– Strenuous= atherosclerosisStrenuous= atherosclerosis

BMIBMI

Work CitedWork CitedBrookes, Linda (2004).Brookes, Linda (2004). INTERHEART: A Global Case-Control Study of Risk Factors for Acute Myocardial Infarction. Lancet.

Retrieved from http://www.medscape.com/viewarticle/489738.

Gulshinder, Chattha (2010). Top Ten Risks of the South Asian Diet. Retrieved from http://www.desiblitz.com/content/top-10-Gulshinder, Chattha (2010). Top Ten Risks of the South Asian Diet. Retrieved from http://www.desiblitz.com/content/top-10-risks-of-the-south-asian-dietrisks-of-the-south-asian-diet

Gupta, Milan., Singh, Narendra., Verma, Subodh (2006Gupta, Milan., Singh, Narendra., Verma, Subodh (2006). South Asians and Cardiovascular Risk What Clinicians Should Know. ). South Asians and Cardiovascular Risk What Clinicians Should Know. Circulation. 2006; 113: e924-e929. Retrieved from http://circ.ahajournals.org/content/113/25/e924.full#F2Circulation. 2006; 113: e924-e929. Retrieved from http://circ.ahajournals.org/content/113/25/e924.full#F2

n.a (2012). n.a (2012). Peripheral Artery DiseasePeripheral Artery Disease. Medline Plus. Retrieved from . Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000170.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000170.htm

n.a (2012). Stroke In South Asians. Coronary Artery Disease in Asian Indians. Retrieved from http://www.cadiresearch.org/?n.a (2012). Stroke In South Asians. Coronary Artery Disease in Asian Indians. Retrieved from http://www.cadiresearch.org/?page_id=442page_id=442

Patel, Kiran C R (2004). The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and ConsequencesThe Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences ; First ; First Edition. Retrieved from Edition. Retrieved from http://sahf.org.uk/uploads/docs/files/21.pdfhttp://sahf.org.uk/uploads/docs/files/21.pdf

Raji A, Gerhard-Herman MD, Warren M, Silverman SG, Raptopoulos V, Mantzoros CS, Simonson DC. Insulin resistance and Raji A, Gerhard-Herman MD, Warren M, Silverman SG, Raptopoulos V, Mantzoros CS, Simonson DC. Insulin resistance and vascular dysfunction in nondiabetic Asian Indians. J Clin Endocrinol Metab. 2004; 89: 3965–3972. Retrieved from vascular dysfunction in nondiabetic Asian Indians. J Clin Endocrinol Metab. 2004; 89: 3965–3972. Retrieved from http://jcem.endojournals.org/content/89/8/3965.abstract?http://jcem.endojournals.org/content/89/8/3965.abstract?ijkey=8fee1377e4f0b42365c1c2632ff1181012bef892&keytype2=tf_ipsecsha.ijkey=8fee1377e4f0b42365c1c2632ff1181012bef892&keytype2=tf_ipsecsha.