Coronary Heart Disease:

Epidemiology & Prevention

Dr Madhur Borah
 Coronary Heart Disease – The Silent Epidemic
Why Does This Matter?
● Leading cause of death worldwide 🌍
● Often progresses silently until a major event occurs
● Affects both young and old due to changing
lifestyles.
 Definition
Coronary heart disease is a heart disease that occurs
when the arteries of the heart cannot deliver enough
oxygen -rich blood to the heart muscle due to narrowing
from the buildup of fatty deposits called plaque .

It is also sometimes called coronary artery disease or

ischemic heart disease.
 Types of CHD
● Obstructive coronary artery disease:
Diameter of a large coronary artery is blocked by
50% or more.

● Nonobstructive coronary artery disease

Blood flow in a large coronary artery is blocked less than
50%.

● Coronary microvascular disease Blood flow

into the tiny arteries within the heart muscle is blocked.
 Global Disease Burden
● In 2019, cardiovascular diseases (CVDs), which include CHD,
accounted for an estimated 17.9 million deaths worldwide,
representing 32% of all global deaths. Of these, 85% were due to
heart attacks and strokes.
● In terms of absolute numbers, countries such as India, China,
Pakistan, and Nigeria have the highest CHD mortality, collectively
accounting for 39.7% of global CHD deaths.
● Europe and Central Asia accounting for 29.7% of total deaths.
 CHD in India
● Coronary Heart Disease (CHD), has shown a significant
increase in prevalence in India over the past six decades.
● Urban areas in India have historically reported higher CHD
prevalence compared to rural regions. However narrowing the
urban-rural gap seen recently.
● Estimated 9%-10% in urban populations and 4%-6% in rural
populations.
● In 2016, CVDs were responsible for 27% of all deaths in the
country, with ischemic heart disease accounting for over 60%
of these fatalities.
Risk factors of CHD
 Non Modifiable Risk factors
● Age: The risk increases as get older, particularly after age 45 for men
and 55 for women.
● Sex: Men generally have a higher risk of CAD earlier in life compared
to women, though the risk for women rises after menopause.
● Family History: A family history of heart disease, especially if a close
relative (parent or sibling) had CAD at a young age (men under 55,
women under 65), increases risk.
● Genetics: Certain genetic factors can predispose individuals to high
cholesterol, high blood pressure, or other conditions linked to CAD.
 Genetics & CHDs
Single Nucleotide Polymorphisms (SNPs) 9p21 Locus – Strongest genetic risk
factor for CAD.

LDLR, APOB, PCSK9 Genes – Cause high LDL cholesterol, increasing CAD risk
from a young age.

ACE, AGT, NOS3 – Regulate blood pressure and vascular tone, contributing to
CAD.

IL6, CRP, TNFA – Involved in systemic inflammation, leading to atherosclerosis.

TCF7L2 – Increases type 2 diabetes risk, a major CAD contributor.

Polygenic Risk Scores (PRS): multiple genetic variants combined to predict

CAD risk.
 Modifiable Risk factors of CHD
● Cigarette smoking
● High blood pressure
● Elevated Serum cholesterol
● Diabetes
● Obesity
● Physical inactivity
● Alcohol
● Stress
 Smoking and CHD

● Accelerates Atherosclerosis: Endothelial damage

● Nicotine increases LDL
● Increases Blood Pressure and Heart Rate: Nicotine stimulates the
nervous system,
● Smoking increases platelet aggregation
● Increases Inflammation and Oxidative Stress
 High Blood Pressure

● Causes Arterial Damage and Atherosclerosis

● Increases Heart Workload and Leads to Hypertrophy.
● Reduces Coronary Artery Elasticity.
● Promotes Thrombosis.
● Other Risk Factors
 Elevated Cholesterol
➡ Elevated LDL Cholesterol ⟶⟶ 🛑 LDL Deposits in Artery Walls ⟶⟶
⚠ Atherosclerosis ⟶⟶ ❌ Arteries Narrow & Harden ⟶⟶ 🔴 Reduced
Blood Flow to the Heart ⟶⟶ ⚡ Risk of Plaque Rupture ⟶⟶ ⏳ Blood
Clot Formation ⟶⟶ 🚨 Complete or Partial Blockage of Coronary Artery
⟶⟶ 💔 CHD Outcomes (Angina, Heart Attack, Stroke)
 Diabetes
● Endothelial Dysfunction: Hyperglycemia impairs nitric oxide (NO), leading to
vasoconstriction and inflammation.
● Atherosclerosis & Plaque Formation: Oxidized LDL triggers inflammation,
forming plaques in coronary arteries.
● Dyslipidemia: High triglycerides, low HDL, and dense LDL accelerate
atherosclerosis.
● Hypertension: Insulin resistance causes sodium retention and increased sympathetic
activity.
● Prothrombotic State: Increased platelet aggregation and fibrinogen raise thrombotic
event risk.
● Silent Ischemia: Autonomic neuropathy masks cardiac symptoms, delaying
diagnosis.
 Physical Inactivity
Increases Risk of Atherosclerosis
● Lack of exercise leads to higher levels of low-density lipoprotein (LDL) and
lower levels of high-density lipoprotein (HDL)

Promotes Hypertension (High Blood Pressure)

● Sedentary behavior weakens the blood vessels and makes them less flexible.

Leads to Obesity & Metabolic Syndrome

Increases Insulin Resistance & Risk of Diabetes
Weakens Heart Muscle & Reduces Cardiac Efficiency
Physical inactivity is associated with higher C-reactive protein (CRP), a
marker of chronic inflammation which plays a key role in CHD
Alcohol
 Obesity & CHD
● Obesity promotes atherosclerosis through dyslipidemia, endothelial dysfunction, and chronic
inflammation.
● Obesity increases blood pressure through Increased Blood Volume: Higher adipose tissue raises total
blood volume, increasing cardiac output and systemic vascular resistance.
● Renin-Angiotensin-Aldosterone System (RAAS) Activation
● Sympathetic Nervous System Activation
 Stress
● Increased Blood Pressure: Stress triggers the release of
adrenaline and cortisol.
● Inflammation: Chronic stress increases inflammatory markers like
C-reactive protein (CRP), which contribute to atherosclerosis.
● Increased Heart Rate: Persistent stress leads to a higher resting
heart rate.
● Endothelial Dysfunction: Stress impairs the ability of blood
vessels to dilate properly, reducing blood flow to the heart.
 Stress & CHD
● Unhealthy Diet: Stress often leads to overeating or
poor food choices.
● Sedentary Lifestyle: Chronic stress can reduce
motivation for exercise.
● Smoking & Alcohol Use: Many people use smoking or
alcohol as coping mechanisms.
● Poor Sleep: Stress-related insomnia can contribute to
hypertension
 New Age Risk Factors
Lifestyle & Behavioral Factors
● Chronic Stress
● Sleep Disorders: Poor sleep is linked to hypertension, obesity,
and systemic inflammation.
● Sedentary Lifestyle: leads to poor metabolic health and
endothelial dysfunction.
● Ultra-Processed Foods & Sugary Beverages: increases
inflammation and metabolic syndrome risk.
 New Age Risk Factors
Environmental & Occupational Factors

● Air Pollution: Long-term exposure leads to endothelial

damage and hypertension.
● Climate Change & Extreme Temperatures: increase
cardiovascular stress, especially in vulnerable populations.
● Workplace Stress & Burnout: Shift work, irregular sleep
patterns, and high job stress impact cardiovascular health.
 New Age Risk Factors
Emerging Medical conditions
● Non-Alcoholic Fatty Liver Disease (NAFLD): Now considered a
metabolic risk equivalent to diabetes for CHD.
● Microvascular Dysfunction: Even in the absence of obstructive
coronary artery disease, microvascular dysfunction can lead to
ischemia.
● Autoimmune Diseases (Rheumatoid Arthritis, Lupus, Psoriasis):
Chronic inflammation increases cardiovascular risk.
 New Age Risk Factors
Technology & Digital Impact

● Blue Light Exposure & Circadian Rhythm Disruption:

Excessive screen time at night affects melatonin levels,
which regulate cardiovascular health.
● Social Isolation & Loneliness: Associated with increased risk
of heart disease, similar to smoking or obesity.
 Prevention of CHD
● Primordial prevention

● Primary prevention

● Secondary prevention

● Tertiary prevention
 Primordial prevention
Primordial prevention aims to create a healthy environment and lifestyle from
an early age before appearance of risk factors.

Promoting Heart-Healthy Lifestyles from Childhood

● Encouraging physical activity from an early age (sports, outdoor play).
● Teaching healthy eating habits in schools and homes.
● Avoiding early exposure to junk food, smoking, and sedentary behaviors.

Strengthening Public Health Policies & Legislation

● Reducing air pollution, as it contributes to cardiovascular diseases.
● Regulating food industries to limit unhealthy ingredients.
● Improving access to affordable and healthy food in all communities.
 Primary prevention
Population Strategy

Lifestyle & Behavioral Modifications

✅ Encouraging Physical Activity

● Promoting active transportation (walking, cycling).
● Creating exercise-friendly environments (parks, bike lanes).
● Implementing workplace wellness programs.

✅ Healthy Diet Promotion

● Public campaigns for reducing saturated fats, sugar, and salt intake.
● Increasing availability of fruits, vegetables, and whole grains.
● Regulating junk food advertisements, especially targeting children.

✅ Tobacco & Alcohol Control

● Strict anti-smoking laws and taxation on tobacco products.
● Public awareness campaigns on dangers of smoking & passive smoking.
● Reducing alcohol consumption through higher taxes & advertising restrictions.
 Primary prevention
Health Policy & Legislative Measures
📌 Food Labeling Regulations

● Clearer nutrition labels to guide healthier choices.

📌 Trans Fat & Salt Reduction Policies

● Banning or limiting trans fats in processed foods.

● Encouraging restaurants & food companies to use less salt.

📌 Taxation on Unhealthy Foods

● Higher taxes on sugary drinks & ultra-processed foods to discourage consumption.

📌 Smoking & Alcohol Regulations

● Banning smoking in public places.

● Increasing prices of cigarettes & alcohol.
 Primary prevention
Public Awareness & Education
📢 Mass Media Campaigns

● Spreading awareness about CHD risk factors & healthy habits.

● Using social media, TV, and radio to encourage positive lifestyle changes.

📚 School Health Programs

● Teaching children about healthy eating & physical activity.

● Including compulsory physical education (PE) classes.

💼 Workplace Health Programs

● Employers promoting active breaks, healthy cafeterias, & stress

management.
 Primary Prevention: High risk strategy
The high-risk strategy targets individuals with elevated risk factors (e.g.,
hypertension, diabetes, obesity, high cholesterol, smokers) and aims to
reduce their risk through medical and lifestyle interventions.

Lifestyle Modifications
🔹 Encouraging Regular Physical Activity

🔹 Healthy Diet Plans

🔹 Smoking & Alcohol Cessation

🔹 Weight Management
High Risk groups for CHD
 Primary Prevention: High risk strategy

Medical Management for High-Risk Individuals

🩺 Hypertension Control
🩺 Dyslipidemia (High Cholesterol) Management
🩺 Diabetes Management
🩺 Aspirin Therapy (Selective Use): Low-dose aspirin (75–100
mg/day) may be used in high-risk individuals without bleeding risk.
 Secondary prevention of CHD
● Early diagnosis and treatment
● Smoking Cessation: Complete avoidance of tobacco
and exposure to secondhand smoke.
● Healthy Diet
● Regular physical activity
● Weight reduction
● Adherence to medications
● Monitoring and follow up
● Psychological support
 Tertiary prevention of CHD

● Medical Management & Pharmacotherapy

● Revascularization Procedures:
○ Percutaneous Coronary Intervention (PCI): Stenting for recurrent
ischemic events.
○ Coronary Artery Bypass Grafting (CABG): In multivessel disease