W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Metaboli...
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W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
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W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt ...
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W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 TECAB using DaV...
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W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 THE HEART FAILUR...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 T...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 HEART FAILU...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 ...
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Naresh trehan

Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Naresh trehan

  • 1. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Cardiovascular Disease Trends in India Naresh Trehan Escorts Heart Institute and Research Centre New Delhi, India Cardiovascular Disease According to recent estimates, ! Cases of CVD may increase from about 2.9 crore in 2000 to as many as 6.4 crore in 2015 ! Deaths from CVD will also more than double. ! Most of this increase will occur on account of coronary heart disease —AMI, angina, CHF and inflammatory heart disease Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005 1
  • 2. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Cardiovascular Disease Data also suggest that although the ! Prevalence rates of CVD in rural populations will remain lower than that of urban populations, they will continue to increase, reaching around 13.5% of the rural population in the age group of 60–69 years by 2015. ! The prevalence rates among younger adults (age group of 40 years and above) are also likely to increase ! Prevalence rates among women will keep pace with those of men across all age groups. Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005 Largest Share in Non- communicable Diseases Cancers, 10% Others, 21% Diabetes, 2% Oral diseases, 1% COPD and asthma, Mental health 5% disorders, 26% Blindness, 4% Cardiovascular disease, 31% Priority non-communicable health conditions in India, by share in the burden of disease (1998) Source: Peters et al. 2001 2
  • 3. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Rising Population Projected trends in population Source: Report of the Registrar General of India 1996 Rising Prevalence and Mortality Forecasting the prevalence rate (%) of coronary heart disease (CHD) in India Estimated mortality from coronary heart disease (CHD) Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005 3
  • 4. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Estimates and trends of coronary heart disease (CHD) cases in various age groups Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005 Trends of CAD Prevalence in India % Prevalence URBAN % Prevalence RURAL 14 Trivandrum 14 12 12 Delhi 10 Jaipur 10 8 Chandigarh 8 6 6 Kerela Rajasthan Rohtak Punjab 4 4 Haryana UP 2 Delhi 2 Agra 0 0 1960 1970 1980 1990 2000 1960 1970 1980 1990 2000 Year of Study Year of Study 4
  • 5. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Burden of CVD: 1990-2020 50 India DALYs (millions) 40 China SSA 30 Mexico LAC 20 EME PSE QAI 10 0 1990 2000 2010 2020 CORONARY ANATOMY INDIANS HAVE MORE COMMON ! Involvement at younger age ! Smaller Coronary Arteries ! Diffuse Distal Disease ! Multi-vessel Disease ! Higher incidence in women 5
  • 6. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Metabolic Syndrome: Prevalence Metabolic Syndrome Prevalence in India: EHIRC Data 6
  • 7. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Metabolic Syndrome Prevalence in India: EHIRC Data 40.0% 33.7% 29.0% 30.0% 19.3% 20.6% 20.0% 7.1% 0.0% Overall 21-30 31-40 41-50 51-60 61-70 299 consecutive subjects aged 20-65 years, without any evidence of CVD, undergoing routine health check-up Metabolic Syndrome Prevalence in India: EHIRC Data 76.3% 80.0% 60.0% 40.0% 16.7% 20.0% 60.0% 40.3% 0.0% Diabetics Nondiabetics 40.0% 24.4% p <0.001 for comparison 20.0% 0.0% Males Females p <0.001 for comparison 7
  • 8. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 EHIRC data contd. Prevalence of individual metabolic abnormalities 50.0% 46.8% 45.80% 28.5% 28.4% 30.0% 12.70% 10.0% Increased WC Low HDL High TG Increased FBS HT EHIRC data Prevalence of Metabolic Syndrome • 1000 consecutive patients undergoing CABG included • Overall prevalence of metabolic syndrome by modified ATP III criteria- – 60.0% Submitted for publication; Accepted for presentation at CSI 2005 8
  • 9. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 EHIRC data 1000 CABG patients • Mean age- 59.73 ± 9.5 years • 88.4% males; 11.6% females • Obesity (BMI)- 100.0% 75.2% 80.0% 50.8% 60.0% 40.0% 14.6% 20.0% 0.0% >30.0 kg/m2 >25.0 kg/m2 >23.0 kg/m2 Obese Overweight Overweight (Asian criteria) EHIRC data 1000 CABG patients Diabetes Mellitus 60.0% 55.2% 47.5% 46.5% Hypertension 40.0% 80.0% Overall Males Females 70.8% 71.6% 70.9% p 0.078 for comparison between males and females 60.0% Overall Males Females p 0.869 for comparison between males and females 9
  • 10. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 EHIRC data 1000 CABG patients 100.0% Dyslipidemia 93.9% 85.6% 84.5% 81.4% 80.0% Overall (LDL Males Females Overall (LDL cut-off cut-off 100mg%) 130mg%) Lipid abnormalities p 0.023 for comparison between males and females 72.5% 80.0% 60.0% 37.0% 40.0% 23.3% 20.0% High LDL Low HDL High TG Parameter Year 2000 Year 2005 p value N 1747 1302 Age (years) 50.0 ± 11.1 43.2 ± 13.1 <0.001 Male gender (79.9%) (78.3%) 0.309 Body-mass index (kg/m2) 24.7±3.9 25.0±3.9 0.034 Hypertension (47.4%) (42.1%) 0.004 Diabetes mellitus (13.0%) (16.5%) 0.012 Dyslipidemia* (76.4%) (62.0%) <0.001 Family h/o CAD (16.8%) (33.5%) <0.001 10
  • 11. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Escorts Heart Institute & Research Centre New Delhi 1988 Angiographies / Year 11000 10011 9603 8974 8990 9123 8829 9000 7945 6520 7000 5544 4826 5000 4092 3430 2917 2527 3000 2135 1623 1011 1000 117 -1000 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 11
  • 12. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Angioplasties / Year 2800 2565 3000 2600 2370 2400 2185 2200 2035 2000 1815 1818 1800 1600 1376 1400 1206 1200 1000 860 800 651 717 600 365 468 400 192 256 200 94 2 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005 Cardiac Surgeries / Year 6000 5000 4176 4280 4016 4150 4000 3680 3360 3142 2751 3000 2493 2106 2000 1737 1750 1863 1555 1145 1283 806 1000 86 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005 12
  • 13. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Total Cardiac Surgeries 1988 – 2005 Dec (N = 51,599) 8097 MISCELL 4040 CONGENITAL VALVES CABG 5555 33686 Age group wise Admissions ( Jan. - Aug. 2006) 26238 28000 24000 No. of patients 20000 16000 13387 11580 12000 8000 5838 4488 3241 4000 581 0 < 14 Years 14 - 18 Years 19 - 30 Years 31 - 40 Years 41 - 50 Years 51 - 65 Years Above 65 Years 13
  • 14. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Ejection Fraction of Surgical Patients (Jan. - Aug. 2006) 1000 Off CPB On CPB 800 742 620 600 400 336 186 200 155 76 96 61 23 20 0 <= .20 .21 - .30 .31 - .40 .41 - .50 > .50 Growth of OPCABs : 1995 - 2005 3500 3000 2500 423 3022 1411 2000 355 349 3400 3444 204 2907 3011 1500 125 1000 2117 1783 1598 1388 1492 1416 500 225 268 286 352 255 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 OPCAB CCAB 14
  • 15. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Age wise Mortality rate in Isolated CABG (Jan. - Aug. 2006) 3.0% (n=287) 2.5% 2.3% Percentage (%) 2.0% n=687) (n=702) 1.5% (n=230) 1.2% 1.0% 0.9% 1.0% 0.5% (n-4) (n=23) 0.0% 0.0% 0.0% <= 30 Years 31 - 40 Years 41 - 50 Years 51 - 60 Years 61 - 70 Years > 70 Years 15
  • 16. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 TECAB using DaVinci Computer Enhanced Telemanipulation System EHIRC Data December 2002 – Dec 2005 • Robotic surgery done - 255 • TECAB 22 – Beating heart TECAB - 20 – Arrested heart TECAB - 2 • EndoACAB 231 – LIMA Skeletonized 152 – ThoraCAB 79 • ASD,Valve Repair 2 Postoperative Data • Complete Ventilation time (hrs) -4.36 • Chest tube drainage - 164 (55ml- 360ml) • ICU stay - 1.2 days • Hospital stay - 4.5 days • Perioperative MI - Nil • Reoperation for bleeding - 6 • New onset atrial fibrillation - Nil • Wound Infection - Nil • Mortality - Nil 16
  • 17. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Functional Ischemic MR Myocardial Infarction LV Remodeling Mitral Annular Dilatation + Papillary Muscle Mitral Valve Tenting Functional Ischemic MR Coapsys Mitral Annuloplasty System Annular Dilatation Restricted Leaflets Type I Type IIIb 17
  • 18. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Patient Selection CABG Patients Ischemic Functional MR Baseline MR Grade ! 2 EF>25% N = 75 Intra-Op TEE: MR ! 2 Post CABG and Hemodynamic Challenge MR " 1 Group 1 Group 2 Coapsys Untreated (Mitral Valve Repair + CABG) (CABG Only) Intra-op MR = 2.7 Intra-op MR = 1.0 N=35 N=40 Coapsys Effect: Intraoperative MR Reduction Pre-tightening Post-tightening 18
  • 19. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Change in MR Grade With 10 Time Grade 4 Grade 3 Grade 2 Grade 1/0 9 8 7 6 5 4 Untreated 3 2 Group 1 0 Grade 4 Grade 3 Baseline Discharge 3 Months 12 Months 12 Grade 2 Grade 1/0 Coapsys 10 8 Group 6 4 2 0 Baseline Discharge 3 Months 12 Months LVED and LVED Changes in Coapsys Patients 19
  • 20. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 THE HEART FAILURE CLINIC AT EHIRC SINCE SEPTEMBER 99’ HEART FAILURE CLINIC AT EHIRC 50 2000 2001 47.4 2002 2005 40 35.6 30 28.8 20.6 20 10 0 No. of Patients Per OPD 20
  • 21. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 THE HEART FAILURE CLINIC CLINICAL EVALUATION OPTIMIZE MEDICAL REHABILITATION THERAPY MONITORING PATIENT & FOLLOWUP HF CLINIC EDUCATION IS IT SURGICAL DISEASE? DATA REGISTRY RESEARCH TRAINING REASONS FOR REFERALS ! OPTIMIZING MEDICAL CARE " PHARMACOLOGICAL " DIET, EXERCISE " PATIENT EDUCATION " PSYCHO-SOCIAL REHABILITATION ! REFRACTORY HEART FAILURE TO CONSIDER FOR " OPTIMIZATION OF MEDICAL CARE " ALTERNATIVE MEDICINE, SECP, PACEMAKER, AICD " INTERMITTENT / DOMICILLIARY INOTROPES " PLAN SURGICAL INTERVENTION ! RESEARCH TRIALS 21
  • 22. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 HEART FAILURE CLINIC !91% HAD CAD, 85% WERE OPERATED CASES !REDUCED HOSPITAL READMISSION RATE !SIGNIFICANT IMPROVEMENT IN EXERCISE CAPACITY IMPACT OF HEART FAILURE CLINIC ON 3 MONTHS POST CABG FOLLOW UP IN PATIENTS WITH LV DYSFUNCTION 22
  • 23. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 No OF POST CABG PATIENTS 240 224 220 200 188 180 167 160 140 120 100 Oct 1997- Oct 1998- Oct 1999- Apr 1998 Apr 1999 Apr 2000 Heart Failure Re-Admission Rates: 3 Months Post CABG 7 6.91 12 11.11 5.99 9.76 Oct 1999- 6 10 Apr 2000 5 8 4 6 Oct 1998- Apr 1999 3 4 2 2.33 1.34 2 1 Oct 1997- Apr 1998 0 0 LVEF <20% LVEF <30% 23
  • 24. W:NDEI2860CD GiveawayRecognizing and Treating Insulin Resistance.ppt 11/16/06 12:23 Myocardial Sudden Infarct Death Coronary Arrhythmia & thrombosis Loss of Muscle Myocardial Ischemia ENDSTAGE HEART Remodeling DISEASE Ventricular CAD dilatation - CHAIN OF EVENTS Atherosclerosis LVH CHF Coronary Endstage Risk Factors Heart Disease Dzau and Braunwald, 1991 Thank You 24

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