1. South Asians Cardiovascular Disease Ashley Marion University of Guelph-Humber Brampton Civic Hospital Cardiac Rehabilitation 0671496

2. Background Geography Geography –location –Climate Culture Culture –Diet –Views on exercise –Prevention and awareness Physiological differences Physiological differences http://www.google.ca/imgres?q=map+of+south+asia&hl=en&sa=X&biw=1280&bih=664&tbm=isch&tbnid=ZetMMCIZNks8iM:&imgrefurl=http://www.southasianconcern.org/south_asians/detail/wha t_does_south_asian_diaspora_mean/&docid=_DVBn8r4DRN7QM&imgurl=http://www.southasianconcern.org/images/sac_photos/south_asians/south_asia_map.gif&w=420&h=389&ei=eVFwT7TiLNH 5ggfbl8xr&zoom=1&iact=hc&vpx=612&vpy=321&dur=1043&hovh=216&hovw=233&tx=112&ty=120&sig=115924055748486242270&page=1&tbnh=132&tbnw=143&start=0&ndsp=20&ved=1t:429,r:10,s:0

3. What puts South Asians at higher Risk? INTERHEART case-control study, 52 countries, all ethnic groups, including South Asians INTERHEART case-control study, 52 countries, all ethnic groups, including South Asians –9 risk factors account for >90% of the population’s noticeable higher risk of MI  smoking, raised apolipoprotein B/apolipoprotein A1 ratio (), hypertension, diabetes mellitus, abdominal obesity, and psychosocial stress

4. Physiological Differences Phenotype Phenotype Biochemical Biochemical Differences in body Characteristics* Differences in body Characteristics*

5. Physiological Differences Exp. Arterial diameter Arterial diameter Altered adipokine activity (leptin, adiponectin) Altered adipokine activity (leptin, adiponectin) –Inflammation = biomarker of atherosclerosis –Raji et al,  Adiponectin= improves insulin sensitivity  good  Adiponectin levels lower in Asian Indians than in whites  increased whole body insulin resistance  impaired fibrinolysis (process of preventing clots)  altered endothelial function  Adipokines  insulin resistance  atherosclerosis

6. Raji et al

7. Conditions to take note… Ischemic Heart Disease Ischemic Heart Disease Stroke Stroke Peripheral vascular disease Peripheral vascular disease

8. Stroke Adiponectin levels lower  increased whole body insulin resistance  impaired fibrinolysis+ Arterial diameter= Increased number of strokes Adiponectin levels lower  increased whole body insulin resistance  impaired fibrinolysis+ Arterial diameter= Increased number of strokes http://www.cadiresearch.org/?page_id=442

9. Peripheral vascular disease What is PVD? What is PVD? –Condition of blood vessels  Leads to narrowing/hardening of arteries  Lower Limbs and feet –Caused by arthrosclerosis South Asians= increase in atherosclerosis South Asians= increase in atherosclerosis

10. Ischemic Heart Disease Aka. Myocardial Ischemia Aka. Myocardial Ischemia –Heart muscle damage/inefficient –Reduced blood supply to heart –Reduced blood flow= ATHEROSCLEROSIS –Risks  Increases with age  Smokers  Diabetics  HPT

11. Barriers What are some of the barriers to working with this population? What are some of the barriers to working with this population? –Language –Culture and tradition  tradition does not change over-night

12. Recap –Adipokines  insulin resistance  atherosclerosis –Insulin resistance  diminished adiponectin levels

13. Considerations for Screening/Diagnostics What do physicians need to consider? What do physicians need to consider? –Aware of prevalence of metabolic syndrome and glucose intolerance in South Asians –Screen  waist circumference and waist-hip ratio, rather than BMI.  Assessment of fasting glucose and a complete lipid profile  a strong family history of diabetes, or impaired fasting glucose, an OGTT should be considered

14. Treatment no evidence to suggest that treatment targets should differ between ethnic groups. no evidence to suggest that treatment targets should differ between ethnic groups. –Exercise* –Diet change –Stress level changes… Not enough studies with regards to different responses to pharmaceutics Not enough studies with regards to different responses to pharmaceutics

15. Example Exercise program Start slowly with aerobics (3 x 30 min with 10 min warm-up and cool down) Start slowly with aerobics (3 x 30 min with 10 min warm-up and cool down) –Walking, swimming –Cycling for most obese, not as hard on joints Strength training Strength training –Lighter weights higher reps –Continuous –Breath, no max lifts

16. Barriers to Exercise Diet Diet HR? HR? –Beta blockers (HPT) –RPE –Beware starting BP –Strenuous= atherosclerosis BMI BMI

17. Work Cited Brookes, 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-risks-of-the-south-asian-diet Gupta, Milan., Singh, Narendra., Verma, Subodh (2006). 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#F2 Gupta, Milan., Singh, Narendra., Verma, Subodh (2006). 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#F2 n.a (2012). Peripheral Artery Disease. Medline Plus. Retrieved from http://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/?page_id=442 The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences; First Edition. Retrieved from http://sahf.org.uk/uploads/docs/files/21.pdf Patel, Kiran C R (2004). The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences; First Edition. Retrieved from http://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 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?ijkey=8fee1377e4f0b42365c1c2632ff1181012bef892&keyt ype2=tf_ipsecsha.