Our activities in all 20 districts of Jammu and Kashmir continue uninterrupted. After Kupwara and Machil, followed by Khan Sahab, Budgam District, we went to the Community Health Center (CHC), Rajpora, Pulwama District, on November 27th to make camp. This camp was under the banner of the Gauri Healthy Heart Project (GHHP). The activities were carried out by the district health authorities under the direction of CMO Dr. Haseena Mir, the Dr. Javed Ahmed Bhat, BMO, had been entrusted with coordinating the health camp with a well-composed team. The program has the blessings of Finance Commissioner Atal Dulloo and Director of Health Services Dr. Samir Muttoo.
The CHC Rajpora is a very well-kept, spacious hospital with several specialties. It has a dialysis facility for patients with chronic kidney disease. Currently, all of the district’s dialysis facilities have been moved here with 5 machines as the district hospital is being converted into a COVID center. The hospital was in the news after a successful hysterectomy was performed on a patient with persistent bleeding from multiple uterine fibroids. Such efficiency in sub-district hospitals is unusual and exemplary.
Treating targets for high blood pressure (BP), diabetes with or without heart disease is imperative. To emphasize this, the GHHP medical team, together with doctors from the district, assessed pre-screened patients with these problems, optimized drug treatment and also provided advice on lifestyle management.
All patients underwent a full assessment according to a pre-formed questionnaire. Measurement of body mass index, blood pressure with a calibrated instrument, random blood sugar and serum lipid estimation with point-of-care instruments. In addition, an electrocardiogram (EKG) was created for everyone by a special EKG device that is able to transfer the high-quality recording reported via the I-Cloud to an app downloaded by the doctors. One of the distinctive features was that we also had access to echocardiography to assess cardiac status in patients with suspected but undiagnosed heart problems.
We saw a total of 127 people, 61% of them between the ages of 40 and 65. All were Kashmiri and spoke to 62% women, with 45% of their families earning less than 50,000 rupees a year, but all had a house to stay and enough land to grow rice and a few cattle for milk. 65% of the patients were either overweight or obese. However, the majority of them were quite physically active in their daily chores. Smoking was not a problem for 85% of non-smokers.
The problem of uncontrolled hypertension (HT) despite treatment:
Of 86 patients (67%) with high blood pressure and drug users, 41% had uncontrolled HT with blood pressure greater than 140/90 mm Hg 8 (9.3%) also had diabetes. This combination, known as the deadly duo, results in a very high chance of having a heart attack, stroke, or chronic kidney disease. Although most HT patients received at least two drugs, compliance was poor and they were unaware of the goals. In our OPD brochure, the goals of blood pressure control, blood sugar levels, and cholesterol levels were clearly mentioned for everyone. The list of medicines dispensed in the health centers must be checked from time to time. For example, it is high time that RAAS inhibitors (such as enalapril / ramipril) were added to amlodipine in district health centers. Likewise, water pills (diuretics – thiazides) must be promoted in this population with high salt consumption. All of these molecules are pretty cheap.
Uncontrolled HT was seen in more than a third of the patients with high blood pressure in all three districts we visited. This finding must be recognized and the treatment strategies designed more aggressively.
An important factor is a high salt intake via “Noon Chai”, which was consumed by 96% of people. Excessive salt intake, a part of Kashmiri dietary habits, is a major cause of difficult-to-treat high blood pressure and need needs, as well as the recommendation to add a water pill (diuretic) to treatment.
Diabetes was present in 25 patients (19%), but was controlled in 83% of patients without exception with post-meal sugar <180 mg / dL. The newer drugs, SGLT2 inhibitors, which improve survival and reduce heart failure, were taken by 5 of these patients. Three active substances from this group are available (canagliflozin, dapagliflozin and empagliflozin). This contradicted our experience in the districts of Kupwara and Budgam, where these active ingredients were not even available from private chemists. We recommended these in everyone and gave them starter kits that we brought with us. Fortunately, dapagliflozin has become generic recently and has brought the cost down significantly.
Of the 118 EKGs performed, 31 were abnormal. Left bundle branch block was seen in 11 (9%) patients, 5 of whom had very poorly functioning hearts. Atrial fibrillation (AF) An arrhythmia was observed in 6 (5%) patients. This abnormality with a very fast and irregular heart rate predisposes patients to stroke and requires lifelong blood thinners (anticoagulants). Aspirin, an anti-platelet drug, does not work in this situation. The treatment of all patients with poor heart function and AF was optimized accordingly after the consultation.
We have performed 11 echocardiographic studies on selected patients in need of this. A multi-purpose ultrasound machine based on the CHC was used. Dr. Gowhar from Pulwama District Hospital participated in the activity.
We diagnosed chest pain in a 23-year-old man with clinical evidence suggesting inflammation of the outer layer of the heart called the pericardium. It has been found that there is a huge accumulation of fluid in this room that could be life threatening. After contacting the HOD cardiology department, he was immediately transferred to the SKIMS tertiary center. He is currently admitted there and is making good progress. We also found 3 patients with very poorly functioning hearts who needed aggressive medical therapy that was started immediately.
As in the other two districts, 46% of those studied had post-meal triglyceride levels greater than 200 mg / dL, 75% had low HDL cholesterol, and a third of them had high triglyceride levels. Most of them were overweight and had high blood pressure. This combination of dyslipidemia, obesity, and HT is known as “metabolic syndrome”. This syndrome is associated with a high risk of cardiovascular disease and diabetes. Changing your lifestyle is key to avoiding these problems. Regular exercise and eating more fruits and fresh vegetables, which fortunately are available year-round, are key along with reducing the amount of rice in meals.
High LDL cholesterol levels were seen in a relatively low percentage of patients of 22%. These patients need a statin group of medicines (atorvastatin or rosuvastatin). Our analysis found that statins were prescribed more frequently in deserving patients in this district compared to Kupwara and Budgam. Excessive rice consumption, hypothyroidism, which affects up to 18% of the rural Kashmiri population, and obesity are major causes of high triglycerides. This in combination with little exercise, high mutton meat and low vegetable intake increases the risk. Medicines are very important when LDL cholesterol levels are high, especially in high-risk patients with other risk factors. Atorvastatin is a cheap medicine and must be used in high doses (40 mg or more) in such people. These reduce heart attacks and strokes by more than a third. The use of pure triglyceride-lowering drugs (fenofibrate), provided they do not exceed 500 mg / dl, has no clinical benefit. Very high triglycerides, usually more than 1000 mg, can lead to serious diseases such as pancreatitis, which can be fatal if not treated in a timely manner.
In addition to controlling high blood pressure and blood sugar, cholesterol levels must be kept very low. Keeping BP near 130/80 mm Hg pays off the most for a low cost. Lifestyle measures are very important tools for anyone with or without high risk. We can postpone serious vascular events like heart attack, stroke, and kidney failure for at least a decade.
The Pulwama district, near the capital, Srinagar, has a significant non-communicable disease problem. Uncontrolled high blood pressure is a big problem. Overweight and obesity are a major problem that is exacerbated by high blood pressure and increased triglycerides, leading to “metabolic syndrome”. Lifestyle actions and public education programs in the district by health professionals, including health workers, are key to success. This, along with the judicious use of inexpensive drugs with appropriate advice, is the order of the day. District doctors must promote these important measures along with public awareness programs through the administration.
Dr. Haseena Mir, Javed Ahmad Bhat, Gowhar, Zubair Saleem and Doctors of the District and the Batra Hospital and Academic Research Medical Research Center team led by Ms. Priyadarshini Arambam.
Pharmaceutical industry to facilitate examinations and provide starter kits for drugs.
CEO, GHHP Ajaz Rashid
Special thanks go to the employees of the CHC Rajpora