The heart of the matter The terrible fear of dying of a heart attack doesn't accompany Dr Krishna Jung Rana to bed anymore.

"Until five or six years ago, before I went to sleep, there was always this fear I would die," says the retired public health expert. "Being a doctor, I knew it was irrational. But I couldn't help myself," says Rana.
Such fears and anxieties are common among people with heart disease. The survivor of two bypass heart surgeries in 1983 and 1984 and a recent angioplasty, Dr Rana is president of the Heart Club.

embers-people with heart trouble, laymen, doctors-meet on the last Saturday of every Nepali month at 9 am at Narayani Hotel to have a heart to heart discussion about prevention, cure, and care of heart conditions.
A major goal of the club is to raise awareness and sensitise people about heart disease, which experts say will still be the leading cause of mortality and disability by 2020. As heart disease becomes one of the leading causes of death in the world, it is now on the priority list of the WHO.

Yet there is the common perception that heart disease is not a South Asian phenomenon. Completely untrue, says Dr RK Kasliwal, a senior consultant cardiologist in India. In fact, the doctor says, there is plenty of research to prove that South Asian genes put one at a higher risk for heart disease-four times more than American and 20 times more than Japanese people. In addition, South Asians generally eat richer food and lead more sedentary lives, at least in cities, both of which contribute to the risk of heart disease.

Men above 35 and women above 40 should watch their weight and lifestyle, and health experts advise "intelligent living" and regular comprehensive check-ups. Ten percent of the population is at risk any given time, and anyone could fall under that ten percent, but the risks are higher for people with bulging bellies, cautions Dr Kasliwal. "There are risk factors specific to this population-the presence of triglycerides (which can lead to a hardening of the arteries), ineffective insulin and weight concentrated in the belly," explains Dr DB Karki, cardiologist and vice chairman of the Nepal Heart Foundation.

Dr Rana has a bible for all this: Reversal of Heart Disease without Operation by American cardiologist Dean Ornice. He swears that a change in lifestyle as recommended by Dr Ornice has allowed him to lead a happier and healthier life. He doesn't have to live with the dread of expecting a heart attack. The 69-year-old has turned vegetarian, quit drinking, taken to walking briskly for 30-40 minutes everyday, and started going through a low-fat, low-salt diet. That's not all. He's started taking an interest in the world and in himself. "I was a taciturn man," explains Dr Rana. "I never talked much, I was just interested in work. Today I'm involved with various clubs in my neighbourhood. And, on the other hand, I meditate. I can't explain enough what a change there's been in my life."

Dr Karki, cardiologist and vice chairman of the Nepal Heart Foundation, says "Regulating ones lifestyle helps patients avoid prohibitive medical costs and undergoing expensive operations." Although there are no comprehensive studies on heart disease in Nepal, Dr Karki says the number of patients visiting private clinics and government hospitals is increasing. Other statistics are also telling: approximately 20 percent of the patients at Teaching Hospital and 15 percent of patients admitted to Bir Hospital suffer from some kind of heart disease.

Rough guide to heart disease and care
There's a surprising amount that can go wrong with the heart. Sometimes heart disease is congenital-a child is born with a defect in the heart, most commonly a \'hole' in the heart. There's also a disorder that may or may not be congenital, called arrhythmia. In this relatively uncommon ailment, the heart has an abnormal electrical rhythm. Patients have palpitations, feel like their heart has skipped a beat and sometimes feel giddy.

Valvular heart disease, where one or more of the four valves in the heart gets narrow or starts leaking, is often due to a bout of rheumatic fever, but could also be an infection of heart valves or due to a degenerative condition seen in the elderly, or due to syphilis.

But the most common form of heart trouble is coronary heart disease, when one or more arteries supplying blood to the heart is blocked. Partial blockage results in an angina while a complete blockage results in a heart attack.

"Heart disease is not a rich man's disease anymore, but coronary heart disease may be more prevalent in urban populations leading a sedentary lifestyle," says Dr Bhagawan Koirala, executive director of the Shahid Gangalal National Heart Centre.

Dr Koirala, a cardiac surgeon, estimates that some 100,000 people in Nepal require some kind of surgery on the heart. But the sad-and accepted-medical fact is that only 50 percent of them will even see a doctor. The centre has one hundred beds and plans to make arrangements for 200 more soon. After initial setbacks, Nepal's only heart centre providing coronary care and cardiac surgery was set up by the government in 1995 on the initiative of a group of doctors who sorely felt the need for a hospital that would exclusively treat people with heart trouble. About 60-90 patients visit the centre daily. The hospital, which cost around Rs 210 million, was built mostly with money collected from health taxes.

There are plans to add facilities like a catheterisation laboratory for which patients presently have to go to India. Catheterisation is a relatively common procedure similar to angiography, in which catheters (hollow tubes) are placed into the heart to evaluate the anatomy and function of the heart and surrounding blood vessels. So much useful information can be obtained from these tests that they are performed in virtually all patients being considered for cardiac surgery or angioplasty.

How long it will take the hospital to become a fully functioning heart centre will depend on the commitment and quality of care, but Koirala is optimistic that will happen in time. "Once started, the increment will not be important. What's important is instilling confidence, faith, and reassurance among patients." Since the first open-heart surgery in Nepal was carried out by Dr Koirala in 1997, facilities have been available at Teaching Hospital and Bir Hospital. But people are watching to see the success rates of the operations. And until they are convinced that these facilities work well, Nepalis will prefer to fly to India for treatment and operations.
"But surgery is not the remedy," stresses Dr Rana who, upon reverting to his old lifestyle after his first bypass, soon had to undergo another operation. The heart club advocates a change in lifestyle to prevent the disease that is a leading cause of death worldwide. Says Rana, echoing Dean Ornice's words. "If you live like an American, you'll die like an American."

Better living through chemistry

Genetics plays a part in determining whether one will develop heart disease, but there are some measures everyone can take to reduce the risk of coronary heart disease. As risk factors for heart disease include high blood pressure or hypertension, high cholesterol levels and blood circulation problems, a good place to start is cutting down on grease, cigarettes, salt, caffeine and, surprisingly, anything that exacerbates diabetes.
South Asians like to believe that a vegetarian diet reduces the risk of heart disease because unlike meat and eggs, the ingredients of a veggie diet are cholesterol-free. But this is not strictly true, because South Asian vegetarians often lay on the ghee, butter, cream and coconut oil, all of which contain unsaturated fats. A degree of physical labour may use up all that fat, but a sedentary lifestyle in the urban areas simply does not.

Smoking is an absolute no-no if there is any reason you might be at risk for coronary heart disease. Nicotine increases the heart rate and blood pressure, and damages the inner lining of the blood vessels-and increases clotting of blood inside the arteries, which affects circulation, which, of course, goes right back to the basic function of the heart. Some studies suggest that every cigarette you smoke can shorten your life by five and a half minutes.

Hypertension, commonly called high blood pressure also affects the circulation of blood and the functioning of the heart. People with high blood pressure know they must cut down on salt. But what most of us do not know is that even if you aren't hypertensive, salt can precipitate heart attack, by increasing the reactivity of platelets, the tiny blood elements that help blood to clot.

Coffee is the other addictive substance to avoid. Like too much salt, it increases the chances of hypertension. And it doesn't just make you excitable-some compounds in coffee are also suspected to increase cholesterol levels. So if you need a bit of a jolt, drink juice, or even tea.

Now for the surprising part-be extra careful if you are diabetic. Not too many of us know this, but heart disease is the leading cause of death among diabetics. Even on a tightly-controlled diet, diabetics have higher blood sugar levels than non-diabetics, and that extra sugar contributes to clogged arteries that reduce the heart's blood supply.

And sugar brings us to: alcohol. It's getting to be a dangerously common little bit of information that a drink or two a day keeps heart attacks at bay. Not strictly true. In younger men (under 40) and pre-menopausal women, excessive alcohol use can cause high blood pressure, irregular heart rhythms, and weakness of the heart muscle, in addition to a host of other problems. If you are older, say, over 60, the benefits of moderate alcohol consumption outweigh the ill-effects, and you can have a peg or two a day without too much harm being done.

If this seems like excessive warning, given that the holiday season is around the corner, remember that other cardinal rule of avoiding heart disease: stay happy, take it easy, and talk to your friends.