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December 1, 1999


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Under Attack!

Shanthi Shankarkumar in Chicago

Dr K Kurian (not his real name) had his first heart attack in 1981 when he was 37 years old. He did not have blood pressure or diabetes and he was a non-smoker. His cholesterol levels were also not high. But he did have a family history of heart attacks. Four years after his first heart attack, an angiogram showed that his left coronary artery was blocked. Ten years later he had to undergo a five vessel or quintuplet bypass.

Six months after his bypass he took part in a landmark study on Coronary Arterial Disease in Indians. He was found to have very high levels of a cholesterol called lipoprotein(a) or lp(a).

His 23-year-old son, who is a medical student also, has high levels of lp(a).

"If I had known about lp(a), I would have been more careful," says Dr Kurian.

His debilitating bypass has forced him to give up practising psychiatry. He now teaches in a medical school in the Caribbean at an easier pace of 25 hours per week.

Medication has helped Dr Kurian to bring down his level of lp(a) to 55 to 70 mg from the high of 131mg.

A nine-year ongoing study of coronary arterial disease in Indians has linked the high rate of heart attacks or CAD to the little-known cholesterol. Lipoprotein(a) is a little known cousin of LDL or 'bad' cholesterol. But it is ten times more dangerous than LDL and 15 times deadlier than total cholesterol in clogging arteries and producing a heart attack.

Dr Enas A Enas, director of the CADI Research Foundation, Lisle, Illinois, spearheaded the study. Other participants include the Madras Diabetic Research Foundation, Madras, the University of Texas Health Care Center at San Antonio, Texas, Mary Imogene Bassett Research Institute, Cooperstown, New York and McMaster University, Ontario, Canada. The Berkeley Heartlab at University of California is also an active participant in the study and is part of a National Asian Indian Heart Disease program. The study has been published in the reputed American Journal of Cardiology and other leading medical publications.

Dr Enas has worked with the Framingham Institute, a leading epidemiology institute that has also accepted his findings.

His findings showed a four-fold higher rate of coronary artery disease in Indians in the US, compared to the general population.

The idea for the study first hit Dr Enas in 1990 when he saw many of his close friends, many of them doctors, either getting or dying of heart attacks at the prime of their life.

"They were doing everything right, but still were getting heart attacks," said Dr Enas.

As treasurer of the American Association of Physicians from India, Dr Enas had access to 30,000 doctors. CADI studied close to 2,000 Indian doctors and their families and found that one in 10 adult males had heart disease compared to one in 40 in white American males.

The CADI study was the first systematic effort to study the problem of the high rate of heart attacks among Indians in America and was commissioned by the AAPI in 1990.

Alarmingly, the high rate of CAD is not peculiar to Indian Americans. Other countries like Canada, Singapore, Malaysia, South Africa, the United Kingdom and others with a high incidence of Indian immigrants also report two- to three-fold higher rates of heart attacks among Indians.

Dr Enas also found that when people immigrate to a country, their heart attack rates intermediate between the country of birth and the country they move into. Indians are the singular exception -- five or six generations down, their incidence of heart attacks is still high compared to the local population.

His findings have shown that the presence of lipoprotein(a) increases the risk of heart attacks three-fold to five-fold, and if there are other risk factors like smoking, then the risk goes up by almost 122 per cent.

CADI research and other studies have shown that one in four Indians in the US, UK, Canada, India and Singapore have high levels of lp(a) (over 30mg/dL).

Although no research is available on Indian women, other studies have shown that the risk of CAD in Asian Indian women is even greater than in men. This is despite the fact that tobacco abuse is virtually non-existent in these women. Asian Indian women also had a higher death rate from CAD than women of all other ethnic origins in the UK, South Africa, Canada, Singapore, Fiji, Mauritius, Uganda and Trinidad.

Simple blood tests can be done to find out if a person has high levels of lipoprotein(a). Dr Enas recommends the tests for all people with a family history of early stroke, heart disease, heart attacks, angioplasty, bypass surgery and other forms of coronary intervention, as well as those with cholesterol problems that is high triglycerides ('bad' cholesterol) and low HDL or good cholesterol.

"Ideally every Indian male over the age of 25 and female over 35 should participate in this project," urged Dr Enas.

Although the high rates of CAD in NRIs have received the most attention in the study, recent studies done in India show equally high rates in urban India.

According to the research done by the All India Institute of Medical Sciences, New Delhi, 10 per cent of Indians in Delhi now have CAD, a rate identical to the one done by the CADI study in the US.

Surprisingly, Indians in the CADI and other studies have had lower rates of the usual risk factors for heart attacks such as smoking, high blood pressure, high cholesterol, obesity and low socioeconomic status. Thus the high rate of CAD in Indians was a mystery until the study reported high levels of lipoprotein(a).

Lipoprotein(a) levels are genetically determined and high levels in children predict a high-risk early heart attack not only in that individual but also in the parents and grandparents. Its levels may vary but it is fairly constant throughout life.

Unlike other types of cholesterol, high levels of lipoprotein can be detected even in newborns. A study done some time ago has shown high levels of lp(a) in the umbilical chord blood of Indian newborns in Singapore is significantly higher than in Chinese newborns.

Diet and exercise do not affect Lp(a) levels. But medication is now available that could lower levels of lipoprotein(a).

"Such therapy should be taken by even those people who have had no symptoms of heart problems, because death or CAD may be the first symptom, as is the case in about 50 per cent of cases," said Dr Enas.

However, he also warns that under no circumstances should the other conventional risk factors (smoking, obesity, blood pressure, diabetes, cholesterol) be ignored.

"A modified lifestyle of a low saturated fat diet and exercise will help to delay and reduce the need for medication", he said.

Dr Enas' Tips for Healthy Heart

1. Start a healthy lifestyle really early in life. Follow a diet with low saturated fat from the age of 2 and daily exercise from age 5.

2. Be tobacco free all your life.

3. Oils, meat and dairy products should be used sparingly.

4. Watch out for the saturated fat -- it is the culprit for coronary disease -- it should be just 7 to 20 per cent of calories. Use canola oil, corn and olive oil.

5. A vegetarian diet does not guarantee protection from heart disease.

6. Cook vegetables for not more than 1, 2 minutes. Stir-fry is best.

7. Eat more fruits.

8. Deep fried food to be avoided.

9. Use only skim or 1 per cent milk. Stay away from all dairy and bakery products.

10. Egg whites are okay, but the yellow is dangerous.

11. Check cholesterol regularly -- good (HDL), bad (LDL), ugly (triglyceride), deadly, lp(a) pseudo-cholesterol (homocystene). If you keep all the five kinds of cholesterol under control and if all other risk facts are also under control, then the risk will be one-fourth the average risk.

12. Blood pressure is a silent disease -- don't wait for kidney failure to start treating it.

For more information, contact Dr Enas A Enas, director, Coronary Artery Disease in Indians (CADI) Foundation, Lisle, IL. E-mail:; fax: 630-961-9554; phone: 630-961-0279. Or call 1-800-HEART-89 ext.301; fax: 650-372-1948.

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