Envisioning Cardiovascular Therapeutics in Next Decade

Tapan Ghose

To meet the growing challenge of non-communicable disease burden in India, cardiovascular diagnostics medical equipment including ECG, echocardiography machine, Holter monitor, loop recorders, ambulatory BP instrument, etc, are expected to see manifold increase in demand, writes Tapan Ghose, Director and Head, Department of Cardiology, Fortis Flt. Lt. Rajan Dhall Hospital, for Elets News Network (ENN).

Increased private-public partnership is urgently required to meet the growing need for trained manpower in cardiovascular sciences.

Other projected expenses would be on respiratory diseases ($0.98 trillion), cancer ($0.25 trillion), diabetes ($0.15 trillion) and mental health ($0.03 trillion).

According to the World Economic Forum and Harvard School of Public Health, cardiovascular diseases top the list of NCDs adding to the projected economic burden between 2012 and 2030. Of the total, NCD burden of $4.58 trillion, $2.17 trillion will be spent on cardiovascular diseases alone.

To meet the growing challenge of disease burden, India is expected to see doubling of ICU beds and equipment utilisation in both private and government sectors by 2030.

Digital technology, innovative ideas, new business startups, easy loan to professionals, lowering of interest rates will open a new chapter in the coming decade in the Indian healthcare sector. Three Ds in healthcare service boom will include doctors and paramedics, drug industry and device industry.

Despite having the largest number of medical colleges in the world, producing 30,000 medical graduates and 18,000 specialists annually, India is far from the World Health Organisation (WHO) norms of one doctor per population of 1,000 (India has one doctor per 1,319 patients). Nurses/ANMs are equally less than the required norms.

Short fall of specialists in community health centre is 81.2 per cent at present. Cardiac diseases require highly trained and skilled manpower for providing the desired services. There is a huge requirement of trained cardiovascular man power in the country. Increased private-public partnership is urgently required to meet the growing need for trained manpower in cardiovascular sciences.

National Board of Examination is required to develop a mechanism to identify the centres of excellence in particular area of cardiovascular therapeutics and include these in the programme, rather than acting passively as an accreditation body only. Trans-radial coronary intervention and structural heart disease therapy should be included in medical curriculum in cardiology. Medical collages should focus on applied research as a part of PG curriculum relevant to our country.

Indian pharmaceutical industrys contribution is immense not only in the India but across the world. India is dubbed as the pharmacy of the world. Multiple cardiovascular drugs made in India are available at an affordable cost. Anti-platelet agents, anti-hypertensive agents, statins, beta-blockers and anti-diabetic medications are available in most of the community health centres in our country.

The devices industry in expected to see a technological revolution in the coming decade in India. Equipment utilised for cardiovascular diagnostics include ECG, echocardiography machine, Holter monitor, loop recorders, ambulatory BP instrument, TMT machines, etc. An ECG is the backbone of cardiovascular diagnostics.

The full potential of ECG are yet to be utilised and used in cardiovascular therapeutics at a mass level in our country. One innovative utilisation of mobile phones is ECG and oxygen (SPO2) saturation monitoring integration.

While most of the available mobile phones with ECG monitoring give only one lead (Lead I) and can be used for rhythm diagnostics, modification of software and utilisation of earphone cable could potentially be used to take all 12 leads recording of an individual. This can be recorded and preserved in the device and can be transmitted for interpretation, utilising the digital platform. I have personal experience of a handheld ECG recording instrument from our country. The device requires refinement. Because of increasing burden of atrial fibrillation in the country, Holter utilisation will be higher. The Holter monitoring, similarly, can be integrated with the mobile technology and can be used more freely at an affordable cost.Rhythm diagnostics using mobile technology and internet are already in use in our country. In keeping with the growth of cardiac disease, the number of cardiac catheterisation labs is expected to double in coming years.

Diagnostics cardiac catheters, vascular sheaths, wires used in the country are mostly imported at present. There is an urgent need for innovation, human trial and patent application in the area of trans-radial and trans-femoral diagnostic catheters and other disposable devices used in cardiac sciences.Therapeutic devices like coronary stents, peripheral stents, vascular stent grafts, artificial heart valves both (mechanical and bioprosthetic) valves will be utilised in more numbers. Advent of nonsurgical technique of TAVR (non surgical aortic valve replacement) is a boon for the heart patients. There is an urgent need to have centres of excellence for this in our country. Structural device therapy is a growing area. Devices for cardiac shunts (ASD, PDA devices, vascular colis and plugs), left atrial appendage closure devices will be increasingly utilised in our country.

Heart failure is emerging as a new tsunami in cardiovascular therapeutics. Precise estimate of the disease burden in our country is not known. Based on my experience of over 25 years in four tertiary care hospitals (government hospital, trust hospital, corporate hospital), I presume that implantable defibrillator implantation (ICD), cardiac resynchronisation therapy (CRT-D and P) utilisation will grow many fold in coming years in our country.

This is largely because of residual burden of damaged hearts (EF < 35%) from premature coronary heart disease in the population. Heart failure will be a major cause of hospitalisation. More number of left ventricular assist devices (LVAD) will be implanted. In keeping with growing burden of heart failure population, number of cardiac transplantation will increase. Cardiac, renal transplantation, hepatic transplantation are available in many centres of Fortis Network Hospital & other hospitals in our country.

Fortis Flt. Lt. Rajan Dhall Hospital recently completed 1,000th kidney transplantation successfully. Expert immunologists and immune suppression agents are available in our country. Sufficient donor heart and recipients are also available in our country. Its a matter of time that we see a huge surge in the number of cardiac transplantations in the country.

At the current rate of 7-8 per cent rate of GDP growth and the governments promise to allocate more funds (increasing GDP percentage from 1 to 2.5) in health care sector; increasing number of both government and corporate hospitals, cardiovascular healthcare is poised to see a revolutionary change in coming years.

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