CARDIOLOGY IN INDIA: OUTLOOK FOR SERVICES AND DEVICES

Communicable disease used to be the largest single cause of mortality in India, barely three decades ago. Non-communicable disease or NCD now enjoys this dubious distinction with Cardiovascular disease or CVD alone responsible for half of all such deaths annually. This is one-fifth of such deaths world-wide and although India's population is one of the youngest in the world a quarter of all Indians aged between 25 and 69 suffer from it. CVDS strike Indians a decade earlier than western populations. Manifesting mostly as ischaemic heart disease CVD takes over 10 million Indian lives every year. Affecting nearly 10% of Indians every year, CVD is the single leading cause of death and the statistics are staggering. Indians have the highest coronary artery disease or CAD rates in the world and conventional risk factors fail to explain why this is so high.

Outlook for Cardiology in Indian Health Care

So, it is but natural that treatment of CVD is receiving more and more attention from the medical community and has become its high growth sector. A confident prediction is that it will stay that way for some time to come. But, we lack the West's structured data collection methods for cardiac mortality and morbidity. The majority of deaths happen at home without knowing the exact cause of death. Hospital-based CV morbidity and mortality data may not accurately indicate the extent of CVD. And to this mix is the affordability aspect. So, it is difficult to assess the extent to which the sector will grow, and make forecasts for services and devices. But back of envelope computation and trends indicate that grow it will.

Between 1990 and 2015, CVDS jumped from 15% to 28% of total deaths and from 7% to 14%

Sunil Khurana CEO & MD, BPL

With the rising prevalence of heart attack in younger section of population, it is important that we continue to monitor our health on our regular basis, especially people with co-morbidities who are at higher risk. New research shows cardiovascular failures are increasingly occurring more in younger population because of unhealthy habits, stress levels, obesity, etc. Wherein bringing serenity in face of life's difficulties might help improve your perception of stress and result in better quality of life and heart health, however its important that we monitor our blood pressure and ECG on regular intervals as prescribed. This World Heart Day I wish you all a happy and healthy life !

of total disability-adjusted life years (DALYS) in India. States with the highest prevalence of high cholesterol levels and blood pressure such as Kerala, Punjab and Tamil Nadu reported much higher rates of CVD compared to the national average. Planners of hospital projects would do well to note this.

CVD is affecting India's young working population in many avoidable but expected ways. High stress levels, unhealthy and sedentary lifestyle, increased intake of processed foods, overindulgence in alcohol are giving rise to other co-morbidities such as diabetes, hypertension and obesity that promote CVD. Smoking may have become unfashionable, but gutka consumption is on the up.

Overall, India has the highest incidence of acute coronary syndrome and St-elevated myocardial infarction (MI). Meanwhile examination by type of CVD reveals:

• Hypertensive heart disease, jumped by 140% during the same period with over 2.6 lakh deaths reported.

• Rheumatic heart disease continues to be prevalent in India affecting an estimated 1.5-2 per 1000 individuals.

• Coronary artery disease affects Indians more leading to very high hospitalization rates. In fact, admission rates are 5–10 times higher for populations younger than 40 years. More than a fifth of diabetics and one-in-ten nondiabetics suffer CAD at one time or another. That said the prevalence of CAD drops below half of this in rural India.

• Congenital Heart Disease is a problem where numbers are a grey area. But it is known that India has significantly many children with CHD and that most remain untreated simply because parents cannot afford it. There are abundant cases of valvar, myocardial and vascular diseases that must be treated in childhood and adolescence.

Despite the many specialist paediatric cardiology centres that have sprung up in India, our numbers of paediatric cardiac care hospitals and paediatric cardiac specialists are nowhere near what are required. Even guidelines for uniformity (standardization) care or training in paediatric cardiology and surgery remain woefully inadequate.

This leads to most patients with congenital heart disease remaining untreated or partially treated. Many of these are doomed to premature death and even those who manage to survive into adulthood face a lifetime of major physical handicaps, imposing further problems of health, lower their productivity and affect them financially as well.

The tragedy is that most congenital heart diseases are correctable, and by fixing them timely before irreversible damage takes place, the longterm outcomes are very good.

Gaurav Agarwal MD, IITPL Director Innvolution Healthcare

Cardiovascular Disease (CVD) accounts for nearly one fifth of all deaths in India and the burden of the disease is assuming dangerous proportions with a general shift towards Non Communicable Diseases in the last two decades. There are nearly 60 million patients with CVD in India and less than 150 Cities with Cath Lab facilities. Less than a million are able to either access or afford Angioplasty, a life saving treatment option for CVD. At IITPL and Innvolution, we are making an effort to make Cardiovascular Care more accessible to a larger segment of society. In the last three years one, we have installed 100 Cath Labs in 65 cities and have been able to touch/save over one lac lives. Eight of these cities didn't have the facility of a Cath Lab before us and patients either died for lack of treatment or had to travel hundreds of kilometres to get appropriate treatment for CVD. We are committed to installing a lab in all 720 districts of India by 2030. At Innvolution also we are constantly striving to make World Class Drug Eluting Stents, Balloon ""Catheters and related devices used in Angioplasty more accessible.

All these services that have been referred to are major health sector opportunities. Allied Services

Besides services related to direct treatment of cardiac issues are some allied ones offering huge scope for ramping up. These include:

• Health Insurance: Despite giant strides that have been made over the last two decades as a service this is far from adequate. To begin with its penetration continues to be abysmally low – limited to employees of large corporations or the relatively affluent.

While tools such as MRIS and sophisticated testing are available, their use and diagnosing itself can be expensive. Health insurance has yet to couple insurance coverage for preventive, diagnostic and outpatient care, with affordability.

• Medical Devices: India imports 80% of the sophisticated kind of equipment (and quite a bit of patented drugs). One way of improving Affordability is through import substitution. India is an advanced nation where manufacturing is

concerned and captains of Indian industry must be made aware of the glaring need for investing and manufacturing such devices. This also presents them with huge opportunities.

• R & D: This is an area of crying need – for discovering drugs as well for manufacturing medical devices. Both industry and banks have to play their part to realize far greater levels of activity. The Government has introduced some sops, but it needs to be kept abreast of avenues to be nurtured and policy tailored to fit. Better coordination is thus required from all the players involved. Public private partnerships (PPP) need to be strengthened in diagnostics and healthcare delivery systems. Artificial heart valves are an interesting example. About 25,000 Aortic valve replacement procedures alone are conducted every year in the U.S. With almost everybody covered by health insurance in the U.S. practically all requiring the procedure go for it. Heart valves come with different levels of sophistication and it must be said that some patient situations such as mitric valves and others demand highly sophisticated solutions. And so, valves in the U.S. can cost anything between $2,000 to $7,000, and trans-catheter TRAV solutions as much as $25,000.

India has more than four times the population of the U.S. and a far greater incidence of heart disease. Thus, the numbers requiring valve replacement in India should be at least around 1.2 lakh. But the problem here is: (i) affordability and (ii) availability of centres and supporting surgeons and para-medics. With just a bit of growth in insurance coverage and improved affordability though there is no reason not to look at India as a market for 30,000 such procedures and as many valves every year. The indigenous Chitra valve has been around for nearly a decade. Relatively basic, it is as good as any comparable device manufactured abroad. And the best part is that it costs just Rs.30,000 versus $4,000 (Rs.3 lakhs) for a counterpart in the U.S. Kudos to the company that brought it to the market and its success world-wide will perhaps spur them on foray into many such initiatives as well.

For device oriented initiatives to start requires a set of initiators with holistic overview of the field – thorough knowledge of the application, manufacturing processes, and assessment of viability. The problem such initiators face is who will invest time and money for this and wait for through the gestation period involved in developing a drug or device. This is improperly appreciated by our banking, financial and the investment community. The good news is that all the cardiac healthcare options covered here will enjoy a booming market subject to being affordable.

Regarding cardiology, Research & Development can ensure handsome returns to the investor. Bankers and investors simply need to exercise patience. A plus point is that investments low capital outlay ones and returns can be very attractive as the products take off. They need to apprise themselves of the world players who rake in revenues to the tune of $20-50 billion annually.

Factors taken and taking shape

• India has in place legalisation for brain death and opened up for heart

With around just 2% of hypertensive people owning a BP Monitor, OMRON with its strong vision of creating a world with ZERO EVENTS (reduce heart attacks and strokes to zero) aims to inculcate habit of regular BP monitoring amongst the people so that they are able to empower their physicians with data for more informed decision making and disease management. Not only BP monitoring, but we have also initiated a path-breaking, one-of-its-kind hypertension plus ECG monitoring collaborative trial with Tricog and Sakra World Hospital in the field of telehealth / remote patient monitoring. The Masanori Matsubara program, targeted at patients that have undergone surgical procedures or MD ablation for the treatment of cardiovascular diseases, aims to establish the OMRON Healthcare India relevance of remote hypertension and ECG monitoring for strengthening the treatment and care regime to reduce cardiovascular complications and deaths.” "

transplants way back in 1994.

• Research in Cardiac Stem Cell is ongoing and has already generated impressive material on the subject at par with research the world-over.

• Work continues on artificial hearts, synthetic biology, biomaterials, and applications involving Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) technology.

Drawback: Quality & Shortages

One issue that the field of Cardiology shares with much of Indian enterprise is improper adherence to quality. Sure! Many of our premier institutions can match the best in the world in both quality and competence but

regrettably this is not so across the board.

And, the discerning patient says so about even quite expensive establishment where it shouldn't be so.

Madan Krishnan VP & MD, Medtronic India

Most cardiac care hospitals, already established or about to be are located in cities and very little of rural India has access to quality care for CVD. Coupled to this is a shortage of specialists, nurses and technicians. Training personnel is thus another need.

Government's Role: Steps Taken and to be taken

To improve affordability and contain profiteering, the Indian government has taken steps by capping the price of some medical devices such as of coronary stents. Price of drug eluting stents is capped at Rs 29,600 and those of bare metal stents at Rs 7500 (down from over rupees one lakh levels). Also, brands of many drugs such as Ramipril and Carvedilol are available at under Rs.5 a tablet rendering them somewhat affordable by even the poor.

But significant volumes of medical devices and drugs for cardiology still need to be imported. Capping of prices is therefore only a part solution. In the end India desperately needs indigenous development of devices, implantables and drugs. Not only would affordability and availability improve but it would also plug the drain of foreign exchange.

Government has taken a number of steps, namely:

• Fresh policies supporting employment of biotechnology

• Providing industry status to healthcare research

• Developing supporting infrastructure e.g. CROS and Animal Testing

• Policies for encouraging R & D

Policies that are adopted by all involved with providing the coronary care should be planned as win-win-win from the outset - for the patient, the manufacturer, institutions and care-givers.

Shape of things to come?

Wireless Technology e.g. Bluetooth & Wifi: Implantables such as Automatic Cardiac Defibrillators are now being Bluetooth enabled. connection that is also wireless).

Remote Patient Monitoring (RPM): Technologies such as Wi-fi are allowing healthcare from afar and cardiology was one of the first to adopt it for standard practise. RPM has proven invaluable in managing heart failure, hypertension and irregular heart rhythm. RPM brings the expertise of the best doctors to rural areas.

Data Storage & Retrieval Systems: Smart Phone type medical devices that are wearable are now becoming common place. Some are similar to watches; others are patches. They record parameters like blood pressure, weight, pulse or electrocardiogram ECG results which are then stored (even in the Cloud) for future use. Already, Apple watches conduct ECGS and can detect irregular heart rhythm and atrial fibrillation. Significantly two-thirds of all cardiac hospitalization was due to atrial arrhythmia. Importantly, cardiac care responses are getting to be immediate and this will save myriad lives. Another benefit is fewer follow up visits, fewer hospital admissions and reduction in stay time at hospital; all of which save on the cost of treatment.

Medtronic has always been committed to addressing prevalent capacity and awareness barriers in the space of healthcare and combines meaningful innovation in its therapies, products, and systems as well as partnerships. This year, the pandemic made it imperative to devise ways of extending care remotely and safely. Our remote monitoring platform in the cardiac space, helped seamlessly integrate with smartphones and tablets, thus enabling patients to securely transmit data from their devices to their doctors via the "technology that they use every day.