Being a cardiologist, Dr Sandeep Jauhar’s fascination with the heart doesn’t come as a surprise. But his interest stems from something very personal—“a malignant family history”. “My paternal grandfather whom I never met died of heart attack, as did my maternal grandfather. My mother died of heart disease. I myself have the beginnings of a coronary disease,” he tells THE WEEK over the phone from Long Island, New York. His new book, Heart: A History, therefore, is a personal narrative (his first two books, Intern: A Doctor’s Initiation and Doctored: The Disillusionment of An American Physician, were both medical memoirs). But it does go beyond the personal. Beautifully written, with prose that reads almost like poetry in places, the book traces the journey of our understanding (and the lack of it) of the heart. In this interview, Jauhar, director, Heart Failure Program, Long Island Jewish Medical Center, talks about what ails the heart, our failings and the kind of research needed to treat the heart. Edited excerpts:
According to a study in the Journal of the American College of Cardiology, death due to cardiovascular diseases declined by a significant 41 per cent in the US between 1990 and 2016. During the same period, it rose by 34 per cent in India. What do you think are the reasons behind the rise?
To be honest, we don't quite know why Indians and south Asians have such a malignant preponderance for heart disease. We just don't understand it. The major studies on heart disease were done in white Americans of European descent. That was the Framingham study, which even when it was started in the late 1960s was noted for its lack of ethnic diversity. So, the usual risk factors for heart disease, like smoking, high cholesterol, high blood pressure and diabetes, were really elucidated for a very specific and ethnically homogenous population. Now, it might be that south Asians have novel risk factors that we just don't understand. We have to look into this. And, there are epidemiological studies now going on that will look at coronary disease specifically in south Asians.
But I can speculate that some of the same risk factors do apply to south Asians. For example, smoking puts you at terrible risk for coronary disease. But it might be that south Asians have unique genetics that predispose them to early coronary disease. For example, south Asians have really high level of lipoprotein(a), which is a novel cholesterol particle that is implicated in early coronary artery disease. I myself have a high lipoprotein(a) level. So I am very well aware of this. South Asians may have unique cholesterol particles that are very small and dense and more likely to burrow into the arterial wall and cause coronary artery disease. Some studies suggest that south Asians have smaller diameter coronary arteries to begin with. So, it is very complicated. We haven't figured this out, but we need to because heart disease is such a malignant phenomenon in south Asia. And, it is growing and we don't quite know why.
I think there are some of the same risks in south Asians that we can point to that explain the high rates of heart disease. Smoking, for example. Also, there is a lot of pollution in urban centres in India that may be contributory. The Indian diet is one that tends to be very high in carbohydrates, which may predispose to truncal obesity and insulin resistance. So those are factors. There used to be a difference between rural and urban India. The differences have shrunk. One of the reasons for the differences is, in rural India there was much less sedentary lifestyle. But as the urban culture gets exported more and more into the rural community, that sort of highly consumptive diet with more sedentary lifestyle is, I think, also contributing to the rise of heart disease in the rural population.
You talked about the rural-urban difference. A study in The Lancet stated that deaths from heart disease among rural Indians have surpassed those among urban Indians between 2000 and 2015. What could be the reason?
No one really knows the answer. We can speculate that the export of urban culture in rural community has contributed, as have diet and overall lifestyle. And, the worsening air quality certainly hasn't helped the rate of coronary disease. The reason why I think that culture plays a role is that in my book I talk about how Japanese immigrants in the United States develop coronary disease that is in line with Americans, whereas Japanese living in Japan have very low rates of coronary diseases. So, there is probably something about changing the culture of a population that contributes to the development of heart disease.
Of late, more and more young people, aged 25 to 30, are suffering heart ailments. Apart from lifestyle, what other factors put them at risk?
We had a patient. A 19-year-old south Asian man, who had a heart attack, a coronary thrombosis, at my hospital on Long Island. We are seeing heart disease much earlier, even in the teen years. And, that is true not just among Indians and south Asians, but also in Americans. There are studies that have shown that 16-year-old Americans have the beginnings of coronary disease. In India and south Asia, the rate of heart attacks in the 25-30 year old population is very, very high. Again, we don't quite understand why. They are probably owing to genes or lifestyle. But we need to do more research to understand novel risk factors in the Indian population.
What could a person with a family history of heart disease do to prevent it at a young age?
I think that until we understand the risk factors, the usual advice would apply, with one caveat. So, the usual advice is don't smoke, eat right, exercise and keep a normal body weight. Those are all important factors. But one of the messages of my book is that we need to pay more attention to our emotional lives, that emotions affect the heart in myriad ways. The way that you have relationships with other people, the way that you surround yourself with people who make you feel good rather than people who take energy away from you and make you feel bad about yourself, our intimate relationships with our spouses, our lovers and our friends, our ability to transcend stress in our lives, all those factors are tremendously important in preventing heart disease.
Are women more prone to heart disease?
I don’t think they are more prone to heart disease. Women do have a very high rate of heart disease. We used to think that women were relatively protected and we now know that is not true. Women very frequently have heart disease. So, heart disease is not a male-centric disease. It affects both sexes, probably, in the end, relatively equally. Women tend to develop heart disease later than men, and for factors we don’t clearly understand, probably related to hormones and the protective effects of oestrogen. But in the end women and men both die of heart disease.
How has heart care evolved over the years?
The last half century has been characterised by huge technological development. From the invention of pacemaker, coronary angiography and stents to defibrillators, heart transplants and artificial hearts, the technology has been just amazing. Drug therapy like statins have also helped reduce mortality. But we may be getting to a point where technology is not going to make the same impact, at least in the way we have come to expect, on the heart. And, we are going to have to focus more on our emotional lives in mitigating the negative effects of the emotions that directly affect the heart. Heart treatment has been mainly characterised by technological improvement; that will change. In the coming decade, there will be more focus on preventing heart disease by looking at risk factors as well as looking at our own psychology.