Cardiovascular Disease Burdens and Challenges in India and Africa

Executive Summary

Cardiovascular diseases (“CVDs”) are the number one killer globally. More people die annually from CVDs than from any other cause –17.8 million or 32% of all deaths in 2017, according to the Global Burden of Disease (GBD).FN1 India is a major, and growing, contributor to these global burdens. In 2017, India had 2.6 million (15%)FN2 of the total 17.8 million cardiovascular deaths, up from 1.3 million (11%) of the estimated 11.9 million cardiovascular deaths in 1990, according to the GBD. CVDs deaths have grown by 107% in India,FN3 and ischemic heart disease (which includes coronary artery disease (“CAD”), acute coronary syndrome (“ACS”), and STEMI)), is the leading cause of premature death (death before the age of 60) in that country.FN4 Reducing premature death from cardiovascular disease by one-third in all countries by 2030 is an important United Nations Sustainable Development Goal (SDG 3.4).FN5 Compared to high income countries, in India, a higher proportion of CAD/ACS patients suffer STEMI, STEMI occurs at a younger age, and resulting mortality is considerably higher.FN6 Adding to these burdens, India’s poor and near poor suffer the greatest adverse effects from STEMI and STEMI care.FN7

Although India has taken a number of notable steps in recent years to attempt to address treatment and care of cardiovascular diseases, including STEMI, the country continues to lag behind many regions of the world, including all other Asian and Latin American geographies.FN8 While there are many reasons behind these lagging statistics, significant factors contributing to suboptimal Indian care include:

1. poor expertise and infrastructural access (particularly in more rural areas), leading to prolonged time-to-diagnosis and time-to-intervention, which are critical to favorable outcomes;
2. poor patient awareness surrounding the disease;
3. insufficient diagnostic and STEMI awareness capacities at the point of first medical contact;
4. significant deficits in the country’s emergency transportation services; and finally
5. large socioeconomic and cost challenges, and related barriers to access.

The organization of this White Paper is as follows:

• In Section II, we provide an overview of cardiovascular disease burdens generally, and ischemic heart disease (including CAD and STEMI) more specifically. We direct our discussion primarily to India, given that it is Tricog’s first and largest target population, but also briefly discuss Africa, a continent of growing interest to that company.
• In Section III, we review diagnoses and treatment access challenges in India, with a spotlight focus on STEMI for reasons discussed in that Section.
• In Section IV, we describe Tricog’s remote ECG technology, which in the context of STEMI aims very purposefully to address STEMI’s diagnoses and treatment challenges. Among other value-adds, the technology:

1. upskills remote ECG diagnoses in locations where ECGs and/or cardiologists are unavailable, without the fixed cost of a cardiologist or specialist at that site;
2. improves awareness of the need for prompt ECGs among patients and GPs that patients typically turn to first with their symptoms;
3. increases the opportunity for new STEMI diagnoses and triage opportunities for patients in need of clinical care, especially in areas of the country where expertise/ECG infrastructure is deficient or absent;
4. increases the opportunity for patients with abnormal reads to be referred to a specialist for care;
5. for patients deemed critical, increases the opportunity for speeding time to diagnosis, time to hospital, and/or time to intervention, for more favorable outcomes;
6. prevents needless hospitalizations (false positives), which contribute to hospital resource burdens and costs for patients, particularly the poor; and finally
7. provides evidence-rich patient data, essential to improved public health understanding and evaluation of STEMI care in India.

• In Section V, we offer a proposed framework for impact metrics and monitoring, should we decide to move forward with an impact investment in Tricog.

Please email c.haynes@teamfundhealth.org to request access to the full report.

Footnotes

FN1 Global Burden of Disease. (2017). GBD Compare. https://vizhub.healthdata.org/gbd- compare/;World Health Organization (WHO). Cardiovascular diseases (CVDs). Fact sheet. Updated May 2017. Available at: https://www.who.int/en/news-room/fact- sheets/detail/cardiovascular-diseases-(cvds).

FN2 Global Burden of Disease. (2017). GBD Compare. https://vizhub.healthdata.org/gbd- compare/.

FN3 Id.

FN4 See, e.g., Alexander, T., et al. (2013). Framework for a National STEMI Program: Consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India. Indian Heart J. 67(5): 497-502. Published online 2015 Aug 6. doi: 10.1016/j.ihj.2015.05.017; Mathew, A., et al. (2017). Population access to reperfusion services for ST segment elevation myocardial infarction in Kerala, India. Indian Heart J. 69 Suppl 1(Suppl 1):S51-S56. doi:10.1016/j.ihj.2017.02.014.

FN5 https://sustainabledevelopment.un.org/sdg3.

FN6 Aggarwal, A., et al. (2016). Newer perspectives of coronary artery disease in young. World J. Cardiol. 8(12): 728-734. Canto, J.G., et al. (2002). The association of sex and payer status on management and subsequent survival in acute myocardial infarction. Arch Intern Med. 162:587-593. Xavier, D., et al. (2008). Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 371:1435-1442.

FN7 Guha, Santanu, et al. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J. 2017 Apr; 69(Suppl 1): 563-597. Published online 2017 Mar 23. doi: 10.1016/j.ihj.2017.03.006.

FN8 Rosello, Xavier, et al. Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality. International Journal of Cardiology; Volume 245;27-34.