Cardiovascular and infectious diseases in South Asia: the double whammy
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.781 (Published 01 April 2004) Cite this as: BMJ 2004;328:781
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Dear Sir
The editorial and the article in BMJ (1, 2), has nicely covered the
issue of cardiovascular and infectious disease in South Asia.
Interestingly no mention was made of association between infection and
heart disease. Apart from causing endocardits and myocarditis, infection
has also been lined with Ischaemic heart disease (IHD) and atherosclerosis
(3), and there is a strong association between development of new
atherosclerotic lesion and chronic infection (4). IHD is increasingly
being recognized as an inflammatory disease, and both C-reactive protein
and fibrinogen is significantly elevated in chronic infections (4). Even
young otherwise healthy patients with only periodontal disease show
evidence of endothelial dysfunction and systemic inflammation (5).
Although studies have not shown a conclusive causal link between infection
and IHD, it is known that an increase in inflammatory markers are
prognostically important, both in healthy population and in patients with
IHD (6, 7). There are reports of lowering of fibrinogen with treatment of
infection (8, 9). Your editorial (1) points out that coronary death in
India are expected to double over 20 years and reach 2 million by 2010.
The increase in IHD in India and other third world countries may be due to
an increase in Diabetes Mellitus and metabolic syndrome, but as
association between infection and heart disease remains an important
contributing factor.
A lot of these infectious processes could begin in early childhood
and by inducing low grade inflammation could manifest or precipitate
atherosclerosis at older age. Alternatively an acute infection can
generate intense inflammatory response and precipitate an acute coronary
event. There are no large scale prospective studies, especially among
healthy individuals showing that lowering of fibrinogen level would lower
the risk of death, but this hypothesis needs to be tested in well
controlled trials.
As mentioned in your editorial, “preventive cardiology has to be
integrated into primary health care” and tackling and preventing infection
may be helpful in prevention of atherosclerosis and cardiovascular
disease.
1.Basnyat B. Cardiovascular and infectious disease in South Asia; the
double whammy. BMJ 2004; 328:781
2.Zaidi AKM, Awasthi S, DeSliva HJ. Burden of infectious disease in
South Asia. BMJ 2004; 328:811-815
3.Leinonen M, Saikku. Evidence for infectious agents in
cardiovascular disease and atherosclerosis. Lancet Infect Dis 2002; 2:11-
16
4.Kiechl S, Egger G, Mayr M, Weidermann CJ et al. Chronic infections
and risk of carotid atheroscelrosis. Prospective results from a large
population study. Circulation 2001; 103:1064-70)
5.Amar S, Gokce N, Morgan S, Luokideli M et al. Periodontal disease
is associated with brachial artery endothelial dysfu7nstion and systemic
inflammation. Arterioscler Thromb Vasc Biol 2003; 23:1245-49).
.6.Toss H, Lindahl B, Siebahn A, Wallentin L. For the FRISC Study
Group. Prognostic influence of increase fibrinogen and C-reactive protein
in unstable coronary artery disease. Circulation 1997; 96:4204-10,
7. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH.
Inflammation, aspirin and risk of cardiovascular disease in apparently
healthy men. N Engl J Med 1997; 336:973-9
8.Yusuf SW, Mishra. Effect of Helicobacter infection on fibrinogen
level in elderly population with Ischaemic heart disease. Acta Cardiol
2002; 57(5): 317-322
9. Torgano G, Cosentini R, Mandelli C, Perondi R et al. Treatment of
Helicobacter pylori and chlamydia pneumoniae infection decreases
fibrinogen level in patients with Ischaemic heart disease. Circulation
1999; 99:1555-1559.
Competing interests:
None declared
Competing interests: No competing interests
Suspected Myocarditis in Sri Lanka
Dear Sir,
The World Health Organization published the first steps of
investigations 17 March 2005.
But in Rheumatic Heart Disease You will not find the pathogen: RHD is
a post-streptococcal-reactive-disease.
The pathogen streptococcus is not there, but it has been there.
Like a Tsunami the post-streptococcal-reactive-disease are on high-
tide in the Northern Territory of Australia, where many children in the
Torres Strait are hospitalized after an outbreak of post-stretptococcal-
reactive-glomerulonephritis.
The children of Sri Lanka suffer from myocarditis.
And Prof. Dr. A. Charles Yankah gave an African Heart Seminar March
2005 in Cape Town, because rheumatic fever and subsequent heart disease
and congestive heart failure will kill millions of children in Africa.
It is one world, and streptococci kill like a Tsunami.
Sincerely Yours
Friedrich Flachsbart
Suspected myocarditis in Sri Lanka.
www.who.int/csr/don/2005_03_17a/en/print.html
African Heart Seminar 2005: 7-11 March 2005.
www.netcare.co.za/default.asp?currentpage=viewArticle§ion=1&article=46
Competing interests:
None declared
Competing interests: No competing interests