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World Heart Academy, Cardiological Society of India, Asian Pacific Society of Cardiology

International Society of Cardiovascular Ultrasound, International Medical Sciences Academy,

Defence Research & Development Organisation, Indian Academy of Echocardiography'

World Academy of Spiritual Sciences, Times of India Group, Express Health Care, ASSOCHAM

J. Watumull Global Hospital & Research Foundation

Medical Wing, Rajyoga Education & Research Foundation

Healthy Heart Education & Research Foundation

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wccPc & wPcHc 2007

Dr. H,K.ChopraOrganislng Chairman

Dr. S.K.ParasharPresident CSI

BK Sarla DidiDir, Reception Committ€9

BK MrituniayDir. Public Relations

BK Dr. RamshalokDir Accomodatlon

Committee

BK Chand l|lishraDir. Entertalnmsnt

Committe€

BK Atma PrakashEditor

M. P. AgnlhotriDlr, Exhibition

Committee

Dr. Satish Kr GuptaSecretary General

BK BhopalOir, Transport

Commitlee

BK KarunaDir, Media Committee

BK SuraiDir, Food/Catering

Committee

M. Lal lOir, Hospitali

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BK Mohini Didi BK Munni Didi

Dr, PrataD Midhaoir, Souvenir Committee

Welcome note from Secreta;- i 3r '

I consider it my privilege to welcome you all to the 2"d World Congress on Clinical &

Preventive Cardiology and World Public Conference on Three-Dimensional Heart Care, the first

ever such conference to be held in India, being organized by World HeartAcademy, Cardiological

Society of India, Delhi Branch, Asia Pacific Society of Cardiology, Healthy Heart Education &

Research Foundation, Defence Research & Development Organization, Ministry of Defence;

Medical Wing of Rajyoga Education & Research Foundation, International Medical Sciences

Academy, World Academy Of Spiritual Sciences, J.W. Global Health & Research Centre, Times

Foundation of the Times of India Group, SCOPE, ASOCHAM, Express Healthcare and Peace

Water House Coopers, to be held at Brahma Kumaris Shantivan Complex, Abu Road, Rajasthan,

from 28'n to 30'n, September, 2007.

With the support and cooperation of all and every one concerned, the first World Congress

held in September last year made a great success story. I am happy to say that we have been

successful in bringing the preventive aspect of cardiology into limelight, but much still remains to

be done. The most notable feature of the first World Congress was the inspiring inaugural

address of His Excellency Dr. A.P.J. Abdul Kalam, the former President of India, which was

received with thunderous applause by one and all. lt was, in fact, the advice of Dr. Kalam to the

medical faculty to the effect that they should follow the three-dimensional approach of treatment

of Body, Mind and Soul, essential to keep the human beings healthy and fit, which inspired us to

organize the World Public Conference on Three-Dimensional Heart Care on 30'" September,

2007, the World Heart Day.

Several developments have taken place here since the conclusion of the first World

Congress, some of which are note-worthy. A Trauma Centre and Global Hospital Institute of

Ophthalmology have come up in Shantivan to offer 24-hour emergency specialist medical care to

trauma patients road accident and medical emergencies, and to provide a well-equipped,

modern tertiary eye care centre. The Global Hospital & Research Centre also propose to set up an

Institute of Preventive Cardiology & Life-Style Sciences with the objective to create awareness

amongst the masses about epidemic of CAD and other life style related diseases, e.9.,

atherosclerosis, Hypertension, Diabetes, Obesity, etc., and the value of adoption and

maintenance of healthy and happy life style for healthy, peaceful and happy living. The proposed

Institute of Preventive Cardiology & Life-Style Sciences will be developed to promote research in

life-style sciences and to conduct diploma courses in life-style sciences for medical professionals.

It is well known that it became possible to organize this World Congress, as also the first

World Congress, with the initiative of CAD patients who have benefited from the CAD project

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President's SecretariatRashtrapati Bhavan,New Delhi - 110004.

(Smt. Pratibha D. Patil)President of India

The president of India, Smt Pratibha Devisingh Patil is happy to know that the '2"0 WorldCongress on Clinical and Preventive Cardiology 2OO7'and the 'World Public Conference on ThreeDimensional HeartCare 2007' are being held during September 28-30, 2007 at Shantivan.

The president extends herwarm greetings and felicitations to the organizers and the participants

and wishes the Congress and the Conference every success.

L5$,_Archana Datta

Ofiicer on Special Duty (PR)

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Shilendra Kr. Singh

All Indians need to be concerned that Coronary artery disease, also its attendant risk factors ofhypertension, diabetes and obesity are in ordinatelywide spread in our country, along with the rest of theworld where too these are spreading. Great advances have been made in the treatment which is nowavailable for this disease. However even now adequate attention is not being paid to the prevention ofthis killer disease.

I congratulate the organizers for scheduling World Congress on Clinical & Preventive Cardiology2007 from 28'" to 30'n September, 2OO7 and the World Public Conference on Heart Care on 30,nSeptember 2007 at Brahma Kumaris, Shantivan, Abu Road, with focus on prevention and control ofcontrary artery diseases.lwish them al lsuccess.

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Vasundbara Raje

I am glad to know that "2"0 World Congress on Clinical & Preventive Card iology (WC CPC 2007)from 28'to 30' September, 2007 and first ever "World Public Conference on Three Dimensional HeartCare (WPCHC 2007)" on 30'" September, 2007 are being organized at Brahma Kumaris, Shantivan, AbuRoad, with focus on prevention and control of CoronaryArtery Diseases.

I hope the Conference with its focus on the preventive side of the science of cardiology would notonlybring into limelight this aspect but also disseminate knowledge about advancement in th is field.

lextend my greetings and felicitations to all the participants & wish the Conference a grandsuccess.

(Vasundbara Raje)

Chief Minister, Rajasthan

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Minister for Health &Government of lndiaNirman Bhavan, New

Family Welfare India,

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Dr. Anbumani Ramadoss

I am pleased to know that JW Global Hospital & Research Centre is organizing Second WorldCongress on Clinical arid Preventive Cardiology and World Public Conference on 3D Heart Care from28-30 September at Brahma Kumaris Shantivan,Abu Road. lam also told that a Souvenir is atso beinobroughtout on the occasion.

The World Congress is an opportunity to the medical fraternity in India to showcase initiativesthat can impact the lives of the rural poor in Cardiovascular disease which is a challenging problem forour country as it has become a wide spread life disease. The Government of lndia have launched theNational Rural Health Mission in April 2005, to mainstream quality and accessible health care to the ruralhouseholds across the country. In the past two years, through the National Rural Health Mission, wehave been able to access innovations in technology to provide quality health care to the poor ano downtrodden. The learnings of such Conferences are extremely important as it provides us opportunities totake technology to the doorstep of rural poor.

The Government of India is committed to mainstream innovations in critical fields of Cardio-vascular disease and the recent technological advances have helped India to perform interventions withperfection and at an affordable cost.

I am confident that the three-day Conference would be able to help in mainstreaming cheapaccessible health care in the field of Cardiology. I hope the deliberations at the Conferences and thetechnical papers presented at various sessions would be fruitful,

lwish the participants and the organizers all success.

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( Dr. Anbumani Ramadoss)

Minister for Health & Familv Welfare India.

Government of India

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Minister, Law & JudiciaryHealth & Family Welfare,Legislative & Parlimentary Affairs,NGO Co-ordination, NRG Dept.Government of Gujarat,Sachivalaya, Gandhinagar 382 010.

Ashok Bhatt

I am pleased to know that 2"0 World Congress on Clinical & Preventive Cardiology 2007

and first ever World Public Conference on Three Dimensional Heart Care 2007 is being

organized on World Heart Day at Brahma Kumaris Shantivan, Abu Road from 2B'n 30.th

Seotember.2007.

A healthy heart is the driving force behind the productive life of everybody.Cardiovascular disorders are very common. I am sure that this conference will provide anexcellent platform for experts to discuss and provide appropriate preventive strategies toconouerthe diseases.

I wish the Conference a very Grand Success

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(Ashok Bhatt)Minister, Law & Judiciary,Health & Family Welfare,

Legislative & Parlimentary Affairs,NGO Co-ordination, NRG Dept.

Government of Gujarat

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Dr. R. K. Srivastava

I am happy to learn that "2nd World Congress on Clinical & Preventive Cardiology (WCCPC2007)" and "World Public Conference on Three Dimensional Heart Care (WpcHC 2007) is beingorganized at Brahma Kumaris, shantivan, Abu Road, Rajasthan from 2g-30 september. 2007.

India is being projected as a hub of Cardiac Diseases in the coming future. lt is an atarmingthing, which is to be tackled jointly by planners, clinicians, Philanthropists and social worKers as nosingle agency can handle this buroen.

we being a deveroping country, have the constraints of economy, infrastructure as wefl astrained man-power. ln the light of our constraints; it I better we focus our attention on preventive andalternative medicine also. Prevention being cost effective will be more relevant for our Society. Abalanced approach of diet, exercise, yoga and life style modifications may prevent the occurrence aswellas progression of manydiseases and help us in attaining the goal of 'health for all'

lam sure the deliberation from the learned speakers will help us in learning and imptementingthe preventive strateg ies.

lwish the conference a success.

@tY:-Dr. R. K. Srivastava

Directorate General of Health Services

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Prof. N. K. cangutyDirector General

I am happy to note that the 2"0 World Congress on Clinical & Preventive Cardiology (WCCPC)and the World Public Conference on Three Dimensional Heart Care (WPCHC)- 2007 are oelnoorganized at Brahma Kumaris Shantivan,Abu Road, Rajasthan from 2g-30 September2007The theme chosen for the conference is very apt for the venue of the Brahma Kurnaris, where theemphasis is on promoting the qualities of humanism, tolerance and never- ending enthusiasm forspreading the knowledge of truth in every sphere of life. This would provide the platform for controlllnoones lifestyle and behavioral risk factors to achieve ootimal health.

The ICMR has been working towards addressing the various aspects on prevention and controlof Non-communicable diseases by organizing need based studies in an integrated manner.Cardiovascular diseases, Diabetes, Stroke, and Cancers are the most important lifestyle relateddiseases facing us. They are facilitated by a group of major risk factors which are amenabte toprevention and control, thus influencing their disease outcomes. While we improve our understandingand skills in the diagnostic and therapeutic modalities associated with these diseases, we should try toinclude other important stakeholders so as to be able to provide a holistic health for all human bernos.llookforward to the deliberation outcomes of this conference and wish it allthe success.

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Navin C. Nanda

It is a great pleasure and honor for me to welcome all the delegates at "2nd World Congress

on Clinical and Preventive Cardiology 2007 and First World Public Conference on Heart Care" from

28-30 September, 2007 which are being organized by the World Heart Academy, Cardiological

Society of India, Delhi Branch, International Society of Cardiovascular Ultrasound, Asian Pacific

Society of Cardiology, Healthy Heart Education and Research Foundation, International Medical

Sciences Academy in association with Global Hospital and Research Center, Defense Research

and Development Organization, Indian Academy of Echocardiography, World Academy of Spiritual

Sciences and Indian Academy of Mind Body Medicine.

This Congress wil l highl ight the numerous advances in the f ields of cl inical cardiology,preventive cardiology, echocardiography, interventional cardiology, cardiac surgery and other

modalities. As heart disease remains a global problem, prevention, early diagnosis, continuous

managementand properfollow-up are vitalto patient care and the wealth of knowledge to be shared

at this Congress will benefit both clinicians and their patients worldwide. As the International

Director of this Congress, I would like to join Dr. H. K. Chopra in welcoming all delegates to thisprestigious conference. I am very sure you will find this Congress very useful and stimulating.

(Navin C. Nanda)

President ISCU,

lnternational Director

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a rG S. Sainani

I am indeed very happy to learn that you are organizing the "2nd World Congress on clinical andPreventive cardiology (WCCPG 2007) & "World Public Conference on Three Dimensional Heart care(WPCHC 2007)" at Brahma Kumaris, Shantivan,Abu Road (Rajasthan)from 28th to 3Oth September 2007 by theCardiological Society of India, Delhi Branch, Asian Pacific Society of Cardiology, Healthy Heart Education andResearch Foundation and the International Medical Sciences Academy rn association with J. Watumull GlobalHospital& Research Centre, Defence Research & Development organisation, Ministry of Defence, Govt. of India,Indian Academy of Echocardiography and World Academy of Spiritual Sciences. There cannot be a better Dlacethan Brahma Kumaris Shantivan to hold such a congress. Secondly, J. W. Global Hospital and Research centre,Mount Abu is the place where original research on the reversal of coronary atherosclerosis with Rajyogameditation is being carried out by Dr. Satish Gupta with positive results. lt will give a first hand opponunrty tonational and international delegates to appreciate the virtues of Rajyoga.

In the new millennium, our country is already facing an epidemic of coronary artery disease and sooncoronary heart disease will become the number one killer in our country. With a litfle over .l bill ion poputation, wehave 600 million persons in the age group of35-65 years which is most susceptible for heart attacks. As of now wehave around 65 mjllion persons suffering from coronary heart disease. This is going to rjse steeply and within thenext 2-3 decades. India will be the global capital of coronary artery disease. our cardiologists and cardiothoracicsurgeons are doing an excellentjob in salvaging sick patients by coronary angioplasty and coronary arery oypasssurgery. Our back is already against the wall and the only strategy is to enforce preventive measures natronwide onan emergent basis.

I am sure your WCCPC 2007& WPCHC 2007 will be an eye opener for our country, as the importantmessages of preventive cardiorogy wiI be conveyed through news media and terevision.

I wish your WCCPC 2007 & WPCHC 2007 a grand success.

sd/-(G. S. Sainani)

PatronWCCPC 2OO7 & WPCHC 2OO7

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PatronwccPc 2007 & wPcHc 2007

Dr. Naresh Tr€han

lt gives us great pleasure towelcome and invite you to join us "2n d Wortd Congress on Clinicatand Prcvenaive Cardiology - 2OO7' & "Wo d Public Conlerence on Thrce Dimensional Heart Care- 2007' being organized by Cardiological Society of India, Delhi Branch, Asian Pacific Society ofCardiology, Heallhy Heart Education and Research Foundation and the Intemational Medical SciencesAcademy in associalion with J. W. clobal Hospilal I Research Centre, Defence Research &Development Organization, Indian Academy of Echocardiography and World Academy of SpiritualSciences fo be herd from September 28 to 30, 2007 aa Bnhma Kumaris, Shantivan, Abu Road,Rajasthan, tndia.

I am sure that this congress has been organized to highlight and share the explosive groMh ofknowledge in thefield of clinical cardiology, preventive cardiology, echocardiography, electrophysjologyand pacing, interventional cardiology and cardiac surgery as heart disease continues to be a dauntingproblem to clinician's world wide. lts preventive strategies, early diagnosis, correct and appropriatemanagementand follow-up can be crucialfor patient benefit.

The conference should evolve guidelines for better patient care. I am very happy to learn thatunder the slewardship of Delhi CSl, APSC, li,lSA, IAE and various other oranisations, this conferencewillserve asthe best platform foran excellentcontinuing medical education in cardiology.

lcongratulate Dr. H. K. Chopra, Organising Chairman, Dr S.K. Parashar, president, CSI andChairman Scientific Committee, Dr. Satish Kr Gupta, Secretary General, Dr. Michael Lim, president

APSC and Dr Anil Kumar, Presidenl Elect APSC, and Chairman Reception Committee (WCCPC 2007& WPCHC 2007), fortheirdedication and outstanding efforts to makethis conference a success.

sd/-(Naresh Trehan)

patronwccPc 2007 & wPcHc 2007

Presldent,Cardiological Society of IndiaDelhi Branch

Dr. Ashok Sheth

It gives us great pfeasure to welcome and invite you to join us in the "2nd World Congress on

ctinicat and Preventive cardiology - 2007" &'wo d Pubtic conference on Thfee Dimensional

Heart Care - 2OO7' being organized by Cardiological Society of India, Delhi Branch, Asian Paciflc

society of cardiology, Healthy Heart Education and Research Foundation and the International Medical

sciencesAcademy in association with J. w. Global Hospital & Research centre, Defence Research &

Development Organization, Indian Academy of Echocardiography and World Academy of Spiritual

Sciences ao be l,erd from September 28 to 30, 2OO7 at Brchma Kumaris, Shantivan, Abu Road,

Rajasthan,lndia.

lam sure the conference willevolve guidelines on various issues in the field of clinical cardiology,

preventive cardiology, echocardiography, electrophysiology and pacing, interventional cardiology'

cardiac surgery cardiac rehabilitation and crystallize the recent trends and newer directions for better

patientcare and wil lmake Delhia perfect hea rt ca re destination forpeoplefrom all over the world'

If irm|ybe|ievethatoptimisationinIifestyleandtime|yinterventionwithmedica|,mechanicaIandsurgical treatment may curb the rising menace of coronary artery disease in a developing country like

|nd ia ' Icomp| imentDrH.K.chopra 'o rgan is ingcha i rman.D| 'S .K 'Parashar 'Pres identcs landchairman scientific committee, Dr. satish Kr. Gupta, secretary General, Dr. Michael Lim, President

APSC' Dr. Ani| Kumar, chairman Reception committee (WccPc 2007 & WPcHc 2007) and President

ElectAPSC, for their tremendous contribution in making this event great success by bringing together

National and International organisations underone roof

I am sure that the memories of this scientiflc feast at the Brahma Kumaris shantivan will be an

unforgettable one.

sdf(Ashok Seth)

President, CSI -DB

lwish WccPC 2007 & WPcHc 2007 greatsuccess

President, International Medical SciencesAcademy (IMSA)Hony. Overseas Adviso(Royal Collage of Physician & Surgeon, Glasgow.Enerilus Prol Dr. M.GR. Medical UniveEity, Chennai,Dir€ctor K. J. Hosoital. Chennai-600084

lr. K Jagadeesan

It gives me great pleaser in congratulating you for organizing the World Congress on Clinical &fteventive Cardiologyand World Public Conference on Heart Care roping in allthe concerned facultiesano 0rgan zers.

It is indeed a gigantic task in front of you. I am sure with your positive approach and dynamismyou will certainly achieve one ofthe best meetings.

On behalfofthe fellows and members of Internalional l\redical ScienceAcademv and mv own Iwish you allsuccess in this endeavor.

kr:+z"Z+-(Dr. K Jasadeesan)

President

International Medical Sciences Academy (IMSA)

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airman\ss

S. K. Sama

World Heart Day is probably the mostopportunetime to hold a Congress ofsuch great imporlance,like theI World Congress on Clinical and Prevontive Cardiology - 2007 and World public Conterence on Threercnsional Heart Care - 2007. ltisallthe more imporlant because Dr H. K. Chopra, the Organising Chairman ofCongress, has involved such important organisations like the Cardiological Society ot India, Delhi Branch,an Pacific society of cardiology, Healthy Heart Education and Research Foundation, International Medic€lencesAcademy in association with J. WatumullGlobal Hospitaland Research Centre, Defence Research and/elopment Organjsation, l\rinistry of Defenco, Indian Academy ot Echocardiography and World Academy ofdtualSciences.

Hearl Disease is lhe second biggest killerand commonest cause of morbidity and mortality not only in ourntry butalloverthe world. ll is affecting the masses in opidemic proportions and most of the surveys held show€cedence of almost'10% amongstlhe urban populalion and 4% in the rural population_

Over 2.5 minjon people die every year due lo cardiovascular causes and almost 60% ofthem die withoutmedicalaid available to them. The mostworying causo for this country is that CoronaryArtery Disease affeclsans 10 to 15 years earlierthan the rest of the wodd. lt is also b€€n observed thal Indians jn anV part ofthe worldmore prone lo CoronaryArtery Disease as compared to olher nalionalilies.

Fora country like India to provide huge budgots for treatment of heart disease is next to impossible. ll is allmore imporlantthat skess is laid on preventive aspects ofdiseaso in theform ofchange in lifestyle and, propercation regarding dietetics and regular schedule for ex€rcise, as well as due attention to str€ss relievinglalities like Yoga and Moditation. Another aspect of tifestyte modification, which needs to lie propagated, isvenlion ofsmoking as smokers are mostprone toCoronaryArtery Diseas6.

It has also been found that obese children when theygrow aro more prone to cardiovasculardiseases andd di€tetics habits should be siarted rightfrom childhoodwlth properregularexercis6.

I am sure with a le6.ned faculty from all over the globe, mutual interaction and d€liberations in thisEr€ss will bo v€ry truitful and strategies which are practical and applic€bl€ to this country wi

evolve andsequently be issu€d as guidelines.

lwish lhe Congress a great succ€sa and onc€ again congralulate the Organising Comnitt€e for lhisodranlmg€ting.

sd/-(S.K. Sama)

ChairmanwAss

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frct4arflio'/s{@PERs IIanaging DirectorPdce Water House Cooper

Deepak Kapoor

It is with great pleasure that I write for the upcoming world congress on clinicar & preventiveand the World Public Conference on Heart Care, being organized by World HeanAcademy,alSociety of India, Delhi Branch, Asian pacific Society otCardiology, College ofAsia Societv

cardiorogy, Hearthy Heart Education and Research Foundation and rnternationar Medicarsciences

nechanisms and organizing such seminars and conferences wouldcontdbuting to the cause of preventive cardioloov.

go a long way in fruitfully

(Deepak Kapoor)Managing Director

AcademyatShantivan Taleti, Rajasthan from September23_30, 2007.The latest figures cleady state that lndians are genetically more predisposed to have Coronary

Atery Disease (CAD), and while in the rest ofthe world CAD has fallen by SO percent, in Indja it is risingand has grown 300 percent overthe last s0 years. I believe that preventive measures are the best control

tcommend the efforts ofthe organizing committee fortaking the initiative to onng together Indian8nd internationaly accraimed cardiorogists on a singre pratform to give their varuabre inputs onManagement of CoronaryArtery Disease.

lwish organizing committee and Dr H.K. chopra all the very best and continued success in arlsuchfuture endeavors.

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Organizing ChairmanwccPc 2007 & wPcHC 2007

H. K. ChoPra

ll is a matter oi qreat pleasure a nd honou r ndeed fof me lo welcome you all a nd invite you,to the word conqtesson

"' ̂ *'i:'ii d;#;;;i; . "sviwliPc zoo'ib""sorsan seo bv worid HearAuada-v rwriAr c: ro roroq rcd' soc erv

;ff i;.;: 'B;,;J i isr oej'a',n pacir'c socJi oicaroiorobv lAPscr Healr"v u?d1-r 'r 'nrr'or drd RFsearch

i"iji'liioiuiECii l,id"atroriat tueaicat sciences Acadernv (rMSA) n assocrarron wirh Groba Hosprtar & Research

i""t,.b?""" n"!""tir' a Development ofganisatron (DRDbi' Mtn slry of D-"fence Govt,,or Lndia Ind an Academv ot

Echocardoa'aony {lAE). Inlerrdnora'� So,'"rv oi calo'ouas". l t ' ' ul l 'asound Isc-' a10 world ALademv of soi i l ral

##; oi;$l, il; ;ero on septemoer zs to te, 2007 and iorLowed by-worrd Pubric conference on Heart care

iriiii'r-i )boil "il s"oi lo"l zooz at srra ntivan tateti Abu Road Rajaslhan (lndra ) over the past d ecade there ha s been a

fii,;;;iil; ii-ii""'*r"oc. in tre neta -oi

Ctinicat Carc'iotogv Preventve -cafdiolosv Echocardiosraphv'

ii"iil"o"ni"ii,i,v r"i"";ironaicaraiorosv a no caroiac su rs ery. rhe object ve oi this confere nc€ is to iocu s o n Pfeveniron

rnrntervenuon and Interuenton to Prevenlon "";i;;i""i'" 6""""ds where are we todav and where are we qoins?

il;;'ii;;d;;;;;irrin"Lae s"""ion" orr'erne;dous clinicarappr cation w th hish academic srandards for inremists'

ohvsicians. cardiooqisls, intervenuonal *ro..s.i"-, ""tdi"" *,ge;;ts vascular surgeons pedialic cardiologisls and

peaialrics cardiac surgeons, cardiac anesthetists elc

lam sure lhe scientific programme pLanned under the leaderchlp of Sclentfic Core Commlltee & prcceedings oithe

**"i"""" *ll ""or""!uio"ilnei to, s"ui,at l"tnins issues ana neier innovalive technoogles and wrll dennltelv help in

cNstalllzino lhe tecentttend" ""0 ""*", """"""""iit "au'nl"a p"t"nt """' fhere willbe specialemphasis on scienliflc

:1ffi"i ii"lil;;;;;;i ;J*""1i i" a'i",r ""iotlosv, preventive caroLo os1,fl!:1,"1'l:h """s""'ive hearr iairure'dvsiDidemta. coronary artery drsease caroLooraueteslmetauotic synd.ome echocard,ography eLectrophvsiologv and

;i#;';';iiyd;;, 't"*1it'* ".s"es-,^""".,,1::1i;i:11.:ll?:1",3:1;:',i5":"il"^,":i?1",#:ililll":i:!,:iS K.Parasha; . PresrdentCSl , and WHA Dr S S (

Drsatish Kr' Gupla, orsa nising secrela4' Gen eri Dr' tritlaeirim presloentePSc DrAnilKumar' President Elect APSC

i"iiii"" ii.,.,," n!",l"tr"lic"mirrtree lwicec zooz1, iorthe r efforrs and dedicat on rn makins this.onrerence a success

More than qle thousand delegates are [key to participale ]n the scientillc delibetatons and more than five thousand

memDerso,oub' ,c wr t lpal rc ipdle i1pLb rc co1 e.e1Cc

l t s h a | | b e t h e e n d e a v o u r o f e a c h a n d e v e r y o n e o i u s t o m a h e l h e C o n | e r e n c e a q l a n d s L l c c e s s

lassure yorJ thal the memories of th s scientillc feast wiLlbe an unforgeltabe one

Once aoain on behalf ofthe members of executive and organising comrn ttee l extend a warm welcome to all of vou'

In every chall€nge, there is uncertaLntyWhen there is uncertaintY, there is detachmentWhen there is a detachment there ls freedorfWhen there is freedom, we surfender ourselves lo cosmosWhen we surrender ourselves to cosmos'The whole cosmos, orchestrate iis dance into your feel

lVaitteya uPanishad

(H K. Chopra)Organrsrrq Chakman

(wccPc 2007 & wPcHc 2007)Chaitman WHA

Vice President CSl, DB. Secrelary Genetal, Wotld HO

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qes "l ls.rBuBgBqptn deprdelqew 'u Ioqsv

BK Nirwair

Hearty congratulations on the '?d World Congress on Ctinicat & preventive Cardiotogy2007 (WCCPC2007)" and "World Pubtic Conlerence on 3D Heari Carc (WqCHC-2002', being hetdatShantivan, Abu Road from 28'"to 30'^ September 2007!

It is heartening to note that the response from all over the world has been encouraging. Theparticipation of highly eminent cardiologists from Bharat and abroad will definitely pave the way for thew0rld to benefit from the presentations ofexpedenced cardiologists and other participants.

The serene environment of Shantivan, with the additional unmatched dimension of spiritualvibrations, wil l surely provide a unique and soothing experience to all the partjcipants. The confluence ofspirituality and science would prove to be a boon to the medical scientists, oatients their families.

lextend hearty congratulations to the Organising Committee and best wishes forthe success ofWCCPC-2007 and WPCHC-2007.

With reoards.

BK Nirwairl\.{anaging Trustee, cHRCSecretary General,Brahma Kumaris

BK Ramesh Shah

BK Ramesh ShahChairperson, Jurisls'Wing of RERFl/anaging Trustee,WRST

BK Brij Mohan

BK Brij MohanChaiFerson,Politicians' Wing of RERFEditor of 'Purity' Sp iritual lvagazine

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3D HEALTH CARE THE MIND, BODY SOUL CONNECTION

- Rajyogini Dadi Janki

A.tministntive Head, Btahma Kumaris,8,500 centrcs att over the wortd in more than 120 countries.

lrosl sLib]e M,nd in l|e wo4d. ar 92 yearc ol dge: has aore energy than apersor of age 29 yea.s. Last year sl-e trave.,ed more lhan . 50,d00 k1ls

There is a deep connection between my inner worldof thoughls, feelings, vision and anitude with my outerphysicalworld, starting with my own body. Undersiandingand slrengthening thrs connection will help us to conque;slrcss and gu de us back to an overall state of health al atllevels, ie spiritual, mental, emotionaland physical.

Innordynamicsof lhesoul

Understanding the innerdynamics ofthe self is anessentia first step. There ,s the heart (reelings). the mrnd(ln0ughls) the inrellecl (decision maKing) lhe conscience(vorce of lrulh) and the subconscious memory lrack(ecording of all rnemories and experiences. )

Our subconscious memory track carries bothpositive and negative experiences. When the negativeones erupl, tney contaminale our hearis and mindsdisaohng tlerr abilty to luncrion ettect.vety and ctearty.When lhoughls and feelings are confused a"d po uted inthisway,lhen the iniettect isn't able to function properly irlorder to make the right decision. The mrno nas aconnection with the intellect and the intellect has a deep@nnection with lhe conscie n ce.

Why is the mind putted in so many differentdlraclions?

The mind has a deep connection wilh lhe senses ofthephysica body. When thesenses become mischievousorinfluenced by matter, this pulls the mind in the directionofthe physica world. On ly when lhe intellect receives a ndimbibes spirtual knowledge, can it control the mrno ano

steer it back lo order. Only then can thesenses and achieve mastery overthem,

control the

What is self mastery? lt is the inculcation andcomplete absorpt ion of spir i tuat knowtedqe.n the intel tect.' I

he intel lectneeds the co-opefat ion ot tha rrrndtofunct ioneffectively. However, when old experiences/memones orsanskars erupt, they pull the rrind. In the face ofsituations, the mind is also influenced and this doesn,tal low the Inter lect ro ru-cfon efecr ivety. In at ot this lheconsc.ence highl ghls whal rs r ight ano wro-g

Themind-bodyconnect ion

Healthcare and being heatthy has a conneclonwilh the mind_ The mind has a connect ion wlth the ohvsicalsenses How we ,se rhe sensFs d, lecls ouf heai lh ' Torex€mple, all the food we eat has an impact on the body. ltts importanl lo take care of our actions. Ourdiet shou d bea saivic one. Everything we do has an impact on ourconsciousness Our Inlel lecl has lhe polent al lo wor( we ,b-l t tsas the tendency lo oecone t.fluenced due to h,voaspects: The qual i ty of the company we keep, and thesustenance we rece ve, e.g from our iami y and cioserelat ionships.

When we do sonelht^g wrorg lhe consctencebites ard makes lhe sour leel gu, lLy. W'1en there ts t ' rei" f luence of bad company, l -e consc ence oeconessuppressed and can't speak. when the conscjence issuppressed, even i fa person is beaten theywon,tbeableto speak thetruth. Thetruth issuppressed and hidden.

Soul consciousness and God consciousnessto rejuvenate health from insideout.

I t is through meditat ion and the development ofsoul consciousness that the intellect will be empowereoenough to work wel l . l twi l lbe able to remain st i l land stableandtoabsorbgoodness.

When you remain in the physical awareness ofbody consciousness then you wil be further influenced byyourold memories theywil lcome up oremerge. Let 's sayin the past, you tooksorrowfrom someone the situation i.;f inished and ihere is nothing in the present our wnen vousee lhal person agarn the nemory wtl energe ano yburvision will change lowards them. Whatever I rememoerwill be reflected through rny eyes and colourthe way lseethings (my vision/perception). When lhere is God'sremembrance, there is God,s enefgy infiuencing me.

Mindnb|lChb

Sanskars3loao8 n|enbaba

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ENJOYING A HEALTHY & HAPPY LIFE

- Ralyogi B.K Ni,wair

Managing Trustee, J.W. Global Hospital & Res€arch Cenlte, Mt Abu;

SecrelaryGsn€ml, Rajyoga Education & Res€arch Foundation,Brahma Kumeds, Mt. Abu.

Sinc€ the wodd came into being, humanity has

relen{essly to be happy. Diferent expedmentsout in both th€ scientific and spiritualistic arenas

Fwide ways and means for a person to feel happiness'8nd

loy for the maximum time in life. However, during the'€nsulng century ospecially ov€r the past fiv€ d€cades,tlr€re have been tr€mendous changes in the lifestyle ofpooplo from all age groups and socio-economic status.

This contury has developed the materialistic outlook,

which has led to extraordinary means ot domestic life,

mod68 of travel, fashion, entertiainment, and the fast-foodqllture. Undoubtedly, all of this requires tr€mendousconc€nlrated efiort in terms of economical well-being so

asio enjoy the fruits of modem science and technology.

This has subsequently led to more and morc pressure on

lh€minds and hearts ofthe earning members offamilies,iJdh€r leading to contraction of physical and mentala msnb much earlier in life than s€en in the previous

genolalions. Each year, the percentage of patients

sufiering from acute diabetes, cardiac problems, skin

diseas€s, hypertension, infant mortiality etc are on the rise.

And so on one side we have the latest and bestfindings in

m6dical r€s€arch that enhance the quality of life in modern

society, wher€as the flip side reveals the outrageous

incldenls of sufiering patients in cities as well as rural

habihb.Theso observations instigate scientists as well as

those dedicated in spiritual services to ponder deeply in

ths defnite direction of arresting further decay of health

sbndards. The root cause of all discomfort and pain in

heahh setbacks should be deciphered minutely, as these

atg omnipresent irespeclive of educational and financial

bac{qrounds. Porhaps modem science has been more

tocusod on providing immodiate Relief through

medication, surgery or alternative clinical troatments.However, some medic€l scientists have of late addrcssedthsse h€alth problems, especially dealing with cardiac

ailmenb, k€eping the preventive methods infocus.

The wise saying, 'Prevention is better than curc"seems to be a crucial method to aid large numbers ofpeople in the world. Simple living and high thinking is an

absolutely efiective solution. The experiments of certaincardiologisis in India and abroad have provided stronginsights as they combine lhe following four factors for ahealthy and happy lifestylel

't. The most significant factor in preventive

cardiology appears to be a high level ofconsciousness, meaning a positive and divine@nsciousness. lt's shocking to see the present

level of consciousness of the common person

because most people have hardly any tame forself-introspection or p€ctice of connectingbeyond the physical realm which would help ancreating positive behaviour and a happyenvlronmenl.

The founding cause is one's self-cenkedthought processes which lead to negativepersonality traits. "Asyou sow, soshallyou reap"and therefore actions stemming from n€gativeconsciousness result in suffering. unhappin€ss,prejudice, hatred, iealousy, competition andwars. The first focus ofan individual ne€ds to beelevation of one's consciousness for whichsimple ways of reflection and mediliation areadvisabl€ and proven to be very efiective inmoulding one's Iifestyle positively.

2. The next vital factor seems to be a balancgbetween mental and physical activities. Th€physical human body needs moderale exerciseto keep the whole system in good shape, andsimple walks in fresh air while approciating andenjoying nature help avoid unnecessary skess

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It

fnaugural Address of His Excellency, Dr. ApJ Abdul Kalam,Former President of India,

World Congress on Clinical preventive Cardiotogy 2OOG,22d September 2006

Venue: Brahma Kumaris, Shantivan, Abu Road (Rajasthan)

-y

Integrated Three Dimensional Approach for Healthcarelam delighted to participate in the inauguratjon of the

World Congress on Clinical and Preventive Cardiologytaking place al Shantivan, Abu Road. I am very happy tomeel and discuss issues with the experts in the fields ofclinical, preventive and experimental cardiology who havegalhercd here and to share their experiences. I amexlremely happythat cardiologists from the U.S., U.K., theNelhedands, [4alaysia and many other countries havealso gathered to deliberate on recent advances in cardiacarg,

CurentSconado

Cardiovascular diseases leading to a variet of heartrglated prcblems have assumed epidemic proportions thewoid overand have become the most common cause offablity in the developed as well as developing naiions.ln lndia, I understand the prevalence of cardiovasculardisesses has increased from 1 % in 1960 to 10 % to 15 %0f the adult population now. Evory year, more than fivemillion people suffer from fresh heart attacks includingnoarly'1.5 million fatalattacks. One oI the crjtical issues is

the recognition, diagnosis and iimely availability ofMedicare at lhe time of attiack including rural areas. Therapid ancrease in the rate of coronary artery diseases inSouth Asia particularly in India, Pakistan, Bangladesh,Nepal and Sri Lanka is deflnitely a cause of concern forhealth specialists ofthis region. The increase in incidenceof diabetics among our population aggravates the heartproblem further. Hence, the World Congress will result jncertain useful recommendations for the medicalcommunity and social o@anizations like the BrahmaKumaris and the institutions like DIPAS, DRDO and manvmore institutions.

Effect of Globalization

Rapid changes in lifestyle associated withglobalization, industrjalization and urbanization of thisregion is probably the greatesl cause for the inceaso inthe rate of cardiovascular diseases. Alterallons infaditional life style due to migration from rural lo urbanareas in India or migration abroad to more prospercuscondilions may aiso be responsible for incr€asing

(Rajasthan)

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sbns pouring slress hormones, which in turn incrcasesthe load on the heart and can set in coronary arterydisease. lf, we can reverse this process by crealng anenvronment of positive thoughts, peace and happiness,thiscan minimize the load on the heart, which shouid leadto rcvercal of the disease. The main hypothesis was byadapting a healthy lifestyle oflow fal high flbre vegeranandiet, moderale exercise and slress management throughRajyoga meditation, we can decrease load on lhe heartwhich in tLrrn should reveFe or halt the disease process.Similady there are many types of meditalion, which maysuit cerlain groups of people. lt has been recognized thatkeeping mindand bodybusythrough good work isanotherwayofYoga-

SludyDesign

This hypothesis was tesled jn more than llve hundred anderghteen patienls, who had angiographica y provencoronary artery disease, Two trials were carried out,I\,lount Abu Open Heart Tdal in which patients served asilerr own controls and Abu Healthy Hearl Trjal in whichhundred and twelve patients received a healthy life slyle,whercas hundred and ive patients seNed as conrot anddid not receive lhe healthy life style intervention. ln fact,lh6 control group was also prescribed the same diet andexetose bul was nol given inslruclions on medllation.Most of these patients had advanced coronary arteryd6ease involving all three heart arteries. These patieniswere lracked over a period of ejghl years by the GlobalHospitaland DIPAS.

Llfo Stylo InterventionThe life style given to these patients was very srmpre anorudimenlary In facl, they received a kaditional Indian diethaving lots offibre, fruiis and sprouts which I understandwas a slaple dietofevery Indian family about flve oecaoesago. The exercise given was simple; a brisk walk both in

the mornjng and evening hours. The major component ofthe intervention was stress management throlghmeditation. The main efforts were to empower patientswith informalion and education on head disease ano nowlhey themselves can controlor reverse it.

Angiographic Evaluationlunderstand that angiograph ies were coded and analyzedby a panel of independent angiographers. The oulcomeappearslo be quile rewarding. Likeany medical treatmenta visibly marked improvement In cardiac health of thesepatrenls could be seen wilhin seven days of thecommencement of the intervention. Their requirement ofdrugs prescribed by lheir cafdiologjsts decreasedmarkedly. The symptoms of chest pain and uneasinessreduced. Theircapacityto exercrse improved dramatlcallv.I understand that afler six months ol nterve-tion sone ;fthe patients were even abie lo take io swirnming. The so_called bad cholesterot, slress hormones proflle improvednoliceably. The psychotogicat or mental health showedconsiderable improvement.The heaftbeat became very rhythmic and natural. TheDrarn waves especial ly theAlpha that I understand are anindicator of mental tranquility increased drarnatically. Infact, the increased Alpha waves could be recorded both0unng eye ctosed and eye open condjiions suggestingthat while they were doing their routine work menbltranquil i tywas well maintained.When theirangiographies were repeated the conrrol groupshowed an increasejn artery blockage whereas ne group,which received life slyle intervention, showed a substantialdecrease jn artery blockage. Thus, this experiment clearlygives us ample evidence to confirm ouf hyoothesis aboutthe efficacy of ljfestyle inlervention in oromotinosuslajnable healthy hearts.Repllcation of ExD€rimentsHowever, lwould suggest thal the specialists gathered at

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Frcm the audience of Doctors

Answer by His Excellency: Regarding the export,mak ng a business you can do afterwards. Butwhatyou donowmakethe India's health is good health using this threedimensional or fou r d imen s ional approa ch. OK.

Q.3, What we can do lo bring awareness's among rhemasses so thal more people who don't know much aboutcardiology, what we can do best so that they Know andbring about awareness in more peoples heart so that wecan 00 much to prevent heartdiseases in lhe society?

Fromaudienceof Doctors

Answer by His Excellency Well it is a good question. Iwould like totellyou how you can do this. Are you a doctor?Now lwould l iketoaddress al l the doctors. When a patientcomes to a doctor, he considers and accepts doctor asGodly person. He accepts that. Now imagine, when youlreat that person, when you are treating a person, he getnumber ot people from his famity and frtends ro see rnepatienl.As a doctoryou spread the informalion, you tell hisfrends, you tell his retatives, how your felative got a heartproblem because of the following reasons. So I willsuggesl these are lhe schedule of three dimensionalschedules he should fotlow. lfyou spfead this informaiion,lhal will be the best teachtng. you wilt become a reacner,nor on y a doctor, you shoutd be a ieacher also. They willbelieve you because you are treating the man or women.You agrce? Yes orno?

Commenls: Thankyou very much His Excellefcy, forthisexcellent lecture. I thought you are a Cardiologist byprofess on, thewayyou spoke.From Dr Abdul Wase, USA, International Faculty,wccPc2006

Comhents by His Excellency: ln rny tast birth I was aCardiologist.Q.4 This islusl a comment, then I wil l ask the questjon.Therc was one presentation today morning where iheyhave collecled data from rural India Andhra praoesn overone lac people, and they found ihe death fromc€rdiovascular disease was 25%. I was shocked see thisnumber.Actuallywhen lwas colning to the conference,

lwas doing some research, I was trying to gel somefigLrres, unfortu nately there is nothing availableon internetin lerm of preva ence of cardiovascuJaf dtseasesspecific€lly cardiac arest and certain cardiac death. So

myquestion to you, Your Excellency is, may be we shouldhave a some kind ofhuge database, thatweshorrld collectallthe data from the different parts ofthe country and try toestablish the problem, how big the probtem is and collectdifferentvariables and then follow those patienl populationover a tong period of lime, as they have oone InFramingham's study and other parts of the UnitedStates.FromtheAudienceof DoctorsAnswerby His Excellency: I ap preciate yourquestion.Inthe beginning as soon as I started presenting the material,l felt the increase in the heart problem since 1960, today itis further increasing. I agree that database rs ro oegenerated, and I wiil see to that every state in my countrylhey put some cl inicat data, cinicat incidences in theinternet about Indjan Hearts some thing l ike that, I wil lgoing lo recommend and suggest so that we know themalerial which create problem. As an expoat you canundersta nd geneticatly Ind ia ns are susce ptible for ca rdtacdiseases that is welt known But lhe question rs, wnal weare discussing, you know, once hearl problem is detecledhow to handle and how to prevenl. So the preventivecard iology treatrn e nt is mostvital. This isthe messagethattheworld congress should spread.

Comments by Dr S. K. parasar, president ofCardiotogicalSocietyof India aboul the previous f igure:

The ICMR (tndian Councit for Medicat Research)has taken a big project and I happened to be a rrember oflhatprojeciandthefirstmeeiing son 15" October2006, inwhich they have setup of a big website and they wii lstuoyrng on acute cardiovascular accidents through outtne country and then collect the whole data and that isslartingfrom 15''October.Comments by His Excellency: But my suggeslon yoLrstart tomorrow the whole the nformation for variouscountries so thatthe database wiltbe avaitable foryou.Q. 5. lam saying just l ike for body we have got ai l thebranches a/l over the world in al l the Medtcat l fst i tutes.Now lhis is a Prevenlive Cardiology Congress, why notwehave a chairon this three dimensionat approach,

at least that start from lndia, so that this lhing can bespread.From G. K. Jain, Participant ofCAD program (Dilwala)

Answer by His Excellency: yes, I will take yoursuggeslion. The best way to do that, I told you anrnternational website you must start, and you areempowered to do in this congress, Dt Selvamurty willdoevery aspects of necessary requifements.

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Our world has been likened to a beautiful book

that is of little use to those who cannot read And in a

similar sense, our knowledge as physicians is a flne and

priceless assetwhose value is vastly diminished unless it

can betaught, disseminated, and practiced throughoutthe

world. In Peru, Calcutta, and Afghanistan l have written

about it in one ofmy president's pages, and I like to callit a

patient in a box. lt is designed to teach physicians at all

slages of their careers how to use new medical devices

and perform new Procedures.

It will allow trainees to practice new techniques

without fear of harming patients. In fact, in the future a

certain number ofpractice hours logged on a simulalorwill

pmbably become required before performing a procedure

on a patient. lt will help us to work and train as a team'

along with our nurses, technicians, and physician

colleagues. Dealing with rare or infrequent complicatrons'

such as caldiac perforation and tamponade can oe

pracliced many times on the simulator' so that when it

aclually happens, the catch team can lespond like a crack

drillsquad. In the nearfuiule, from the first venopuncture

thal a medicalstudent performs to a complex angioplasty

in the last year of cardiology iel lowship training,

procedures will be taught in such virtual reality settrngs

Perhaps, also in the future, low volume operators will be

able to make up for lack of paiient numbers by

documented hours speni praclising on a simulator' I

submii to you that virtual reality is an unquestionable part

ofour educational future, and it is a means through wh!ch

wecan spread knowledge al loverthe world l twil lchange

foreverhowwe teach, test, and treat.

We must educate the public of ihe wrong dolngs

and unethical practices they are subiected to What else

can we do, as individua cl inicians and as a College, to

improve ihe quality of the cale that we deLiver? How can

we demonstrate that quality to regulatory agencies, third'

parry players, and, mosi importantly, to our patients and

their loved ones? ln searching for an answer to these

questions, we must firsl look 1o the nature of our

relatlonship with the society in which we l ive

We are social animals with a need to coexisi in the

company ofothers, and to interactwilh lhem.

It seems to me that the moral glue that binds us

together comes in lalge measule from ouI accountability

lo those others. For each of us is accountable in someway

to someone.... . . a husband to his wife, a parent to a child,

a physician to a patienl. We knowthis and live by it

And in these interactions, we think of ourselves,

fot the most part, as honorable men and women wilh

standards that are an unshakable part of our

accountability to society. Those slandards are founded on

an lnderlying knowle4ge oi what is rlghl and what is

wrong.And, as physicians, we think of ourselves as

knowledgeable and competenl professionals wlth a

dist inct understanding of what is r ightfor our paiients, and

what is not. We know this with complete confidence And

rarely, ifever, do we find the need io queslion il

And, in the most Lmmediate sense' that

accountabiliy applies direcuy to the vulnerable state oithe

patients whom we treat. I like to think that good healih is

when your body does not talk to you, when i t is s i lent You

are largely unaware o ofyour body when you are healthy

You don't consciously think about having an arm a neao'

ora siomach. But you knowverywel l that you have a back

when it aches. And you know very well thai you have a

heart when your chest hurts. l t is then thal your body lalks

io you. We physicians tend to see people when they are

mostaware oftheir bodies, when thelr bodies are talk lng lo

them a lot ,which meansthaiwe seelhem when theyareal

their most vulnerable. We see them when they are

undressed n every wayphysica ly, emotionally, and

spir i tual ly To see them so places us in a post ion of

enormous prrvi lege and responsibi l i ty. Because, we are

al l the sarre when we aIe naked.

The wise and the fool ish

The mighty and the weak.

The wealthy and the will be gone.

Al l the same.. . . al lvulnerable.

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THE SCIENCE AND ART OF MEDICINETherc arc qualties beyond pure nedical competence

lhal patients need and look fot in their physicians. They wantftassunnce. They want to be looked after and not iust lookedont. They wanl lo be Istenecl to. fhey wantto feel that il nakes adlfr eE n$ to th e p try si c i a n.

- Nonnan CousinsThe importance of becoming a doctor is not fully

realized by the majority of students at the timeofjoining themedical course. I\rost of us took up medicine because thatwas considered the best choice at thattime. The studentsare perplexed further by the negative attitudes oftheir ownseniors. teachers and the complexity of the society we live.

Having chosen medicine as a profession, the best way to

deal wilh it is to go all out and not be contented with half

hearted efforts at it. Happiness in life lies in doing

something closestto oursouls in the best possible manner.

The following paragraph from one of the most respectedphysicians ofour time emphasizes the scope of medicine

in all its dimensions.Ilo gteater oppoftunity ot obligation can fal to lhe lot of a

hunan being lhan to becone a physician ln the carc of lhe

sufleing he needs technical skill, scientif,c knowledge and

hunan unclerstanding. He who uses these wilh courago with

humilily, anrJ with \'r'isdor' will ptovide a unique setuice to his

feltow nan, and will build an enduing edifice of chanctet within

hinself. The physician should ask of his destiny no more than

this: he should be content with no less- Tinsely R Harrison

The limitsto medicine arc besiexpressed byTrudeau:

To cure sometimes, to relieve often, to comfort always' to

be able io do this, we requirc to cultivate attitudes that

enable us to gain a broad knowledge of the subject of

medicine, technicalski l ls and the wisdom to usethemwellln the dedication to his volume Undetwoods, stevenson

wtot!6:There arc men and dasses of man that stand above the connon

herd. the soldiea tha sailoa and the shepherd not inhequently;

tl9D adist nrcty , rarelier still, the clergyman; the phvsician almosl

as a rule. He is the flower (such as it is) of out civilization; ancl that

stage of nan is done with, and only remembered to be naNeled

atin hislory, he will be thought to have shared as little as any in the

delecBofthe peioct, and most notably exhibited the viltues ofthe

ace, Generostty he has, such as ls possib/e to ttose whopftclice an arl, never to those who dnve a trade; clscretion,

leslecl by a hundred secrets; tact, tied in a thousand

ambarassmenlsl and what are nore impodanl, Herculean

cheeiulness and courage. So it is thal Mich bings air and cheel

into lhe sick-roon, and often enough, though not as often as he

wishes, bings healing.Wilfiam Osler maintained that "The practice of

medicine is an ad, not a tade:a calling, nota business: a

ca ing in wttich your heai will be exercised equally withyouhead...."

The science of medicine is easily leamed in ourtraining. To practice medicine as an art requhes life longcommitment and dedication. The practice of any artrequires style. Aswe practice the art ofmedicine, developa style ora manner ofourown, a method by which we dealwith our patients, students and colleagues Theingredients ol an deal physician Involve compassion.gentleness toward patients, a balanced disposition andcoolness of mind especially under stress. The ability tocommunicate well is particularly important as mostofwhatwe do involves either teaching patients or students

ln his address to the medicalstudents at Harvard

MedicalSchoolin l92TDr.Peabodysaid:"The prcctice of medicine in its tlroadesf sense inclrrdes

the whole relationship of the phystcian with the patient lt is an att

based lo an incrcasing extent on the nedical sciences bul

conprising much that still remains outside the rcaln of anyscience. The an of medicine and the science of nedicine are nol

antagonislic but supplenentaty to each other. Therc ts no norecontradictian between the science of nedicine and the aft ot

meclicine than between the science of aercnautics and the an of

flying. Goad practice presupposes an underctanding of the

sciencesthat cont.ibote ta the structurc af noden medicine, botit is obvious that sound professional training should include much

The treatment of disease mav be entuely inpersonal;

lhe care of a patient must be conpletely perconal The

significance of lhe intimate personal rctalonship betweenphysician and patient cannot be too slronglv emphasized, fot in

an extraotdinarily larye number of cases both diagnosis andtreatment are diectly dependent on it, and failute of the voungphysician to establsh this relationship accounts for nuch of his

ineflectiveness in the care of patients. What is spoken of as a

clinical pictute is not just a photograph of a nan sick in bed: it is

an @pressionisfic painting of the patient surrounded by his

home. his work, his relalionship, his fiends, hts ioys, so/.owshopes, and fears. Thus lhe physician, who aftempls to Eke carcof palient white he neglects those factors that contibute to theenolonal life af his patien{, is as ursci€rffic as lhe rnv€slrgalorwho neglects to contrcl all the conditions that nay affect his

experiment. The good physician knows his patients thtough and

thtough, and his knowledge is bottght deady Tine symrythy,understanding nusl be lavishly dispensed, but the rcward is Io befound in thal personal bond which foms the gteatest satisfaclionof the practice ot nedicine. One of the essential qualities of the

clinbian is interest in humanitv for the secrcl of the care of thepatient is in caing fot the patient."

His instrlction is even more pertinenttodaythan in

II

I

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'uralsls luesed aql ul op sluoplsa.l.lo suelalslqdesnoq se quolled p orsJ 6uuel suJ[ reqlpuods plnoqs /{eql sluerled qI^ leep ol ureal olJap.ro ul seullqlsuodser lecrurp ̂ue ue^!6lou eJequepnls r$po^ lealulla Jlorll6ul.rnO )uolled ̂ue olqlel uoôrou souluexareqleu luepnls eql ')iee/\

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'eurcrpeLU ol alqgJtldde IpelncHed ere pue eNnlIqpezreuruns lseq o.te uotssalold elo salstnbol oql /26!

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8.

it is not rare that by the time they finish theirmedical course, many f ind i t dif f icult tocommunicale with Patients,

Thoroughness: lt is essential in all medicalmatters, be it a preparation fora talk, examination,or patientevaluation and management.Horesfy. The ability to admit a mislake, lakeanother opinion or help when we are not surerequires courage and conviction on our part. wemust conduct ourselves in an irreproachablemannerso that noteven the slightesi dou bt wouldbe raised aboutour Integnty.Aftfiude. Adoctor should be tolerani and patientWe should avoid judging people and laking sidesbecause we undertake to take care of everybodyirrespective of theirorigin orstatus.Appearance: We must pay aitention toappearance and behaviour as society often tendsto judge us on this basis. A dignifled and cheedulmanner is part icularly important in dealing withsrcKpeopreThe grace of humility: w hatever excellence oneachieves in medicine, there can never beperfection in it. There are always places to go andpeople to meet from whom we can learn to dobetler lhlngs This teal izaton makes us humDleand withoJl lhrs quali ty o'e stands oul as anintolerable character.I)nreseNed respect fot excerlerce. Excellencein any branch of science or medicine, fromwhatever person, insti tutton or country l temanales, should be respected and dulyacknowiedged. lt is true that healthy competitionor r iva,ry helps In achrev ng the h,gherobJeclives lnmedicne, bul when carried too far i t becomescounter-productive.

patients and their familes is an indicator of whatone is going to be. This is the time one musi learnto interacl with people and patients. lt is notenough to be a good student. One musl striveto bea likable person in thecollege, hospital, and home.Once cultivated, these habits like bad habits arecontagious. The best iargel is the students atvarious levels who are yet to be spoiled byexposure lo the tricks of lhe trade of medicinetoday.While examining and evaLuating patientsTact, sympalhy and undetstanding are expected of the

physician for the patient is na nere collectlon ot symptoms,

signs, disadered functions, danaged organs. and disturbed

enotons. He is human, feand and hopetul, seeking reliet,

help and reassurcnce. To the physican as to the

anthrcpologist. nalhing human is stunge or repulsive The

misanthrope nay became a snan djagnaslician of arganicdlsease. Blf he can scarcely hope ta succeed as aphysician. The true physicjan has a Shakespe arean breadthof inlercst in the wise and the faolish the praud and the

hunble, the stoic hero and the whining rogue. He cares for

Tinsely R. Harr isonWhile we do our besi we should be prepared to face

thanklessness and even exploi ial ion from some peopLe. A

certain degree ofobiuseness or lnsensit vily to criticism is

sometimes necessaryin a professiona .Final ly, al l that s done in med cine s based on lhe

convict ion, that human l i fe s valuab e and human beings

requirelo be ireated with dignity and respect. As a doctor iyour first reaction to the person is suspicion and hatred,

one should nol pursue a career In cl in ical medicine. Those

of us who are rel igiously or iented should realze ihat our

rel igion is mediclne and al l other rel gions pale before i t .A good example ts the best sernon.

With the rapid advances lhat occurred n the asl decade,med cine has become more remuneral ive and extremelycompeti ive. The competiUve atmosphere brought out lhebest in some individuas and nst i tut ions eadrng tosuperlatve performance. However some nst i tut ions andindividuals wi l ted mora ly under th s pressure and tookrecourse to devious methods of dea ing wi lh the problem.

For lhem, each pat ient is a prospect on whom almosl al ltesls and few procedures can be done. They later call upthe referr ing doctor and tel l h im or her how much money

can be made on that pat ient. unnecessary Invesigattons,surgeries, or nterventions have become commonplace.However lhe system of fee-splitting s deslroying the soulof medicai praciice. This praclice takes away a I lhe trustthal pat ienis come lo us with. Th s distrust wi l l cont inue logrow i fmedicine is debased with such praclces.The tragedy af life is what dies inside a nan while he lives.

9.

10.

11.

12. Unswetving conviction that good things areposs,brei In the present aimosphere of medicaLpraclice and med cal educat on, contributed to byihe profession, lhe pol i t ic ian, lhe bureaucrat, i t iseasy to give up all hope of anything extraordinaryand lo become partofthe corrupt system. On y thestrong conviclion ihat right things are siill possib e

and the courage towithstand thepressures and put up with criticism helps toachieve the desired goals. These ideals should bemaintained in sp te of heavy odds in one s day today work. The besi time to slarl learning iheseatt tudes is now when one isa student allhough ii Lsneverioo late even for an older doctor The atUtudetowards friends, classmates, seniors, iunLors,

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I

and play;lhey help us to distinguish righlfrom wrong_

Values are not like static rules. They can be useo In adynamic va); in our daily practice. For example, a Londonpsychiatristwho helped to develop the values programmetells ofwhen a physician sought her advice on whethertocarry out major procedures on a patient with very poorquality of life. The psychiatrist asked, "What woutd bekindestfor the patienl?" You could never find an answer toa question like that in a textbook, but by raising theimportant value of kindness, this helped the physiciansolve his problem.

To recover awareness of such values, an approach usingIacilitaled small-group experiential learning has provedvery effective. Time is allowed for silence, reflection,medilalion, and sharing in small groups. We used the"Va ues in Healthcare", a programme developed by JFwhichfocused on three key principles: (1) "physician, heallhyself'(2) Learning through experjence (3) Rclcvance to

. Physician heal lhyself codes of medical ethicsacross the world include requirements for compelentmedical advice, confidenlia'1ir no harm or injustice to thepatrent, and working with compassion, love, sympalhyandrespecl lo human digrlity. These are seen as ourprofession's grealest assets, greater even than scjentificknowledge and technology. However, overrecent decadeslhey appear to have been sidelined in our training. Wesupportand develop the personal wellbeing ofthe doctorsratherthan focus only on improving theif clinical skills. Theprogramme raises morale and give a sense ofpurpose.

. Learning ihrough experience traditionally, formaleclures. personal study, lutoria ls and oraclicalexper'enceare !sed alongside apprenliceship learning. Litf legurdance is given for enhancing the qualities of calmnessand compassion expected ot doctors. Paradoxically, anduninlentionally, these qualities may actually be lrained outof us. lt was decided that these qualjlies could best beoxplored through direct inner experience. An approacnusing fac,lilated small-group experrenlta leafntng wasadopted. Time was allowed for silence. reflection,meditalion, and sharing in groups of two and four in asupporlive environment to encourage the discovery ofpersonal values and insights.

. Relevance to work Rapid changes in society,organizalional structures, medical and informational

technology and patients' expectations have led toaddilional burdens on healthcare professionals oflenresulting in states ofchronic tiredness and demoralization,and emotional and physical exhaustion (burnout)_ Vehave found that stress and lts consequences can beaddressed by working with certain key values 'peace',' pos i t i v i t y " , " compass ion " , " coopera l i on " , , , va lu ing

yourself' and'wellbeing laking care in practice,,.

At Global hospital in Mumbai, this type of approachhas contribuled signiflcantly to a cullure of care that isproviding a healing environmenl for staffand patients.Programmes were conducted for both the medicalandadministrative staff members giving them space tointeractand to experience and express lherr individ ualcrealrvity, uniqueness and special i t ies. In theInteraclions, we use a lechnique called appreciativeinquirywhich focuses on ascertaining the best in eachother, eliminating the common practice of criticism.With such methods, trust both in the self and othersgrows, a sense of personal empowefment increases,and the ability lo care appropriately for the selfcolleagues and palients is restored.

We have used a model of mind-/nte igence-personalitywhich controls thoughls, emotions, att tudes, feelings andjudgmenls. Anything we speak or do f irst starts in the mindas thought. These are positive, negative ano wasleihoughts. The iniel lect judges or balances the pros andcons dflven bylhoughtand it guides words and determinedactions. The key we have !sed tn practicing value basedmedicine js empowenng the mind daity by morningmeditation a 30-minute sttting n silenceand giving positivedirection to the thoughts using powers of love, napprnessand peace looking at the brighter side of every difficultsituation, and maintaining a posit ve a i tude.

Many cornptaints, conflicts and situationschallenging our values come up in real l i fe. Theempowered mind isable to handlethese diff icu l t situationswith relative carmness. contioence ano compassionlooking althesituai ion holist ical ly Dadi Janki, presidentoflhe Janki Foundation, a former nurse at 90 years ofage stillsustains herself and others so well that she is in constantoemand as a speakeraround the world.' 'Whenthe mind learns howto sustain peace, and the heartknows love and happiness, healing takes place. Thishealjng can be shared because feelings of peace andhapptness also reach others,"

''

*

I

WHYWORLD CONGRESS ON CLINICAL &PREVENTIVE CARDIOLOGY?

Prevenllve Cardiology & Cardiac Rehabllitation - The only hope to combatthe epidemic of Coronary Artery Disease (CAo)'

Dr. Satlsh Xr. GUPI,�,St Consultant Preventive Cardiology & Cardiac Rehabilitation,

JW Global Hospital & Research Centre, MountAbu, (Raj)Secretary General, WCCPC 2007 &WPCHC 2007

Pdncipal Investigator & Co-ordinator, CAD Research Project, GHRC

The theme of World Hsart Day 2007: "TEAM

UP FOR HEALTHY HEARTS"

"Preventive Cardiology represenb an inter-disciplinaryapproach to scientifically evaluate the burdon of disease

due to cardiovascular disoase (CVD), determine the

multitactorial aetiolgy ofthe various disoders and evolve

an integrated strategy to promote the requisite biological

and socialmilieu to reduce the risk of CVD to the individual

and to prevent the loss of valuable manpower and

economic resources to the community.'

Prevention is absolutely essential, if the fruits of our

development are notto be engulfgd and devoured by the

epidemic of CAD. The diagnosis and therapy of CAD is

often technology oriented and costly. lvlany of our people

will not even have access to such facilities. The loss ofyoung and productive lives, including many ofthe best and

the brightest, due to premature CAD results in a colossalloss of manpower and economic resources to the nataon

and in deep personal tragedy for the bercaved and

bu rdened families.

The lndian Ocean Tsunami killed 2.9 lac people and

received extensive media coverage. In contrast, the

TsunamiofCAD is ki l l ing4lac people every Mo months in

India alone without anycoverage in media or due attenlion

from Health authorities.

At present the country lacks a comprehensive plan for

CAD control. An urgent need ofthe future is to formulate a

national CAD control programme. Such a programme

should aim at primordial prevention of cadiovascular

diseases relaled to children, primary prevention of CAD,

hypertension diabetes and obesity through modulation of

life style and eariy diagnosis and effective management.

The national Prcgramme should also plan to provade

adequate facilities for disability limitation and rehabilitation

to improve the quality of lite.The community based preventive shategies are effective

is clear from the experience of several developedcounties, where mortality from CAD has shown a declane

over the past two decades. This has principally been due

to an altered lifestyle (in fact a retlrn to sanity), with

reduction in tobacco consumption, a healthier diet and an

emphasis on physical activity. There is no reason whyweshould notinitiate measuresto promote a healthy lifestyle,

as CAD epidemic has already become a horrendous

reality in our country. ln fact, we cannot afford to delay

efforts aimed at evolving appropriate strategies, initiating

commun i t y based campa igns and e f fec t i ve l yimplementing an enlightened public health policy thatplaces greatet value on human lives than on the vested

interests of countervailing forces like thetobacco industry.

In the long run, prevention of CAD will be more cos!

effective. in terms of both direct and indirect benefits, thanmedical management of disease that has been allowed todevelop, ltwillalso save farmore moneythan the revenue

earned by tobacco exports. What we need are policy

makers who are conscious and conscientious in their

commitment and health professionals who will constantlyfocus the attention ofthese policy makers on the priorities

ofprevention.The paramounttask ofthe medicalprofession is to project

this felt need for preventive cardiology to the policy

makers, to makethem more conscious ofthe problem and

recognize the public health policy imperatives. Forthis, aninformed consensus amongst scienlists is necessary so

that valid recommendations are evolved, dejargonizedand appropriately 'packaged' for the easy comprehensionof both the policy makers and the communityat large. Valid

scientiflc evidence needs to be transformed into powerfulpublichealth policy.This effort needs to bring iogether cardiologists,p h y s i c i a n s , p e d i a t r i c i a n s , e p i d e m i o I o g i s t s ,biostatisticians. nutritionists. behavioral scientisls andpolicy makers in common effort to make va{id

recommendations for appropriate public health action- To

motivate clinicians towards active involvement in

prcventive programmes is not an easy task because thegains of prevention are 'anonymous' unlike the clearly

ioentillable patrent whose therapy provides immense

salisfaction- The message of prevention, both at the

community level and at the level ofthe individual patient,

however reouires collective action of forces committed toprcvent CAD in India and a purposelul coalition willhaveto

be forged in order to evolve and implement appropraatepreventive slrategies.

The need of the hour is preventive cardiology:

implementialion of preventive programmes for CAD,

diabetes, hypertension and obesity.The country must gear itself up to plan and amplement sucha programme. A dedicated commitment from policy

makers, politicians, statesmen and physicians is essentialto enable ini l iat ing and implementing a NationalProgtamme for Prevention of Cardiovascular Diseases inlndia-Cardiac rehabil i tat ion- physical exercise or acomprehensive disciPline?In order to emphasise the multifactorial approach tocardiac rehabrlrtatron, it is wortr^ noling the EuropeanSociety of Cardiology definition of cardiac rehabilitation,which is:"The rehabilitation of patients with coronary hean

disease is defined as the sum of inlerventionsrequired io ensure the best possible physical,psychological and social conditions so thal patients

with chronic post-acute cardiac disease may, by theirown efforls, preserye or reserve the proper place insocietv"

The goals ot cardiac rehabilitationMedical goals

Prevention of sudden dealhDecrease in cardiac morbidity, infarction, andgraft closureRel ief of symptoms: angina, breathlessnesslncrease in work capacity

Psychological goalsRestoration of self confidenceRelief of anxiely and depressionlmproved adaPtatron to stressRestoration of enjoyable sexual actrvityRelief of anxiety and depression in padners orcarers

Socia, goarsReturn io work, if appropriateIndependence In l re act iv i fes of dai ly l iv ing inthe eldedy and in those with severelycompromised lefl veniricular functron

Health seryice goalsReduction in direct medical costsEarly discharge and early rehabilitalionFewer drugsFewer readmissions

The role of cardiac rehabilitation

Ea y mobilisation is now considered essenlialafrermyocardial infarction; the rehabilitation programmeshould begin as soon as the patient leaves the coronaryc€re unit Increasing importance is being given topsychological counselling, Iifestyle modification, stressmanagement, and exercise programmes followingmyocardial infarction Traditionally, patients with anginapeclods have not been included in rehabiliiationprogtammes, but exercise and stress control mayalleviale symptoms and reduce lhe need fordrugs Aflerangioplasty, patients are not usually enlered iniorehabililaiion programmes, but it is likely that manywould benefit Depression can be a major problem aftercoronary arlery bypass surgery and should beaddressed by a rehabilitation and/or specialisedpsychiatry team Prior to surgery for valvular heartdisease, patienls may become seriously deconditionedand benefit from a suitable postoperative exerciseprogramme Although congenital heart defecis areusually correcied in childhood, later counselling ontraining, employment, pregnancy, etc, is of great valueHea failure patients have lraditionally been consideredunsuiirable for rehabilitation programmes, but lifestylemodifrcation is important and larlored exerciseprogrammes can be of benefit

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Diabetes mell i tua -- Insulin r€sistance,hyperinsulinemia, and elevated blood glucose areassociated with atherosclerotic cardiovasculardisease. A significant number of patients with anacute l\rl have previously undiagnosed diabetes.In lhe worldwide INTERHEART study of patientsfrom 52 countries, diabetes accounted for 10percent ot the population attributable risk of a firstMl There is compelling evidonc€ of the value ofaggressive therapy of serum cholesterol (goalLDL-cholesterol <100 mg/dL [2.6 mmoul]) andhypertension in pati€nb with diabeles (goalsystolic pressure less than 131) mmHg.Hypoglycemia- - Low plasma glucose levels mayalso be associated with an increased risk; theremaythus be a U shaped relation between fastingplasma g lucose and mortalit

Obeslty- Obesity is associated wilh a number ofrisk factors for atherosclerosis, cardiovasculardisease, and cardiovascular mortality. Theseinclude hypertension, insulin resistanc€ andglucose intolerance,hypertfi glyceridemia, reduced H Dl-cholesterol,and low levels of ad jponectin.

Metabollc syndrome-Patients with theconstellalion of a bdom inal obesily, hypertension,diabetes, and dyslipidemia are considered tohave the metabolic syndrome (also called theinsulin r€sistance syndrome or syndrome X).Individuals with the metabolic syndrome have ama edly increased risk of coronary arlerydisease.Chronic kidney diaeaae - The increased@rcnary risk in patients with end-stage renaldisease has been welldescribed, but there is nowclear evidence that mild to moderate renaldysfuncljon is also associatod with a substantialincrease in CHD risk.

10. Ltfostyle factors-A diet rich in calories,safuEt€d fat. and cholest€rol contdbutos to oth6rdsk factors that predispose to coronary heartdis€ass. As noted above, weight gain promoteslho major cardiovascular risk faclors and w€ightloss improves them.ll. Exorcb6 - Exercise ot even moderate deoree

has a protective effect against coronary heartdisease and all- cause moriality. In the worldwld€INTERHEART study of pationts from 52countries, lack of regular physical activltyaccounted for 12 percent of the populatjonattributable risk of a first Ml.

12. Cigaretto smoking - Cigarette smoking is animportant and reversible risk factor for CHD. Th€incidence ofan Mlis increased six fold in womenand threelold in men who smoke at least 20cigarettes per day compared to subjectrs whonever smoked. In the worldwide INTERHEARTstudy of patients trom 52 countries, smokingaccounted for 36 percent of the populationattributable risk ot a first l\4L

13. Diet -There isgrowing evidence suggesting thatftuit and vegetable consumption is inverselyrelated to the risk ot coronary heart disease(CHD) and stroke. The worldwid€ INTERHEARTstudy of patients from 52 counhies found that lackof daily consumption of fruits and vegetablesaccounted for 14 percent of the populationattributable risk of a first Ml. High fiber intake isalso associated with a reduction in the riskofCHDand skoke com pared to low intake.

14. Psychosocial factors -There is ampleevidenceof association betlveen a number of psyohosocialtactors (including depression, anxiety, hostility,social networks and support and occupationalstress) and cardaovascular morbidity andmorlality. Adverse psychological characteristicstend to cluster with traditional biologic andbehavioral risk factors. The link betweenpsychologic stress and atherosclerosis may beboth direct, via damage of tho endothelium, andindirect, via aggravation oftradilional risk factorssuch as smokjng, hypertension, and l ipidmelabolism. Depression, anger, stress and otherfaclors have beon correlated with c€rdiovascularoutcomes. ln the worldwide INTERHEART studvof palients from 52 muntries,Psychosocial shess accounted for 28.5% of th€oooulation attributable risk of a fi rst Ml.

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PROCESS OF ATHEROSCLEROSISDr Rat n Rathod

MBBS, MD, DM (Cardiotogy)Consultant Cardiotogist, Vashi, Navi Mumbai

,. tt _is ch€racterized by intemal les|on caltedan€romas'or fibro fatty plague thal prolrude into the|gs|on,. wo?kens lhe media and undergo Series ofcompttcation3. American hearl associaiion classifiednuman annrosclerosis lesion

lntosixType IType llTypo lllType lVType l7Type I

types.- les|on- |es|on- leston- lesion- |es|on- lesion

TYPE-i,,l6sion is characlsrized by tsotat€d macropnagos andTYPE 2 {FATTY STREAKIL€sion isnot srgnifi can y raised, it is composed of tDrd tr ed roamlans wln t-Vmphocyles and extracellular lipid in small:l:Ym

F,qtty -stj_egl appea I in aorta even below one year

orageand in allChildren above 1O years ofage.

TYPE 3 (|NTERMEDIATE)

lir".r.1?ff.T6lriTaIexrrace utarripidpoors.

Lco,,1s, rsq:f_rarsed, focatptague within intima having coreor np|o and covering fibrous cap. plagues haie 3components , a) Cell component b) conne;live tissue &

::[::iJi'* matrrx c) intracerlurar & exlracellujar lipid

TYPE siesion has lipid core andfibrotic layer.

TYPE 6- lesions have haemorrhage, thrombus andruoures_

:,:.9:11n1lli:?,I*"ase rhe endorheriar perneabitity);ncrease teukocyle and rnonocyte adhesion a;demrgraron, Inside lhe inlima. lt altered the expression ofenoohe atgene product(1 CA[4 tand V CAM i)

Lipo-protein also.enters the cell vall. Monocyte which areT]9ii:11"19 the inlima fron the circutaring broodrranslerred Into macrophages and foam cells, Release ofadrvateo hclors from,platelets and macrophages migratesmooln. muscte cells from medial wa

lo iniima.Macropnag€sand smooth muscle cells engulflhe lipid andrr causes the deposilion ot lipid inside the arlerial wallmereoy causing obstruction to the arterial lumen.

(fatty do0(tatty streak)(lntermediate)(atherorna)(tibroatheroma)(complicated tesjon)

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I sLsoldode rerllerlm .reopun lol srll enssll cllolelasoleqle lo{e q}e€p llec lelpreJoû 'salqledoluolplec polellpI 10 L-rortecrJrclec eql ur luelodru! eq êul slsoldode 3tqtedotpt pue aluJaqcs qr,{ uolelcosse ulpunoli[uecorI leql lesodord eql ot p€l seq pue urnlclec !t l.lcu sslclss^ uo€q seq stsoldode 'ulalsls lelncseôlprec oql ulI xuleulo uoller.uroj aql qllM peletcosse slslsoldodP enssllI citoradsorerlle ui 'ejouLeq}rnl enssrl c0oJolcsoreqle suoqeclldt! | cqned eleqt lueculuEls aêq ̂euJI rjeunq urerlBua,\pe aqllo slloc tplngseÛad pueL!ruosp^ u./slueqaour atloldode aql lo lo4uoc snq-L suoleclloull

I esen aqt qlrM uorpunluoc ur pue suotsel cqotolcsoleqle lecloolollled seq slunoule pocnpel pue a^lssacxaI oul.ruaiuii elpour eql lo slloc elcsnur qlootrrs tlloq ulslsoldodv sensslllo uoleroua6€plo Itldore pue

I urpunoj osle sr srsoldodv slesse^ leLuJou q)li peledLloa 'SOIV ul uolleldap a coqdul^l lecuec se qcns srapJoslp

I sisolaooe 1o aruepl^; poseer.u! Moqs 'euJoleqle ol peal uea slsoldode lo uoleln6ol leLulouqv uolleln6al

I er{l Jo eroc uapeFpldlleql ^lte|cadse eur[u|eql urpaleaol ]elnllec pue luauldoleêp lo lueuoduJoa lelluesseI sa6i,toolceu., pue a;beld .llorepsoieqle eql lo uouod ue sl slsoldode suJslue6lo lelnllaclllnur ul slPublsI "'prqu te,r'tr' "ql ul po)P3ot llledrculd sllec apsnul relnlloae4xe pue 'sulxol 'o6eulep lelnllace4ur '€6eulPp

I qiooil teut u,v\otts aêq sorpnls eseql souelP cuoe vNo Gulpnlcul 'llnurqs luor€lJlp Jo requlnu e ̂q polelllul

I prre 'prtorec ,Oeuoro. cqorotcsoteqte ut stsoldode punol sl slsoldodv pe6euep ̂a^lssecxa lo luepunp3l are leqlI o,reu suerunq pue sleLulue qloq ulsolpnls eldlllnn sllec lo leôulol aql Jol 6uu olle qleop lloc jo urslueqcaulI a^|lcalas ̂lq6rq 's^0ce 'peululeloord e sl 'lse4uoc

I srsoretcsoraqle qlrM po)eraosse qleap lloc 6ululeô6 ur 'slsoldodv qleep llsc soluedLuocae leql sulelord JoI susrueqcau aql u! lseialur ol.ll ut ecue6rnso.l ueeq 6uunleuop aql pue seuelquroul lelnllocJo uoldruslp aqlI seu areql s rsoldode lo suisru eqa€uJ oqllo 6utpuelgopun 'lle. aqt lo uollsoBlp cleLulzue aql uo4 6urllnsel se6ueqcI raqlnl a,.]l l.t]r^\ 'lluecer erov\l slloc oseql lo q]eop €ql lect6oloqdrour io a6uel e ol srejer srsorceN ̂boloqdloLll| trq perolol anleld eql urr.llr/v\ sltac lo uorleclldel lo sseaold pue ltlsrLueqcotq 'slue^€ ]o ecuenbes 'uJslueLlceul JoI e se srsorelcsoreqle paqucsep Moqclrn uoLl/l^ '8981 sural u I pouuep ueeq aêq 'slsoldod e pu e slsoJc€ u qleopI arurs ulroul ueeq seq srsorolcsoJeqle urssollloc llsc lo stlroi lalrlsrp z'sapEcop e )sed eql !l

| :saseaslo fuEuoJo3 ul slsoldodv uoD.nporlulII saseosrp oseqllo uorss€roold aqleleln6ar eseeslpfueuorot slsouelselI ot/qltrqe pue 6urpuplsrapun rnorequnl ̂lalll lllM geploslp slsorolcsoleqle qleap llac slsoldode :sproM ôyI eseql ur srsoldoc,e pue qw\or6 retnllec Jo 6urpuelslepunI lcerj jq1 :ernlre1 ueaq pue suorlcrelur lelpteoor(ru esees lp fuoue Ireuoloc

I orlpntcui-'.'.oieicsoreqle fueuoroa u.Lorl dolerap ,o slssua6oqled aw ul elol alqlssod sl pue 'uo[eln6o1

I r",ii sarbrpu,t. Jo 16olorslqdoqled oql u! pe'"crldL,,r sll'slsoldodelo uollcolep eql6urpre6or slulod '(eI ̂\erârI ,reiq ""q slsol'dode ,{lleuo0lppv srso.lolcsolarlle ol sl olcpe slql }o Lllle oql slsoldode llqlqulleur src}'e,I p,(6bplslqaol.tteo eql ul alor e ̂eld ,4eu srsoldode )eql 6uqclrsuocose^ seeleqM 'slsoldode ocnpul ̂eul sJolcejI qso66ns srsotdod e p6seel.u!tllt/l^ eluraloJolseloqcrediq 6ullellpose^ :slsoldode llec elosnu qlooLlls lPlncseÎ pue uorsuelred,4q srol.pJ lslr relnosPô!p./ec aleln6el osle ll ulsuololOue pue aplxo cu)!u se WnsI iq p uo0e'co."" eq1 lnq 'u,lroulun lo^ se sl eseeslp socuelsqns e^0ceosen slsoldodejo srslleuJ cllouebpueI ,tiuo:oc tb ,tootots,tqdoqled aql ur srsoldode lo alol laPxe le3luraqcolq uleseepul uelq peluedulocce'^qledolrale

I oqt slsoidod" saseercui qsruo6elue roldecer ullaqlopuo lueldsuer pue 'slsouslsar 'slsolelcsoleqle fueuoloc

| ,tq |'-uneqlopue lo uotlqlqul elouroql]ni slsoldode ul peruesqo ua€q seq slsoldode lo acuoplâ aluoleuvI rrec i"'ri,loora pue edinur qlooLus Jelnaael olelnoel sseoslp clloJepsoleqle ̂leuoloc Jo i6ololsfqdoqled

I ;i uisier6ror" pue 'urpqlopua aplxo culru se qcns eql ul alo.l e IPld leur slsoldode teql lsa66nsI itsorotoior"qt" irl pe.,elle erB terlt slolelpeu s^lpeosel eleo slsolcau Llorl lcullslp pue palelnoel llaleclllulI ',( euotltppv snssr) cllotelcsolaqle ul slsoldode slleql qleep llac lo llllol eûce ue s! slsolooov| 1o oeryeuj relncelou, lo uorssardxo poseolcur sql :l5e45qv

I 90699 N}\t lel$qcou MS lS ls./ll O0Z slullC oêr,l!

'seseasro retmseôrpre3 pue sutctpe$l leuralul to lueqredeo 'oyt{ uPuirs l rrurv o} aru€puodsarroCII uuln latseLt.ou uoltepunol oiel'{ pue.lu!|3 oêy{ '( s c U) I6ololE reln.€loy'{I pue tulilu:ertco!8 Jo lueuJl]edeo oql pue ( l V !f 'H U O -S S U 'S9 "H O Er\lld)I seseasro .ietncseôlprec puP autcrpoll Purslul,o lueu{iedeo aql luorlI

I ueuret rurv:ueurs o usqou rfI sau,|toH U prêo l4re \LtcS Suaqo! ll6ro!6ues addasnre:lepseH p!êo lseE'W r elculed

I aseaslq ftauv fueuoloC u! suolleslldurl pue gdoJuoC olsegI stsordodv I

L-

A HEART ATTACK IS NOT A DEATH SENTENCEI- Dr. A3hok S6th

FRCP(LOND), FRCP(EDIN), FRCP(IREL), FACC, FSCAI, Dsc (HoNoRls CAUSA),AWARDED'PADMA SHRT

Prssidenl, Caddological Society of India-Delhi Branch

Dr€ssure, diabetos, sedentary lifestyle, obesity, familyhlsbry of the problem, stress and smoking whichdamages thg lining ofthe arteries, promotesthe clotting of

A heart attack is a feared' disease,which often strikes without awarning and leaves dreadfulconsequences - both physical and

. However. a heart attack does not have toa dealh sentence. lt can be the beginning ofa new and

more productive lite if unhealthy lifestyle practicesbe substituted with healthier ones along with the

of a oositive attitude towards life.

A heart attack occurs when a clot in a coronaryblocks the supply of blood and oxygen to an area of

heai muscle. While it seems to occur suddenlv andwihout waming, the process underlying the event

been probably going on for many years. /l occursa clot in a coronary aftery blocks the supply ot blood

oxJ4qgn to an area ofthe heart muscle- The scientificfor a heart attack is "Myocard ial Infarction myocard ial

Rehabilitalion (More ca n he put ln ifyou want.,.)Recovery begins only 48 hours afier a h€art

attack. Within a fewdays, the tissues of the heart begin toheal and, if there are no complications, you may bedischargedfrom hospital afrer five to seven days.

As the weeks pass, the damaged muscle isreplaced by scartissue. During this period, one should becarefu | to increase physical activity levels only gradually.

Exercise helps to speed recovery. A gradualincrease in exercise helps the heart to get back in shapeand adapttoany scars left behind. ltalso improves generalwellbeing and encourages good quality and regularsleep.It helps test out the heart so the patientand doctor becomeaware of any residual problems, such as angina orbreathlessness.

In uncomplicated cases, you should be back toyour normal routine after4-6 weeks.

Exactlywhen you return to work depends on yourjob and howserious the heartattackwas- Take it in stagesand rest when you feel tired- Some physically strenuouswork may be avoided in the immediate post-recoveryperiod.

Avoid long journeys and stressful drivingsituations, suchas in a cityorin the rush hour, foratleast4

Many people wory that sexual activity may be tooskenuous after a heart attack. But research shows thesefears are generally unfounded. Like all exercise, take atslowly atfirst, especially for lhe first4 weeks

In order to eliminate the risk of repeated attacks,one has to stick to the medication prescribed by thetreating cardiologist and bring meaningfuland committedchanges in one's lifestyle.

Making healthy lifestyle choices would includetaking care of the major risk factors, which lead to heartproblems. These include:

. Familyhistory

. Diet- balanced meal, whatwe eatand adherencetomealt imings

The factors that mav lead to a heart attack includedeposition in the artery wall, high blood

,lowerc the levelof "good' cholesterol in the blood,spurs thecontractions ofthe blood vessels, tending tolhom closed-

Afrer a hearl attiack we have noticed two broadSome Deopl€ learn to value lile more, while

olhers develop an ongoing fear of another attack. lta iact. that about ten ogr cent of those who have a heart

will expeience another one within a year. This risk,gddua y dtops to thrce to four per cent, every

.../ttts saatbtic needs fo be confined)

In order to prevent a second heart attack, someIng heart centers prescribe a rehabil i tat ion

which includes making changes in one's lifeAl Max, Heartand Vascular Institute, New Delhiwerohabilitration guidance, which not only treats the

medically, but tiakes care of both - the mind andsince lhey arc, afterall, one. I really believe in that it

€qually important to know who the patient is and whathlmtick ratherthan what justwhatthedisease is. In

it i6 a well-established fact that 50 percenl ofcardiacst6m lrom physiological reasons and 50 percent

d8€where, includ ing the mind.

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sse4s .

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'loqocle'seDerP6rc 6e ssnqe ecuqsqns ûv .

algrl for signs of an impending heaat attack, such as aheart or shortness of breath. The trouble is, these

also normal responses to physical activity or stress

Some people with heart-related PTSD go to greatlo avoid these reminders theystopclimbing stairs,love, or doing other activities that make the heart

faster Some also stop taking medications that remindofthe h€art attack.

counselling has an impottant lol€ tohero. Treating PTSD starts wiih talk th€rapy thatio help a pqlson come to t€lms with a lraumatic

by coniuring up memodes ol it in a safe. Reconnecting with p6ople, interests, andalso helps is anothergoal oftherapy.

Depression affects one infour people afrer a heartItis lt's criticalto address anydepression you may

sufiedng - it won't just go away on its own and it canit more difficult harder for you to make any

lifestyle changes orfollow the treating doctol'sadvice. on particular treatments. Without specific help,trcse who become depressed don't recover as well as0rcymight. Some mayothelwise- Some such patientsalso

boneit from anti-depressa nts.

Anxiety about leading a "normal" life, afrer anailack is also an importantconcem ofpatients.

lf you lake part in a cardiac rehabilitation prcgramme,

$ey'llbe able to ofiertreatments ranging from medicationlo group therapy and stress management (stress andanger may conhibute to a hea( attack by produclngdlanges in they our body that increase the your risk forbloodclots).

Have taken it from a websib, can be modlfted it

lhought aPproprtateManagement Plan Posl heart attack

- Angioplasty, surgery orjust medication: The fact

that someone has had a heart attack is no

absolute indication thatthey rcquire one ofthese

invasive therapies (called'levascularizataon

Procedures").Some factors that favot the need and benefit of a

revascuIaization prccedurc include.. The continued recurrence of chesl pain afterthe

heart attack has initially "completed".

. Evidence that there is slill muscle in the

distribution ofthediseased artery, which is at risk

of dying if the vessel, should totally occlude

again. That is, it is suspecled thal although the

artery did close at the time ofthe heart attack, it

reopened enough to let some blood through and"salvage" someofthe muscle in its distribulion.

. Moderate, but not minimal or huge amounts of

muscledamage.. The vessel causing ihe heart aftack berng large

with more than minorbutlessthan total blockage.Some factors, which would tend to favor a "less

aggressive" approach (thal is, lreatwith medicine

alone)include:Atotal lyblockedvessel. Quitesimply,ihisvesselcannot get any worse.A 100% blockage is less of

athreat in mostcases than thosethatare blocked

from 90-99o/d, whichhavea high. Incidence of, repeat closure and another heart

attack.. Ablockage ofless than 50-70%.. Vessels where there is a lot of blockage, but

where it appears that all of the damage has

akeady been done. For example, if all of the

muscle in the distribution of an artery has died,

there is noneed to bypassthatvessel, since itwill

only supply a scar. Remember, it is the muscle

that's important-the only pointotan artery is as

aconduittothatmuscle.It is also not unusual to find out that other heart

arteries have blockage, and this will also

influence whether bypass or balloon procedures

arerequrred,

Symptoms of a heaat attack

Tha classic symptoms of a heaft attack include:

Pain in the chest. neck, iaws, back, shoulders, orams. The pain may be severe, or moderate in intensity.Ths pain may be described as "crushing", "heavy" or'pfessurelike", These same sensations c€n occlr in theolher locations just mentioned.

This pain can be accompanied with intense sweating,akeysignthata heartattack is occuning.

Shortness of breath, nausea, or vomiting are also@mmon.

There is, often, a distinct feeling that something isrcally wrong. The pain does not always involve the leftarm. lt could be the right or both or no pain in the arms ata .

olrt se{leurouqe altoFelp 'ssocold cluraqcslro uolsua}xe lo sesnec loqlo lElaês aq uea eleql leôaloull

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reversible restrictive physiology, development of a ny othernew complicaiion etc. (b) recurrence of chest painfew

common clinical situations encountered ate reocclusion ofinfarct related artery ischemia at a distance, developmentofpericardilis, any other non-ischemic cause ofchest pain(c)newmurmursduring hospital ization (d) restr ict ivefi l l ingpattem seen in first echo which reflects increased LVfillingpressure, and echo can be a guide to plognosis andmanagement (e) first echo done within 24 hours ofadmission and the second echo usually delermines theprogress of the patienl.

Assessment of complicalions: The variouscomplications of AMI can be readily diagnosed bytransthoracicecho. These include LV systolicdysfunction,LV aneurysm/thrombus, pericarditis, myocardial rupture,acute [,4R, concomitant RV dysfunction etc. Only aminority may need lra nsesophagea I echo. For the varrouscomplications, no hemodynamic confirmation is needed,as a well performed echo provides complele information.

Post AMI risk stratification/prognosis: This isan important goal in Al\,'ll because it has a bearing on themanagement strategies. The various complicationsmentioned earlier are not included. Few predictors ofguarded prognosis, as assessed by echo, are as follows,only some ol which would be highlighled: (a) degree ofwallmotion abnormalily and hencethe systolic f! nctio n (b)infafct extension (c) infarct expansion and degree of LVdilatation (d)more than mild va lvu lar reg urg itation (e) rightventrcular function (f) LA volume. In lhe lasi couple otyears lhe prognoslic value of RV dysfunction in cases ofAMI wiih LV dystunction has been reaLized. In a study of4'16 patients of Al\41 with LV ejection fraction of <40%, 79patienls were found to have RV dysfunction. The overallcardac evenis including dealh, heart fai lure was muchhigher in patients with RV dysfunction. As such RVevaluation should now be routinely performed in AI\,llespecially those with LV dysfunction . Doppler diagnosticvarlables.- n recent years,some of the Doppler var ab eshave emerged as important adverse prognosiic indicators.Some ol thern include: (1) N,'litral valve Doppler flowpatternr The mrtral deceleration time, which indirectyreflects LA and LV pressure re ationship, of less than 140msec. predicls an adverse prognosis (2) Pulmonary veindiasto ic deceleration l ime of ess than 160 msec. has anadverse prognoslic sens tivity and specificity of 97% and9670 respectively (3)Tissue Doppler lmaging (TDl)r TDIvelocities, recorded at various annu arsites reflectglobal

and regional systolic and diastolic functions in both

longitudinal and radial axis. A systolic and early diastolic

velocities of <3.0 cms/sec. and a late diastolic velocity of<4.0 cms/sec. carries a very poor prognosis (4) Velocaty

rat ios:The rat io of mi lral Doppler 'E' veloci ty and TDlearly

diastolic velocily of >15 indicates an increased LVEDP As

such, allthe above Dop ple r varia bles should be an integralpart of al lAMl siudies. LAvolume' l t has been shown that

an increased LA volume ( > 32 ml/m.sq) determined

echocardiographically within first 48 hours of acute Ml

carries a guarded prognosis with increased 1 and 5 year

mortality rate. These patients also have increased

incidence of moderaie to severe MR, cardiogenic shock

and increased LV systolic volumes.

Pre-discharge stress echocardiography: This

appears to be less popular iesi now with the widespread

use of coronary angiography and early intervention.

However the lmportance of thrs test lies in the fact that

short term event rates, lonq term mortalty, re infarction

rates, and overallcardiac events are much more In those

with a positive stress echo in comparison with those with a

negat ivetest(81%vs.18"/o) Usual lya dobutam ne echo ispreferred as the test can be controlled and continuous

echomoni lor ing isposs ble. Oneofthema n indicat ionsof

low dose dobutamrne echo rs to dernonsirate myocardial

viabillty. This group of patients have excellent prognosis

fol lowng revascular izat ion father than medica therapy

which carr iesan adverse prognos s.

Echocardiography lor guiding therapy: Echo can p ay

a significant role n assess ng the effectveness and/or

change in therapy based on cl in ical status, complcal ions

and specif ic Doppler f indings These include (a)

assessment of LV dyslunct on or degree of LV expansionguides treatment with ACE inhibilors (b) pers stent LV

dysfunct ion wth viabl l i ty wi l need revascular izat ionprocedure (c)Doppler paramelers of reversible restr ctivephysiology helps in guid ng therapy with d uret ics and

inotropes (d) occasiona pat ients cont inue to be

h y p o t e n s i v e d e s p i t e t r e a l m e n t w t h d o p a m r n e

/dobuiamine whose doses may be unnecessari ly

increased to get a desired effect but paradoxically leadsto

moreworsening.

Echo demonstrates that these patients develop

significant LVOT gradients due io dopamine exacerbated

dynamic LVOT narrow ng. As such il is withdrawal of ihese

drugs and subst i tut ing with vasodi lators which leads lo

69

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ROLE OF ECHOCARDIOGRAPHY IN EVALUATION OF AHYPERTENSIVE PATIENT

Ravi R Kasliwal, Manish BansalDirector, Echocardiography, ESCORTS Hospital, New Delhi

Hypertension is a widely prevalent health problem and isassociated with considerable morbidity, mortality as wellas tremendous economic burden on the health caresystem. The adverse outcomes associated withhypedension result mainly from its deleterious effects onvarious organ systems in the body, notably thecardiovascularsystem, baain and the kidneys. Detection ofiarget organ damage therefore has considerablediagnostic, prcgnostic and therapeutic significance in theevaluation of hypertensive patients. Echocardiographybeing easily available, relatively inexpensive, safe andveBatile is widely used for this purpose and providesvaluable information about various cardiovascular effectsofhypertension.

Role of echoca rdiog rap hy in evalualion ofhypertensive patients

Deteclion of Ieft ventricular hypertrcphy (LVH)Presence of LVH is known to confer 1.5_3.5 times

incrcased sk ofadverse events in hypedensive subjects.The predominant pathophysiological drsturbance seen inLVH is diastolic dysfu nction which manifests as exertionaldyspnea, heart failure and an increased risk of atrialanh!.lhmias. In addition, LVH also causes impairment ofcoronary flow reserve whach, in association withconcomitant atherosclerotic diseases, may result in bothsyslolic and diastolic dysfunction ofthe left ventricle. Notsurprisingly, regression of LVH with therapy has beenshownioresull in benefltin both short-term and long{ermoutcome in these patients.

Echocardiography is a sensrtive and accuratetechnique for detection ol LVH. Using echocardiography,LVH can be found in nearly 30% patients withhypeftension whereas ECG can detect it in only 5%palienis. The prevalence ofLVH is much higher in patienlswith severe HTwith almost 90% of them having evidenceof LVH on echocardiogram.

Echocardiographic detection of LVH is based oncalculaton of LV mass-index. LV mass-index >95 9/m'inwomen and >'115 g/mr in men are indicative of presence ofLVH. The American Society of Echocafdiographyrecommends the following formula for calculation of LVmass-

LV mass =0.8 X{1.o4[(LVtDd + pWTd + SWTdf -(LVlOd):D+ 0.6 g, -where PWTd, SWTd and LVIDd areoosterior wall lhickness, septal wall thickness and LVintemal dimension measured at end diastole, respectively.These linear measurements ca n be made directlyfrom 2Dimages or using 2D{argeted l\,4-mode echocardiography

in the parasternal long-axis view

Apartfromjust the presence of LVH, the pattern ofhypertrophy also influences the prognosis. The risk ishighest in patients with concentric hypertrophy, less ineccenkic hypertrophy and the least in concentricremodeling. The distinction between the different pattemsof LVH is based on LV mass index and relative wallthickness (2PWTd/ LVIDd) (ngure 1)-Detection of LVH by echocardiography helps in confirmingthe diagnosis of hypertension, guiding selection of anti_hypertensive agents and in monitoring response lotreatmenl. Although blood pressure reduction is the mostimportant factor involved in regression of LVH,independent effects of various drugs also play animpodant role. Angiotensin converting enzyme inhibitors,angiotensin receptor blockers and calcium channelblockers have been shown to be more effective than othefanli-hypenensive agents.n induc'ng I VH regression

Diastolic dysfunctionDiastolic dysfunction is present in over 1/3'"

patients with hypertension and is a common cause forshortness of breath in these paiients. Echocardiography isconsidered to be the most preferred technique forassessment ofdiastolic function in ihe clin ica I practice. Onthe basis of mitral inflow pattern, pulmonary vein flowpattern and miiral annular tssue velocity, diastolicdysfunction can be categorized into impaired relaxation,pseudonormal pattern and restrlctive pattern. lmpairedrelaxation is the commonest torm of diastolic dysfunctionassociated with hyperlension. Restrictive patlern, on theother hand, is uncommon in hypertension in absence ofother concomitant pathologies. However, when present,restrictive pattern is associated with worse outcome.

Leftat al sizeSince lefi atrium (LA) is exposed to LV pressure

during diastole, any increase in LV pressure results inconcomitant rise in LA pressule and subsequently LAsize.LA size is therefore considered to be'the HbAIC of LVdiastolic function'. Numerous siudies have demonstratedstrong association between LAsizeand the riskofadverseca rd iovascu la r ou tcomes in d i ve rse popu la t i onsubgroups.

Echocardiographically the LA volumes arc bestcalculated using either an ellipsoid model or Simpson'srule. The biplane area-length method whi6h is based onlhe ellipsoid model is the preferred method for thispurpose. LA volume by this method is calculated as-LAvolume= B (A1) (A2)/3 (L), where A'l and A2 reprcsent themaximal planimetered LA area acquircd from the apical4-and 2-chamber views, respectively, and L is length. The

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TOTAL ARTERIAL REVASCUALARIZATION OF THE HEARTUSING BILATERAL INTERNAL THORACIC ARTERY GRAFTS

DR. SUDANSHU AHATTACHARYYA, I\,4S. IVCH, FIACTSDR. C. S. HIREMATHDNB, MCH

INTRODUCTION joined to the Ll[4A pedicle over lhe antero-lateral surfaceThe ultimate achievemenl in of Lll\,4A with an oblique incision and made as a 'Y ' graft

coronary artery bypass surgery is to using 8-0 monofilament suture. The ITA is dilated byhave all patienls undergoing the spraying 1;20 papaverine saline solution on the lumen ofoperation survive free from coronary

events, angina & reoperations for as long as possible.Knowing that the greatesl cause offailure ofthe operationis obstruction or occlusion of the vein bypass grafts, 60%ol lhese vein grafts close by 10 years which results fromintimal hyperplasia or atherosclerosis. Selection of anidealbypass graft that remains free ofobstruction appears1o be one of the most important factors in achieving thisgoal.

The internaltho€cic artery (lTA) is an aimost ideal& dynamic bypass conduii. lt has been shown to remainrelatively free from intimal hyperplasia & atherosclerosis,and from obstruction caused by spasm. lt has the potentiallo meet lhe increased demand ofblood flow & grow in sizewith t me. Another advantage of the ITA is that only oneincrsion is required, thereby avoiding the discomfort &polential complications of addit ional incisions Sincebypassing lhe left anteriof descending ai(ery (LAD) withLefl inlernal thoracc artery (LITA ) ncreases 1o-yearsurvival, bypassing more, or preferably al, d seasedcoronary arleries wiih TA grafts may extend longevity,minimize coronary events, & reduce lhe need forreoperation.

In most cases, patients with three-vesse!coronary artery disease can be operated by tota aateriarevascu arzation with TA grafts using the Y grafttechnique lo al l the coronary arteres even in enlargedhearls by us ng the tandem/sequent al techn que.OPERATIVE PROGEDURE

The heart is exposed through a medianslenotomy. The right & left pleural spaces are entered &the ITA'S are examined foradequacy of pulse. High powermagnfical ion is used for dissecton, preparation &

Dlssection of Lll\.4A & RIMAi Chest walL isretracled wilh a mammary retractor,left iniernalmamrnaryai(ery is dissected and it s used as a pedice graft & isenglhened by excising iis surround ng muscles, fat ,fasca & semi-skeletonizing il. Arteria & venousbranches are secured with hemostalc cllps.The ITA isexamined for adequacy oi pulse, s ze, injury, dissection &the presence of alherosclerosis.

The Right internal mammary artery (RIMA) isdissected similarly; way near the thoracic inlet it isdissected free from the thymus gland to increase theavalable ength. RIN4A is taken out as a free grafi and

the conduit and inspected for adventitial haematoma ordissect ion.

Forthe lasl S years we have been using Octopusasa stabi l iz ing devicewith lessthan 1% conversion rate toon pump surgery. However if the patient is unstable ournext choice is to do a beatng head surgery with aintroduct ion ofan Inlra aort ic bal lon pump (IABP).

The Ll[,4A ls used lo bypass the anterior vesselsmostly the diagonals and left anterior descending artery(LAD) in a sequent ial manner, & the RIMA is used lo graftthe obluse margrna s & the posterior descending arteriesin a sequent ial manner using 7-0 monofi ament suture.

Whenever the disease is difluse we make nohesitation in doing an endartereciomy on a beating heart.Many Redo surgeries have been done by lhe sameprocedure as well. Whenever LIMA is patent from theear ier surgery, Rll\,lA is taken out as a free graft &jo ned toLlf ,4A(old graft)&convededtoLlMA RINrA'Y' graft .

ln the last 14 years we have operaled more than7500 cases Excelleni resu ls have been obtained wilhtotal arterial grafls w th a very few requiring repeat surgery.From the year 1999 onwards we are operatng on abeal ing heart and before that cases were done on pump

We advocate lhis surgery even n fema es,overweight & diabetes mel l tus pal enls. ln clos!re of thesternum we use 2-3 slernal bands & feel that a propermmob lzalon of the sternum is of utmost mportance toavoid postoperal ve sternaldeh scence.

There is no stat ist ical d f ference in infect ions neither diabetes or non-diabetes rne i tus pal ients.CONCLUSION

Totai arter]a revascularization with lhe lTAs, themosi dealbypasss graf l , has the potent ia to signi fcant lyncrease long terrn event free survival & dramaUcal lyreduce the need for reoperaton in pal enls with three-vessel dsease The procedure can be performed withacceptable mortal i ty in patents of al l ages, males &females, d abetes me l i lus , non diabetes mel l tus, obesepat ents & includ ng those with poor veniricles or left ma ndisease & even in some pat ents requir ing re operat ion.Dedicat ion to impeccable precsion of technique in thepreparation & anastomos s of ITA grafts is paramounl tothe success ofthis procedure.

It is always recommended to the Cardrovascularsurgeon with extensive experience & interest in ITAgrafting.

"HEALTHY HEART : lN A HOLISTIC WAY"(PREVENTIVE CARDIOLOGY IS THE ONLY HOPE IN THE FUTURE)

RELEASED ON THE OCCASION OF WORLD HEART DAYDr H. K. choora

Chief Cardiologist, lvloolchand MedcityOrganising Chairman, WCCPC & WPCHC 2007

Mce President, CSI Delhi BranchSecrelary General, lMSAWorld HQ

The prevalence ol coronary artery disease isrising rather steeply in ourcountry, in general, and Delhi, inparticular. Cardiovascular Disease (CVO) is assumrngepidemic proportions in India. To a very large extent, heartattack is selt-inficted by ourfaulty lifestyle, whichweadoptright from the childhood. The prevalence of coronaryArtery Dlsease in adults was 1% in 1960, l l% in 2003,'14% in 2007 in India in the urban population, CAD isfour times higher in Indian in all age groups. To be anIndian is itself a risk factor for premature CAD. Risk forCAD is twenty times higherthan Japanese. CAD is moreextensive, more difuse and multivessel and morepremature in Indians as compared to its counterparts inWeslem and European Wodd. cVD mortality isdecreasedby60% in Japan and Finland, by 50o/o inAustralia, Canadaand USA and by 25% in Europe. According to wHoProjections there will be 100% rise in mortality from CAD inIndia by year 2015 if drastic step for lifestyle optimizationare undertaken. Rapid urbanization, globalization,induskialization and health hansition are the main factorsfor preftature CAD in our country. Dr. Dudley WhiteJohnson, from San Francisco once said, Tnybody getl,nga heaft aftack below the age of 80, it is his or her own fauft;after the age of 80, ]t is God's w///'. one should not haveheart attack in the prime of his/her life when he/she isimportant notonly to thefamily, butalsotothe community,society and nation. In fact, we are the cause and we arethe cure ofthis malady of CoronaryArtery Disease by thelifestyle we have, which should be in accordance with thelaws ofnature. Ahealthy heart is an expression ofourownperception, thoughts, interpretations and choice making.Thus, a healthy heart is not a matter of chance, bul it is amatter of choice. We should know lhe fact lhat wisdom iswhatwe are, and notwhatwe have, Women arefortunateto have lower prevalence of coronary artery diseasebefore the age of 45 i.e. menopause. Afrer menopause,the prevalence of CAD is same as men. over 25 Lacpeople dle of Heart Attack in our counlry every year.Out ofthese, l6lac die wilhin an hour of HeartAttackbefore eventhe medical aid is available.

Whatis Heart?

Heartis a holloworgan ofthe size ofa fist, situatedin the center of tho chest behind the breastbone. lt beats

60-80 times/minute and almost one lac times in a day andpumps about 5 liters of blood/minute lo different parts ofthe body including brain, kidney, lungs and other tissues.Infact it works likea double pump. The rightcellofthe heartpumps blood into the lungs where it is filled with oxygenand the left side ofthe heart plmps this oxygen rich bloodthroughoutthe body providing oxygen to 60 trillion cells inhuman beings. lt has four cham bers named as right ahiumand left atrilm, right ventricle and lefl ventricle. The bloodejected from the left side of the heart from left ventriclegoes lo different organs and tassue ofthe body through themajor artery ofthe heart called as aorta and its branches.The blood from the lefr side of the heart is purified andoxygenated while the blood from the right side ofthe heartfrom the right ventricle goes to the lung and is not purifiedand is deoxygenaied and geis purified in the lung beforegoing into left atrium lhrough pulmonary veins. The rightatrium ofthe hearl receives deoxygenated blood from theveins, which drain into two major veins called as inferiorvenacava, and superior venacava, which opens inlo rightatr ium. The heari hasfo!rvaives named as (a)mitralvalvehastwo leafletsand is situated between lhe lef( atrium andlefl venidde (b)aortic vave has three leafleis and issituated between the left ventricle and aorta (c)lricuspidvalve has three leaflets and is situated between rightakium and right ventricle d)pulmonary valve has threeleaflets and is situaled beh,veen right ventricle andpulmonary artery. Heart has two major arteres namelyrightcoronary adery (RCA)and left coronary artery (LCA).They arise from aorta and supples blood to ihe hearimuscle. The two major branchesof eftcoronaryartery arenamed as left anterior descending a.tery (LAD) andcircumflex artery (CX). Eesides these there are manybranches of right coronary artery, LAD and CX. Heart hasits own physiological pacemaker, the electrical impulsesoriginate from SA node (Sinoatr al node), this node is the"heart 's brain"which isihe cenierand sources ofi ts neuralenergy and then propagatestoAV node (Aterio ventricularnode)and then propagates to r ightand left bundle and theoerkinie fibers etc. like a bank cashier the heart handlesvast sum and earns relative y a very srnall salary for itssurvival.

The survival of the heari and the life of its ownerdepend on the patency of these coronary arteries.According to Ayurvedic teaching healthy human body is

like freely flowing river. Whenever there is slagnation ofblood flow what we call as stasis then the heallhycirculalion is replaced by accumulation what we call asatherosclerosis (hardening of the arteries with plaqueformation, ulceralion leading to plaque rupturc andlhrombus formation leading to angina (heart pain)orheartatlack.

Whalarethe Risk Factors for HeartAttack?

The maior risk factors responsible for heartallack 6an be classified as modifiable and non-modiliable. The modifiable riskfactors are smoking, highcholesterol, unmanaged negative skess, obesity centralobesity (pot-belly), lack of physical activity, faulty diet,uncontrolled high blood pressure, unconkolled diabetes,excessive homocysteine levels inthe blood, etc. Thenon-modifiable risk factors, on the other hand, are advancingage, male sex, post-menopause state in women and astrong family history of Coronary Artery Disease in thetirst-degree blood relatives of lhe person.

Tobacco, in any form, chewable or non-chewable, such as cigarette, bidi, hookah, cigars andpassave smoking are equally injurious, and are majorpredisposing factors for a premature heart attack andsudden dealh. Smoking, by virtue of various chemicalssuch as nicotine, carbon monoxide and various otherchemicals, narrows the coronary arteries, lherebyreducingthe blood flow to the heart muscle. This hardensthe coronary arteries and oxidizes the cholesterol LowDensity Lipoprotein (LDL Bad Cholesterol). lt alsoincreaseslhe stickiness of the blood by increasing plateletaggregation and adhesiveness, thus increasing clotformation. CoronaryArtery Disease has been seen in 80percent of smokers.

Today, if we smoke cigarcftes, then tomonovctgarcttes will snoke us. Today, if we chew tobacco, thentomorowtobacco will chew us. lfwe really want to bypassthe bypass suryery tobacco ctops should be replaced byvegekble crops. We can haltthe menace oI head attackbyeradicating the habil of lobacco consumption from oursociety. From mind body perspective smoking is vatarelated activity and use smoking as an attempt to reduceanxietyorshess.

Elevated levels of total cholesterol, LDL (BadCholesterol) and triglycerides are associated wilhhigh risk of premature Coronary Artery Disease. Thenskas especially high when elevated Aiglyceride levels aremore than 150 mg%, cholesterol levels of more than 150mg%, high LDL (Low Density Lipoprotein) of more than 70mg% and low HDL (High Density Lipoprotein GoodCholeslerol) of less than 40 mg% in males and less than

50 mg% in females. Oxidation of LDL cholesterol is alsoone of the crux of premature hardening of coronaryarteries- Total cholesterol and high density cholesterolratao of more than 4.5 is a powerful predictor of CoronaryArtery Disease. Doctor Larry She|witz ofthe L,niversity oICalifomia at San Francisco has shown in a sludy MultipleRisk Factor Intervention Trial, that men aged 35-57 withcholesterolcounts over 300 over more than four times aslikely to die from coronary head disease as compared lomen wjlh the cholesterol levels of less than 180 mg%. lthas been documented in one of the studies done inFinland, where the heart attack fales are highest amongstthe people in the world. lt is due to their faulty lifestyle.Remain cholesterol fit, if you really wanl to preventCoronaryArtery Disease.

Behavioral patlerns, including negativeemotions such as aggression, competitiveness,hostility, jealousy, anger, cynicism and othernegativeemotions multiply the risk ofCoronary Artery Oiseaseby manyfolds. Acute unma11ageable negative emotionalstress can precipilate plaque rupture in coronary arteriesdue to sudden release of catecholamines, which maycause a massive heart attack. Our thoughls have alremendous influence on the health of our heari.Tranquility of mind and positive emotions such aslove, compassion, humility, harmony, peace, altruismand magnanimity can prevent Coronary ArteryDisease. Yoga and Primordial Sound Meditation alsoplay a tremendous role in preventing CoronaryArleryDisease.

Mind Body concept and Heartattack

According to Mind Body conceptwe existon manylevels such as physical, mental, emotional and spiritual.Positively based lifestyle changes have a positiveinfluence on the health ofthe heart. N,lind body medicineteaches us that the healthy heart is an expression ofdynamic slream of intelligence and the consciousnessgive rise to lhis reality. By changing your perception in thepresence you can change your life for tomorrow. You catn

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Cent ra l obes i t y (po t -be y ) has beendocumented as one of lhe risk factors for prematureCoronaryArteryDisease. Ain hospitaldata(MN4MSStudy2007) published in Indian Heart Journal by choprahketal2007 showed that prevalence of metabolic syndrome is65% and it is 70% in females and 60% in males. CentralObesity or Pot-Belly is the most powerful predictor ofmelabolic syndrome with highest prevalence belween theageof40-60 yrs ofage. Apot belly more than 36 inches inmale and 32 inches in females increases the vulnerabilityfor premalure coronary artery disease (heart attack andsLoke(paralysisbymanyfolds). ' .Longerthewais ine,shorterthe lifeline and vice-versa,,, l\,,lorbid obesity is ahigher risk for many illnesses such as heart attack,hypertension, diabetes, cancer etc. pedect weightmanagemenl may hall the menace of morbid obesity byregular exercise, yoga, dieting and meditation and mindbody balance strategies.

Physica I inactivity lack of exercise is also one oflhe sk factors for CoronaryArtery Disease. lthasbeendocumented in one of the studies in U.K that the incidenceof Coronary Arlery Disease is higher in postmasters thanjn postalclerks, and it is higher in bus drivers than in busconduclors. Reg u lar physical exercise. especially aerobicexercEes such as walking, wogging, jogging, cycling,swimming, dancing and skiing, increases the myocardialefliciency, €duces blood pressufe, imptoves caroracoulpul, decreases peripheral vascular resislance andproduces new collateral vessels (natural bypass), lhushelp in bypassing the bypass surgery. Exercise,€specially walking for twenty minules every day,I€eps heart attack away. Exercise also reduces badcholesterol, increases good cholesterol and reducesobesity- One should never do any unaccuslomeoexercise, as it may carry a risk of prematurc heart attack.Thebestexercise afterthe age of40 is brisk walking, on adaiv basjs, in a beautiful, lush green ga.den, which will€netgrze you, One should avoid anaerobtc exerctsessuch as weightlifting, push-ups, etc. as they rncrease rnetendency for hypertension. lfirmly believe in ,,use yourbody orlose it".

Diet -Adiet rich in saturated fats and cholesterolc€n raise blood cholesterol. These foods include oils richin saturated falty acids, such as palm and coconut oils,tatly foods of animal origin such as beef, pork and lamb,and highfatdairy products such asbutter, whole milk, hardcheese, egg yolk, elc. ltjs recommended that one should@nsume a lot of vegetables, fruits, cereals and pulses,and for a non-vegetarian diet, one can have chickenwilhoutskin, and fish, which conlains Omega,3 fatty acids,which are protective for the head, low fat dairy productssuch as skifi milk, and low fat yogurt, etc. Olive andCanola oils are monounsaturated oals and may be even

more beneficial in reducing blood cholesterol thanpolyunsaturated oils. Eating the right food at the righttime, in the right plac6, in the .ight manner and in theright dose, makes the heari healthy. We are what weeat! Avoid saturated fats and take more ofmonounsaturated fats (N4UFA) and polyunsaturated fats(PUFA). Refined oils are befler cooking media lhansaturated fatty acids. Eating heatthy food at a righttime, atraght place can influence our body metabolism, Accordingto Mind body medicine, eating is a holy experience inwhich energy and information from the environment areconverted to life energy. We must eatwhen we are seflledIn our mjnd and we should experience not only lhe tastebutalso the sight, smell, texture ofthe meal. ', We are whatwe eal. Whatweeat is important, butwhat is eating usismuch more imporiant."

lJncontrolled diabetes jncreases the risk of CoronaryArtery Disease by virlue of increasing the oxidation of lowdensity LDLcholesterol, and hence it enhances hardeningof the aderies. Adequate controt sf diabetes preventsCoronaryArtery Disease.

Hypertension is a medical term for high blood pressure,which threatens not only coronary arleries but also brajn,eye and kidney arteries. Blood pressure Increases meload on the heart muscle, which has deleterious effect onthe circulation in the coronary arteries. Both systolic anddiastolic hypertension is equally hazardous for prematurecoronary arlerydisease. Uncontrolted high btood pressuremay rncrease the thickness of heart mLrscles and reducecorcnary orculatton. 80 percent of unconlrolled,moderately hypertensive pattents have definite CoronaryArtery Disease. Thus, blood pressure, both systolic anddiaslolic, should be adeq uaie ly controlled.

"Hypertension is a silent killer."The common predisposing factor for accelerated

hypertension are slress, excess of salt consumption,obesity, unconkolled diabetes, indiscriminate use of nasaldfops containing ephedrine, excessive smoking,excessive consumption of alcohol may precipitatehypertension. Mind body interventions such as yoga,meditation, exercise, massage therapy, sattvic diet,wergnl management, slress management, adeq!atesleepmay help in managingthe hypenension.

Homocysteine : Recently, it was documentedthal homocysleine, which is derived from a diet hioh inanimal proletns, can increase the chances of heart a-ttackby three folds. In 1969 Dr Kilmer N,lcou y of Harvard tirstdocumented that homocysteine might play a key role indevelopment of coronary artery disease. In a study of15,000 of healthy doctors, it was determine at high tevelsof homocysleine corelate with three folds increase in the

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I firmly believes that 95 percenl of diseases allover lhe world including premature head attack,hypertension, stroke (Paralysis), metiabolic syndrome,obesity, high cholesterol, diabetes mellitus, anxiety statesand even cancers and recurent infections are caused byfaulty lifestyle, which is an expression of imbalance ofthemind and body. Faulty lifestyle incudes inability to copewith the stresses of daily life, such as meeting deadlines,work stress, negative competition, lack of productivity inthe corporate world, ego, arrogance and anger, etc. Hequoted recent data published by WHO report suggestinglhat nearly half of India suffer from anxiety giving rise topanic rcactions, fit of anger, woriisome behaviour,s a d n e s s , m e m o r y d i s o r d e r s a n d f r e q u e n tabsenlmindedness because of underlying chemicalimbalance by increased levels of epinephrine, norep inephr ine , co r t i so l and a l t e red dopamine ,dghydroergotiamine, endorphins and serotonin levels. Ifirmly believe that lack of exercise or no exercise, eatingthe wrong food, at a wrong time, at a wrong place, in awrcng manner, in a wrong dose, in a wrong envhonment,consumption ofjunk food, tobacco in any form, excess ofalcohol, drugs, mental a nd environ mental pollution, lack ofcommunication, miscommunicalion or no communication,lack of underslanding, misunderstanding or nounders tand ing , f a l se imag ina t i on , f ee l i ng o fhopelessness, helplessness. suppression. repression.fustralion and depression amongst fellow beings are themain components of a faulty lifestyle. l\ry main emphasisison the rising incidence of metabolic syndrome, which isalso called as Insulin-Resistance Syndrome or NewWorldsyndromeorChaos Syndrome orObesity Syndrome.

The optimisation of lifestyle in a holistic way byspiritual practices is the need of the day. By spirituality Imeanlhatactfrom the eye oflhe soul, which is the field ofsilence, infinite possibilities and pure potentialities, andnot from the eye of the body or the eye of the mind whichmaterialistic and full of negative stress. The spirilualpractices include regular meditation 20 minutes morningandevening, regu lar practice of yoga including allthe eightfimbs yama fdo's & donl's/ , nlyama (self-discipline) , asana(various yogic postures of exercise), pranayam (breathingexercises), pratihata (contemplation), dharna(concentrction), dhyana (meditation) and samadhi(hdrscedence). This helps in stress management, angermanagement, anxiety management, ego management,arTogance managemenl, sleep management, choicemanagement such as abstinencefrom tobacco, excessivealcohol, excessofsalt, fried food, fafrichfood such as redmeat, yellow of egg, liver, kidney, brain, etc. He strongly

increase magnesium levels. That is why it is called as a"superstatin , which helps in reducing prematurehardening of the arteries, thereby reducing the incidenceof coronary artery disease. He said, "yyhat you eaaalefrnitely matters, but what is eating you mealetsmuch more!" He also opined that"how long you ltye lsalrtghL but how we you live definibly maaters", Hesaid,"We are busy, busy, busy in eeming money atdrecosa ot losing health, and then we arc busy, busy, buayin losing that money and trying to earn health!"

I am of the firm ooinion thal "llme has come tomarket Healthy Heart in a Holistic Way Now PracticeSpirituality, Optimize lifestyle, l,,lake Perfect Choices, ActLocally and lmpact Globally". Holistic Lifestyle by spiritualpractice in scientificway is the need ofthe day to combatanxiety related problems in nearly halfof india and wholeof the world including heart attacks.

I firmly believe that Medical Tourism with Holisticapproach has tremendous poteniialto attract peoplefromall over the world to come to India for medical treatment,with a healing touch, which is missing in the Weslern partofthe world- | believe that, "CrratScar-is the need oftheday, i.e., to devote more time to interactwith the patienltoundersland the underlying problem and its rootcause, andsolve it in a very subtle manner and not unjustilied CATScan. These days, doctors all over the world hardly giveany time to chal with their paiients, by the time paiientstads speaking, the prescriplion of the doctor is ready-Prescribing a sleeping pill is not ihe answerl Hearing withpatience with a lot ofcompassion and holistic approach isthe needoftheday.

The most famous "lnter-Heart Study" dataconducted in 52 countries of the world and publishedrecently, which has shown new emerging factors for thepremature heart attacks in Asians because of negativestress such as hosii l i ty, cynicism and negativecompetition. The study has also shown that healthy heartcan be enhanced byconsumption offruitsand vegetables,praclice of regular exercise and stress managemenl.Indian data from my own study published in Indian HeartJournal, (N,,lMN,,lsstudy, chopE etal 2007) that 65 percentof Indians are suffering from Metabolic Syndrome (PotBelly, Hypertension, Diabetes, High 8ad Cholesterol andLow Good Cholesterol) which is the major cause ofpremature heart attacustroke (paralysis) in our countryThe lvletabolic Syndrome with significant morbid obesity istouching epidemic proportions in India, due to faultylifestyle and poor mindset. The lifestyle optimization inHolistic way from Dr Dean Ornish (USA), Dr S.C.l\,,lanchanda (Delhi) and Dr Satish Gupta and Dr WSelvamurthy ([/t.Abu), which has shown very clearly thatCADc€n be prevented, regressed and reversed which has

recommends thatone should consume fruits, vegetables,nuts especially almonds, which are healthy-heart nuts, ona daily basis. Almonds reduce bad cholesterol and

been documented by coronary angiogram and reductionof bad cholesterol, increase of good cholesterol andreduction of strcss hormones such as epinephrine,norepinephrine and cortisol levels and increase in thelevels of happy chemicals such as serotonin andendorphins, etc.

"The health of the world is an expression of our ownperceptions, our own thoughts, our owninbrpretations, our own experiences and our ownchoices. Thus the health of the world is not by chance,but it is by choice".

I quote Albert Einstein who once said, "We are not thepackages of flesh and bone with wisps of memory anddesire, but we are a web of infomation and energyintetwoven with intelligence and emofiors." we canenliven our prana (vitalforce), enliven ojas (glow), enlivenlejas (intelligence) by practicing perfect lifestyle in aholistic way, right from childhood and nol after we fallvictim to diseases.

The good news is heart attack (CVD) is preventable. lfmain skfactors including high blood pressure, high bloodsugar, high blood cholesterol, tobacco use, ovef weighland obesity (metabolic syndrome), inadequate intakefruits and vegetables, physical inactivity and negativestress levels are reduced by optimization of lifestyle in aHo ist icWay. Theii t leforthe World Heart Day is "Team upfor Healthy Hearts . Lifestyle optimization in a HolisticWay right trom childhood, timely medicalization withpoly pi l l (containing Aspir in, Ramipir i l , Atorvastatinand Betablocker such as Metoprolol or Atenolol) assecondary prevention at the age of 50 may definitelyhalt the rising menance ot coronary artery disease,which is need ofthe hourand postpone the

need of relatively expensive coronaty mechanicalintervention.

r ight environment. Eatonlywhen you are hungryeat freshly cooked food in a quiel relaxedatmosphere and eal s low y and don'teat when youare upsetandavoid overeat ng.

Have satlvic vegetarian 'ood and not lamsrc orrajsic food. All6 tasles including sweat, sour, salty,bittef, pungent and astringent should be includedin every meal. As most of ihe coronary arterydisease are pilta or kapha imbalances.Eat more naturalfoods such as vegetables, fruits,salads and nuts Almonds, etc. have atleast fourto five servings olfruits and vegetables daily.Do not eatjunkfood such as fried food or sweets,etc.Don'1 consume excess salt especial ly throughprocessed food.

. Keep away from TV or Computer as much aspossible and devote nore lime for physicalactivity.

. Avoid a"pot bel ly abdomen.

. Avoid l.]naccustomed exercise.

. Remaincholesterol'fit.

. Remain balanced in i fe.

. Have adequate restfor 6-8 hrs everyday.

. Don't burn both the ends ofthe candle at the samettme.

. Avoidlust,angef,greed.egoandattachment.

. Be honest, t rulhfuland dedicated forworK

. Have good sccialsupportsyslem

. Workwith sel i referraIand notw th oblect referral .

. Don't fee onely

. Have perfectchoices to achieve any goal in a verypeacelu manner.

. Deve op int imate re at ionship.

. Become an embod ment of posi l ive emotionssuch as ove, compassion, hum l i ty, fai th,c o n f i d e n c e , p e a c e , h a r m o n y , b e s s a n d28 Point Programme for Healthy Heart

. Drink hvo glasses of water daily empty stomachand aboul2litres ofwater in a day.

. Exercise dailyfor30 minutes.

. Do notsmoke orchewtobacco.

. N,,leditate for 20 minutes in the morning andevening,

. Nraintain optimum bodyweight.

. Take a body massage daily, only for 5 minutes 1.(Self-Massage "Abhyanga"). 2.

. Eat the righl food, at the righl time, at the righiplace, in the right manner, in lhe right dose, in the 3

happrnessHave planned daiy rout ine and set weeky,month yand yearly p ans.Take ani ioxidants such as ycored containinglyocpene, folcacid and naturalvi tam ns

"Eighty Potenl ial Benef i ts ot Healthy Li festylein a Hol ist ic Way (Proved Scient i t ical ly)

Be Hol ist ic and enhance your ntel l igenceBeing Hol ist c and enhance yoLrr decision taking

Be Ho[st. ard enhance yo-r pefecr cho ces.

80

4 .5.6.7 .8 .

L

10 .

1 1 .12 .13 .14.15 .16 .17 .18 .19 .20.2 1 .22.23.24.25.

27.28.29.30.3 1 .32.33.34.35.

37.38.39.40.41.42.43.44.45.46.47 .

44.49.

Be Holistic I and blossomyouryouth.Be Holisticand growyoungerand live longetBe Holisticand enhance your perception.Be Holistic and enhance your positive thoughts.Be Holist ic and enhance your perfectanterpretations.Be Holistic and enhance your perfectexperiences.Be Holistic and get rid of addictions such assmoking and alcoholisum.Be Holisticand getrid ofmetal pollution.Be Holisticand be happy.Be Holistic and be successfu l.Be Holisticand be prosperous.Be Holisticand be atpeace.Be Holisticand be a perfect leadetBe Spiritualand be a perfect professional.Be Holisticand be perfectbusinessman.Be Holislic and be perfect architect of your life.Be Holisticand be beautiful.Be Holisticand be lovable.Be Holisticand be sublime.Be Holistic and enhance your wisdom.Be Holisticand enhance your richness.Be Holistic and have tranquilityofmind.Be Holistic and have perfectlifestyle.Be Holistic and getid ofanger-Be Holisticand get rjd oflust.Be Holisticand get rid ofjealousy.Be Holisticand get rid ofanogance.Be Holisticand get rid ofhatredness.Be Holisticand get rid oflurking grief.Be Holisticand enhance your potentials.Be Holistic and get rid of vindictiveness.Be Holistic and enhance your vengena nce.Be Holistic and become moretolerant.Be Holisticand betruthtul.Be Holisticand be honest.Be Holisticand get rid ofbigotryBe Holisticand bea perfect being.Be Holisticand enjoythe giftof life.Be Holisticand experience heaven here.Be Holisticand got rid ofnegative emotions.Be Holisticand get rid ofcyncism.Be Holisticand nurture love and compassionBo Holisticand nurture altruism.Be Holistic and havo perfect envionment withinyou and outside you.Be Holisticand have perfectsleep.Be Holistic and perfect digeslion.

50. Be Holistic and be in the present moment.51. Be Holistic and have perfecttime management.52. Be Holistic and have perfect selfmanagement.

53. Be Holistic and have perfect organisational

managemenl54. Be Holistic and have perfect family managemenl

55. Be Holistic and have perfect society, community,

corporate and nalional managemenl56. Be Holistic and have perfectworld management.57. Be Holisticand beselfless.58. Be Holisticand be hopeful-59. Be Holisticand be creative60. Be Holistic and get rid of irritability.61. Be Holistic and get id ofhostility.62. Be Holistic and have conlentment.63. 8e Holisticand have humility.64. Be Holistic and experience divinity, etemity.65. Be Holisticand beflexible.66. Be Holisticand be simple.67. Be Holistic and be polite.

68. Be Holistic and be new69. Be Holist icand equipoise.70. Be Holisticand be intuitive.71. Be Holist icand be kind.72. Be Holistic and have perfect will power.

73. Be Holistic and have perfect knowledge.74. Be Holist icand be humours.75. Be Holistic and be strong.76. Be Holistic and have faith.77. Be Holislic and be in harmony.7A. Be Holistic and be a master79. Be Holistic and experience the treasure of

silence within you.

80. Be Holistic and be healthy, physically, mentally,

socially, psychologically and emotionally.

We are fulfilling the theme of World Heart Day"Team up for Healthy Hearts" by organizing a mammoth

event World Congress on Clinical and Preventive

Cardiolology for more than fifteen hundred doctors from

India and abroad on Sept 28-29, 2007 and a World PublicConference on 3D Heart Care for more than fivethousandeminent persons from different walks of life, organizing"Walk for Healthy Heart" on Sept. 30, 2007 at Brahma

Kumaris Shantivan,Abu Road, Rajasthan, India.

CARDIAC RESYNCHRONIZATIONTHERAPY FOR HEART FAILURE

DR. T. S. KLER, DR. APARNAJASWALExeculive Director. Cardiac Sciences

ESCHORTS Heart lnslitute & Research Centre. New OelhiThe syndrome of congestive Dualchamber pacing isaccomplished by placing

heart failure is responsible for pacing wires in the right alrium and right venlricular usingsubstantial morbidity and morality. slbclavian or cephalic vein access. In CRT, an additionalPatients with heart failure have wire is inserted via the right atrium thrcugh the coronaryshortness of breath and a limited sinus inlo a cardiac vein on the laleral wall of the leftcapacity for exercise, have high

rales ot hospitalization and rehospitalization. and dieprematuroly. The primary mode of therapy for thissyndrome is based on antagonism of neurohormonalpathways activated in the failing cardiovascular system.Drugs thatantagonize these pathways decrease mortalityand morbidity and in some cases improve the undedyingstruclural abnormalities of the hearl, a process termed"reverse remodeling". on the basis of a large number ofclinical hials, a regimen comprising up to six classes ofdrugs has become the cornerstone of therapy of heartfailure. lvlechanical suoDorl with lefi ventricllar assistdevices and heart transplantation are reserved for lheminority of patients who have severely decompensatedhearl failure. Despite these therapeutic advances, it isgenerally accepted that current therapies do notadequatelyaddresslheclinical needof patientswith heartfailure, aRd additional strateg ies are being developed.

Cardiac Dyssynchrony and the Rationale forResynchronization

The heart relies on a coordinated seeuence ofelectrical impulse generation and conduction that allowsrepeated filling and emptying of the atria and ventricles.Cardiac electrical activity depends on the integrity of thesinoatrial node, the ahiovenhicular node, and thespecialized conducting tissue of the His-Purkinje system.In approximately 30% of patients who have CHF;aberrante l e c t r i c a l c o n d u c t i o n i s n o t e d o n s u r f a c eelectrocardiogram as QRS prolongation of 120 ms orgreater The delay in ventricular electrical activationcauses abnormal ventric! lar contraction, termeddyssynchrony. In the setting ofCHF, the consequences ofthis electromechanical abnormality are abnormalventricular lllling, reduclion in the left systolic output, andworsening of mitral regurgitation. Several studies haveshown that inhaventricular conduction delay is anindependent risk factor for mortality in hea rt failure.

The aim of Cardiac Resynchronization Therapy(CRT).is to improve electromechanic€l coupling in lheheart by generating a more efficient sequence of rmpulsegeneration and conduction. CRT involves atr ialsynchronized biventricular pacing. The immediatehemodynamic benefits ofthe procedure include improveddiastolic filling and more efficient systolic contractality.Mortality from CHF is a result of either progressive pumpfailure or sudden death caused by anhythmia. CRT canslow the progression ofpumpfailure and, when combinedwith an implantable cardioverter defibrillator (lCD),preventsuddon cardiac death.

Tochnique

ventricle. The left ventricular lead can also be placedsurgically via thoracotomy or laparoscopic thoacostomy.Lefl ventricular lead placement is lechnically difficult;however, lhe complication rate has dramatical lydecreased as exDerience with this Drocedure hasincreased. The Dresence of a Dacemaker lead in the leftventricular free wall allows for simultaneously pacing ofboth ventricles and more physiologic ahioventriculartiming. The result is more effective lefr ventricularcontraction and imDrovement in stroke outDul,

lndications

Eligibility crileria for treaiment with CRT areadapted from published studies. Briefly the two mostimportant criteria are severe symptomatic heart failuredespite optimal medicaltherapy, and ORS p.olongation.

Table 1. Indications for Cardiac ResynchronizationTheraov

. New York Heart Association (NYHA) functionalclass lll or lV heart failure desoite ootimal medicaltherapy.

. QRS duration grealerlhan 120 ms

. Systolic heart failure with ejection fraction less then350/r

. Left ventricular end diastolic dimension qreater than55 mm

The major l imitation ofal l lr ials was that they usedonly the ORS width, i.e., an elecirical parameter, as aparameter to assess left ventricular dyssynchronyalthough it is the mechanical dyssynchrony, which is lhemain corectable cause ofreduced oumofunction in thesepatients. The correlation between electr ical andmecha nical dyssynchrony is weak. This is underscored bydaia showing that despite the dependence of the aculehemodynamic improvemenl to CRT on baseline ORSwidth shortening ofthe QRS complex is not correlated toihe hemodynamic effect, especially in LV pacing. Inaddition. baseline ORS width in the l\.4lRACLE trial did notappear lo cofielate well io cl inical improvement.Thereforc, it must be assumed lhat it ls not only the widthofthe QRS complex alone but also they lype ofconductiondelay that influences the mechanicaldyssynchrony whichis the true cause of in-efficienl systolic left ventricularconhaction in these hearts.

M e t h o d s F o r A s s e s s i n g L e f l V e n l r i c u l a rDyssynchrony

There are principally two methods that have beenused in clinical studies for assessing left ventricular

dyssynchrony: magnetic resonance imaging ([IRl) andechocardiography. Early experimental data suggest thatcardiac MRlmay be a suitable toolfor quantifying systoliccontractile dyssynchrony. However, whereas cardiac lvlRlmay be regarded as the gold standard for assessing leftventricular wall motion, it is expensive, not generallyavailable and cannot be repeatedly performed in patientswith an implanted device. Thus the assessment of lefrventricular mechanical dyssynchrony and its conection byCRT has emerged as an intense area of research forechocardiography.

Table 2: Echocardiographic Parameters lorassessmenl of L€ft Ventticular DyssynchronyTable 2. summarizes the echocardiographic methodsthathave been described in the literature for characterizationand quantif ication of left ventricular mechanical

dyssynchrony. According to the imaging modality used,the parameters used in the assessment of left ventriculardyssynchrony may be classified into parameters deivedfrom M-mode, conventional Doppler, two-dimensionalechocardiography and tissue Doppler lmaging (TDl).

The role of Cardiac Resynchronization Therapy (CRT)without an ICD in reducing mortality from heart failure isstill unresolved. A recent meta-analysisfrom a randomizedhials using cRT alone (2 trials) and CRTICD (2 kials)suggests that cardiac resynch ronization reduces mortalityfrom progressive heart failure by 51%. Although CRTalone clearly improves symptoms of heart failure, theaddition of a dellbrillator appears to confer significantimorovement in survival. The Comparison of MedicalTherapy, Pacing, and Defibrillation in Heart Failure(COMPANION) trial enrolled patients to medical therapy,medicaltherapy plusCRT, and medicaltherapy plus CRT-lCD. This study, the first to directly compare CRT and CRT-ICD in patients without esiablished criteria for defibrillatortherapy, confirmed that the addition of a deflbrillator toCRT has a significEnt impact on reducing heart failure_related mortality-

CRT represents an impodant adjunct to existing medicaltherapies, and patients in reported hials were continuedon angiotensin conveding enzyme inhibitors/angiotensinreceptor blockers, B-blockers, diuretic agents, and

aldosterone antagonists as appropriate.LimitationsThe most important limitation of CRT as a modality ofheatment for CHF is a relatively high nonresponder rate.Lack of response to CRT is explained by suboptimalpatient selection and technical questions relating toplacement of the lefr ventricular lead as well as timing ofthe atdoventricular inteNal delay. Several studies havesuggested that lissue Doppler and magnetic resonanceimaging may be superiorto QRS prolongation as a markerof cardiac dyssynchrony. Further experience in patientselection, lead placement, and pacemaker programmingwill hopefully maximize patient benellt from CRT andreduce comDlications.

Complications

complicationsofCRTare shown in Table 3Table 3: Complications of Ca.diac Resynchronizaliontherapy in Palientswith Head Failure

In a recent multicenter trial (the N,'lulticenlerInsync ICD Randomized Clinical Evaluation (MIRACLEICD) trial involving more than 400 patient, the overallcomplication rate was approximately 28%i however, mostcomplications were minor and no mortality was reported.

omplicat ion Incidence (%)

Lead placement failure 1 1

Coronary Sinus Dissection 3Lead Dislodgement 1 . 6Venkicular tachycardia/fibrillationCardiac Perloratron 0.8Hean ErocKPericardialeffusion 0 .5

Failure of lead placement was the mosl frequentcomplication, and cardiac pedoralion and coronary sinusdissection were the most serious advelse events,Complication rates appear to be lowest in centers whercthe procedures are frequently performed and where thephysicians have a large numberofpatients.Conclusion

Over the last 10 years, the rate of hospitalizationforCHF has increased by more than 150%. This trend wil imost likely continue because of an aging population andincreased survival after acule myocardial infarction.Cur.ently, an estimated 10% of patienls with CHF areeligible for CRT: these patienis have a low ejectionfraction, evidence of dyssynchrony, and severe symptomsof CHF despite optimal medical therapy- For a treatmentmodality that is free ofcompliance issues and appears tobe well tolerated, CRT should be considercd for allpatients who have advanced CHF and meet exastangcriteria.

In patients with CHF, CRT has the potential toimprove exercise capacity and patient well being, reducerehospitaliation, and most likely, reduce mortality. Whencombined with an lCD, CRT also reduces the risk ofsudden arrhythmic death. Several ongoing largerandomjzedtrialswill shed morelighton patientselection,technical issues ol lead placement, role ol CRT in atrial

septal lo postsriorwan

lnledenticular mechanicaldelay LV pe-ejection de ay(onser ofqRs- ons€l ol

2 0 Quaniilicalon of septal iolatoral wall molion dslay

Percsniage basal LV wilh

to peak systolic conlraclion

EF

IMPACT OF CARDIAC REHABILITATION ONOUALITY OF LIFE IN INDIAN CARDIAC PATIENTS

Kirti Nigalye, Stephen Fallows, tlrike Morris & Kevin SykesCentre for Exercise & Nutrilion Science,

University of ChesterChester CH1 4BJ. Enoland

Background: Previous studies have evaluated

the individual effects of coronary heart disease(CHD), diabeles mellitus and obesity on healthrelated quality of life outcomes. Due lo lhe risingincidence of these co-morbid conditions, ii isimportant to study the impact of cardiacrehabilitaton on quality of life on those wilhcombinations of these conditions.

components.

Resurlsj All the four groups i-e. diabeiic, obese,diabelic and obese & conirol had similar baselinecharacteristics, bul the mean pre weight was82.60 I 14.91 kg and the mean posl weight was79.69 r '12.97 kg. While the mean body massindex (BMl) pre and post was 31.181 6.35 kg/m2and 29.42 t 5.40 kg/m2 respectively. Overqualityof life measures significant difference (p<0.01)between four groups were found in physicalfunction, role function, vilality, socialfunction, roleemotiona{, general and mental health. Also asignif icant difJerence (p<0.1) was observedbetween physical and mental componentsummary. However mental healih, menlalcomponenl sumrnary and general health showedstrong differences pre and posl cardiacrehabil lal ion 'or dl l grorrps and bodiy painshowed the least d ifferences pre and post cardiacrehabil i lal ion.

Conclusion: This sludy provides information

about impact ofcardiac rehabililation on qualilyofl i fe in Indian population. But there is st i l l need ofresearching the pathological and physiologicaleffects of cardiac rehabilitalion and focusing theneed of cardiac rehabiliation on palients wrthcoronary heart disease (CHD). Continuedresedrch on idenlifying patients with chronicconditions and providing cardiac rehabilitation aspfimary preventon would be-efrl In redLcrngfurlher morbidity and mortality in such patientsand also ensure a belter quali ty ofl i fe.

Obr'eclive. The purpose ofthis was to delermine

the impacl of four weeks of cardiac rehabililationon patients with either myocardial infarction ([rl)or who had undergone coronary artery bypassgraft (CABG) in an Indian population.

Subr'ecfsi The sludy was conducted in Asian

Heart Institute, a [,4umbai based hospital. 100patients padicipated, 73 males and 27 femalesaged between 40 60 years. The mean age formales was 53.9714.56 and mean age for femaleswas 55.6314.49. At baseline the mean height ofthe part icipants was 1.63 t 0.09m. Of the 100participants 32 participants were identified asType 2 d iabelic patie nts, 34 as obese patients and34 participants were both Type 2 diabetic andobese.

/lretfiods. A general assessment queslionnarre

and a gener i c Shor t Fo rm-36 (SF-36 )queslionnaire was used pre and post cardiacrehabiliiation programme lo test the potentialeffect of cardiac rehabilitation on quality of life. Amultivariate analysis was performed lo examinethe eight scales of SF-36 and two summarymeasures of physic€l (PCS) and menlal (MCS)

'UMa &ert hiend and. yutt uozntefl2tnq L5 .t4u4 .aq! E mrnnarg.

THE ROLE OF PSYCHOLOGICAL STRESSORS IN PATHOGENESIS OFCORONARY ATHEROSCLEROSIS AND CORONARY EVENTS

Mnod Kumar GuntaMD, FACC Interventional Cardiologist

Chi6f of Cardiology, The Heart Center, Bakersfield, CalifomiaDireclor, Cardiac Cath Laboratory San J Hospital, Bakersfreld, Califomia

Pr66ident, American Heart Associalion, Ksm Chapter, Califomia

Heart disease is lhe number onekiller in America and the developedworld including India. Although the

impodance of psychosocial fuctors in the developmentand expression of coonary artery disease (CAD) hasbeon debated, recent literature now establishes thatpsychosocial tactors contribuie significantly to thepalhogenesis of CAD. However, because the literaturerelating psychosocial factors to CAD is multidisciplinarythere may be an under apprecialion of the strength ofsome of the epidemiological and patho-physiologicalobservations that have been reported.

We will review the relationship betweenpsychosocial stress and CAD development, withemphasis on the following psycilosocial factors:

('1) Depression(2) Anxiety(3) Socialisolation(4) Chronic and sub-acute life shess

Although these domains can ovedap, epidemiologicaldatra for each domain will be reviewed sepaEtely,emphasizing studies that have used the "hard"

cardiovascular end points of myocadial infarction and

cardiac death as outoome variables. The implications ofthese findings relative to the prevention and treatmenl ofCAD will be discussed.

How does psychosocial slress conl bute to heartdisease?

Let us look at an example. when we are facedwith great stress like a tiger, we respond with the fight orflight reaction. For this, as illustrated here, God hasDrovided us with tools of skess hormones like adrenalineand nor-adrenaline. To fight or night, we need strongermuscles in our body and legs. For lhis, we need moreenergy provided by higher level of blood sugar, higherlevel of blood circulation ( provided by higher heart rate T

and blood pressure ), higher level of oxygen ( and thushigher respiratory rate ).

With tiger we either face it or run and then the

||ltllilrlll J[J; utf

stress is over. With modern society the stress becomeschronic, as for example when we deal with an angry bossall day, and then traffc and then 2* shifl, etc. the stressreally never goes away. This reaction becomesmaladaptive when it becomes chronic and our body isused to a higher level of blood sugar ( ie., Diabetes ),higher level of blood pressure ( Hypertension ) and higherrespiratory rate and thus chronic psycho-somaticdisorders.This neuro-hormonal response of our body is thru ANS (automatic neryous system )Two Parts to the ANS: lt allhappens automatically!

1. Sympathetic NS - Stress Response (helps usrespond to the stress)

2. Parasympath€tic NS Relaxation Response(helps us recoverfrom the shess)

We naed lnorc of paEsympathetic and less ofsympathetic respons€s lo achievo a peacefulmindand body.Let us now examine some of the maiorJraychostr€ssols:

Episodes of major depression are characterizedby the presence of a depressed mood and markedlydecreased interest in allactiviti€s, persisting for at least 2weeks and accompanied by at least 4 of the followingaddit ional symptoms: changes in appetite, sleepdisturbance, fatigue, psychomotor retardation or agitalion,feelings of guilt or worthlessness, problems concentrating.and suicidal thoughts. Although community basedoccurrence of depression is around 5% that numberincreases to around 15% forthose with some form ofCAD.Recent epidemiological sludies evaluatang therelalionship between depression and CAD among heallhyand CAD populations consistently demonstrate asignif icant prospective relationship between theoccurence of major depression episodes and theincidence of cardiac events.

Two additional findings are notable. First, thepresence of depressive symploms, in the absence ofdiagnosed majordepression episodes, is also associatedwith an increased sk for cardiac events. Second, anumber of studies support a gradient between themagnitude of depaession and future cardiac events.Together, these data suggestthat riskforCAD associatedwith depression exists along a continuum, according to themagnitude of depressive symptoms.

One parlicular aspect of deprcssion, the absenceofhope, has received particular attention. Hopelessnesshas been linked lo sudden death, both in observationalstudies and in animal models of hopelessness. Recently,pospective epidemiological studies have also reported arelationship between symptoms of hopelessness and lhedevelopment of CAO. In one sludy, for example, a "yes'

answer to the quoslion "(During the last month) have youfelt so sad, discouraged, hopeless, or had so manyproblems that you wondered ifanything was worthwhile?"more than doubledthe riskoICAO.

A study looked at whether anger incneasedrlsk of hean aftacks. They tracked 1623 hearl pati€nts.They lookod at "What happenedlhe two hours b€for€yourMl?" and found that anger increased risk of Ml by230%-

lJntil recenlly, evidence linking anxiety to CADwas limited to demonstrations of elevated mortality ratesamong psychiakic patients with anxiety disorders-Increasing evidence now links anxiety alisorders to

development of cardiac events in generalpopulations. Most notably, 3 large-scale communily-based studies, including one invoiving 34,000 men, havenow reported a significant relationship between anxietydisorders and cardiac death.

Since the late 1970s, a series of prospectivecommunily-based studies have examined the influenceofsocial factors on lhe development oI CAD. Initial studiesfocused on quantilative aspects of social su pport, such aslhe presence of family aflilialions, number offriends, andthe extenl of one's part icipation in group andorgan izational activities. This domain of measurementhasbeen called one's "social network." Within this domain,some studies evaluated the influence of oartner status(living alone, maritalstatus, and/or marita I disruption ), andothers have assessed aspects of "instrumental" (ie,tangible) support, such as access to guidance andpractical community services. Over time, however, thequalitative nature of one's social support system (eg,amount of perceived emotional support) has also beenincreasangly subject to study.

A relatively small network has been found, on

average, to be associated with a 2- to 3-fold increase in theincidence of CAD over lime. Similariy, low levels ofperceived emotional support confer an even greaterincreased risk for future cardiac events. Significantprognostic relalionships are present in most of lhesestudies, and the risk ratios aae substantial- For instance,Berkman et al observed a nearly 3-fold increase insubsequent cardiac events in post-Ml patients reporting a

low level of emotional support, and Williams et alobserveda similar 3-fold increase in mortality over 5 years amongCAD patients who were unmanied or had no significantconfidant in their lafe.

Work-related stress is the most widely studiedchronic life stress relative to CAD. Although many aspectsof one's work environment relative to lhe development ofCAD have been studied, much interest has focused onmodels of inherent "tension" at work. One such modelhasbeen the 'job strain" model, defined by Karasek et al asjobs with high demand but low decision latitude. In oneprcspective study of 1928 male workers followed up for 6years, job shain was associated with a 4-fold increase inthe risk of cardiovascular systemrelated death.

Solutions:We have lo reverse lhe cycle ot stress related

inc rease i n neu ro -ho rmona l imba lance . Theparasympathelic nervous system ( PNS ) needs to bestimulated and have a control over sympatheticnervous system. But since these systems aleautomatic, we don't have a control over these so wehave lo go deeperand deeper and p.actice over mindandthus a controlcan be achieved.

In a recent study; Retardation of coronaryatherosclerosis with yoga lifestyle intervention" featurcd inJoumal of the Association of Physicians of India, Yogaeffects were evaluated on retaldation of coronaryatherosclerotic disease. In this prospective, randomized,controlled trial,42 men with angiographically provencoronary arterydisease (CAD)were randomized to control(n = 21) and yoga intervention group (n = 21) and werefollowed forone year. The active group was treated with auser-friendly program consisting of yoga, control of riskfactors, diet control and moderate aerobic exercise. Thecontrol group was managed by conventional methods a-e

risk factor control and American Heart Association step Idiet. At one year, the yoga groups showed significanlreduction in number of anginal episodes per week,improved exercise capacity and decrease in body weight.Serum total cholesterol, LDL cholesterol and triglyceridelevels also showed greater reductions as compared withthe conkol group. Revascularisation procedures(coronary angioplasty or bypass surgery) were lessftequently required in the yoga group. Coronary of aninterdisciplinary nature. By encouraging research andcollaboration that span across disciplines, the futuredevelopment of interventions for angiog raphy repeated atone yearshowed thatsignificantly more lesions regressed(20% versus 2%) and less lesions progressed (5% versus37%)intheyoga group. Compliance with the programwasexcellentand no side effects were observed-

The following image reprcsents coronary atherosclerosis:

In the real world, biobehavioral interventions arenot undertaken in the absence ofother medical regimens.Thus, a u sefu I practical desig n for future studies is one thatincorporates effective medical treatment (eg, lipid-lowering therapy) and conventional lifestyle modifications(eg, dietary recommendations) with stress reductiontechniques such asYoga and meditation in allpatienis.Mosttechniqueseffectthe PNS. eg.,Gentle stretching decreases m uscle ten sion;Deep relaxation activates the PNS; improvement inim mu ne function through repairand Iestoration;

Breathing techniques- help increase the lungcapacity and improve oxygenation abdominal breathingquick and easy way lo manage stress and activate thePNS any where and an!'time reverse the effects of stress.,Guided imagery positive imagery has a positive eflect onthe physiology;

Meditation increased awareness and focusshown to have an effect on the physiology- PNS effect.Other examples: Body can'l dist inguish betweensomething actually happening and imaging thatsomething is happening LEN,4ON or WORRY (the mostcommon form of imagery) OR image one hand in onewater vessels will constrict and cold water they constictand that relates directlytoyourheart.

Scientists from a wide variety of backgroundshave contributed to the observations noted in this article.TheAmeican HeartAssociation and American College ofCardiology have kemendous potential for spurring mo€formal communication and cooperation psychosocial riskfactors could derivethe synercistic benefit represented bythe maxim "thewhole isgrcaterthan the sum of its parts."

Blood

ROLE OF PERSONALITY IN CORONARY HEART DISEASEIMPLICATIONS FOR BEHAVIORAL CARDIOLOGY

G6rard J. MolloyUniversity College, Psychobiology Group,

Department of Epidemeology & Public HealthTonington Place, London, UK

Psyc,flologists make the temporal distinctionbetween traits and states in descibing psychologicalphenomgna. Traib refer to enduring psychologicalcharacteristics of an individual in terms of their action,€motion and thought. The combinalion of thesecharacteristics constitutes an individual's personality.S'tates refer to transient psychological experiences suchas anxiety or happiness. The current consensus is thatthere are five broad personality dimensions- These areextraversion versus inlroversion, neuroticism versusemotional stability, conscientiousn€ss versus unreliability,agreeableness versus antagonism and openness toexperience veFus closed mindedness. Personality traitshave been associated with a range of physical,psychological and social outcomes with moderateconsislency. In the case of coronary heart disease (CHD),personality has been linked to both physiologicalresponses and health and illness behaviors, and there issome evidence for the indeoendence of thesemechanisms. This work has demonstrated plausiblebiological and behaviolal mechanisms underpinnin9 theobserved associations between personality and healthoutcomes in CHD. The use of patient personality dala inclinicalcardiology, however, has yetto be esiablished-

Why is it important?

How can understanding personali ty helpcardiologisls imprcve the trealment oftheir patients? Thisis the question that needs to be answered by any area ofpersonality research hoping to get the attention ofpractising cardiologists. Researchers in this area oftenpoint to the fact that it was a team ofcardiologists thatwaslargely responsible for laying the foundation for over fourdecades of research into the role of personality in CHD.The formulation of type A behavior pattern (TABP) wasmainly in response to clinical obseNations of CHDpationts behavior during consultation by US cardiologistsMeyer Friedman and Ray Rosenman. TABP wascharacterized by hostility, impatience, competitivenessand dominanco.Although the concept was responsible forinitiating the development of a systematic body of worklooking at the links between personali9 and healthoutcomes in CHD, and some early research detectedhypolhesized associaiions with CHD morbidity andmorlality, subsequent studies did not confirm that TABPwas reliably linkedto CHD. Neverlheless in the RecurrentCoronary Prevention Project, a randomized controlled trialof a TABP behavior-health outcomes in CHD, and someearly research detected hypothesized associations with

CHD morbidity and mortality, subsequent stldies did notconfirm that TABP was rel iably l inked to CHD.Neverlheless in the Recurent Corcnary PreventionProject, a randomized conkolled trialofa TABP behaviorchange intervention, the intervention reduced overt typeAbehaviors and also reduced lhe rate ofrecurrenl coronaryevents byneady 50%. Furtheranalysis demonstrated thalamong patients with a mild previous infarction, lhebehavior change inlervention reduced the occurrence ofcardiac death. These compelling results indicated thatchanging the overt pathogenic behaviors associated withparticular personality types may have considerableimporlance and potentialfor treatment in CHD, However,personality research has yet to make a significantcontribution to lhe practice of clinical cardiology. This maybe due in parl to confusion among clinicians about whatpersonality is and how it relates to other establishedpsychosocial risk faclors thal are considered in themanagement of CHD. Additionally, inadequale aflenlionmay have been paid by personality researchers indisseminating their findings to clinical audiences andconsidering how they might translate into clinically usefulknowledgeor skills.

Behavioral mechanisms in secondary prevention otcoronary heart disease

Afocus on lhe behavioral mechanisms may offera particularly promising avenue for future personalityresearch aiming to influence clinicalpractice fora numberofreasons. First, personaliiy by definition cannot beeasilychanged itself to any sign ificant deg ree. Second, there area range of behavioral-change techniques thal have beendeveloped and used with some success to change specificbehaviors relaling to CHD, for example, planning forphysical activity and self-monitoring of blood pressure tomanage hypedension. These simple behavioral-changetechniquescan be used bythose involved in thetreatmentofCHD patients to encourage patienl self-management ofCHD. This aooroach would allow both a scientific andpractice agenda for personalily research to be addressedsimultaneously. Third, after acute clinical intervention,symptom stabilization and discharge, CHD patient'shealth outcomes are largely determined by appropriatesecondary prevention and sellmanagement behavior inthe community. Palients must adhere lo increasinglycomplex regimens of medication, initiate and maintainappropriate levels of regular physical activity to promotehealth and in many cases resume productive economic

activity. Achieving these behavioralgoals may be more orless likely for particular personality types. Understandinghow personality relates to achieving these benchmarks inthe recovery process can help cardiologists to moreaccuralely assess risk of poor self-management andconsequent morbidity.Future perspective: personali ty & behavioralcardiology

In response to the strong evidence demonsfatingthat adverse lifestyle behaviors, self-managementbehavior, emotional faclols and chronic stress canpromote atherosclerosis and adverse cardiac events,behavioral cardiology has gained some recentprominence. Behavioral cardiology involves ancorporatingthese factors into the practice ofcardiology and attemptingto modify these factors to enhance patient outmmes.While the use of personality data has notfigured widely inrecent discussions about behavioral cardiology, futurestudies should examine the relevance of personality dataforthis approach to clinical practice. lfpersonality datia canpredict which patients may be more likely to engage inadverse l i festyle behaviors, have poorer self-management, experience emotional distress. have lowsocial support and chronic family or work stress. thencardiologists could quickly identifythose patients that maybe ai dsk and facilitate lhe modiflcation of these riskfactors. The development of the type D or the distressedpersonalitytype may bea step in the rightdirection asthispersonality type aims to identify patients that are bothprone to experiencing negative affect and who are sociallyin hibited. These two factors appear to act synergistically inpredicting CHD morbidity. Recent work has linked thispersonality type to the consultation behavior of patientswith head Iailure. This study demonstrated that heartfailure patients with type D personality experaenced morecardiac symptoms and more ofren appraised thesesymploms as worrisome compared with patients with anon type D personality. Paradoxic€lly, patients with a typeD personalitywere less likelyto report these symptoms totheir cardiologist or nurse. Seeking appropriate medicalattention following symptom onset is critical for thesuccessful management of condations related to CHD. lfpatients with type D personality are less likely to get aconsultation, then knowledge of type D status may be of

use to the cardiologist in assessing isk of adv€E€outcomes- This linking of personality types with potentiallymodifiable adverse patientbehaviors makes a slrong casefor the role of personality in the clinical management otCHD.

ConclusionFuture work investigating the links between personalityand coronary heart disease will have to demonstrate thalgathering peronality data is an effjcient way of captudngmost of the wellestablished modifiable psychosocial riskinformation. While personality may explain risk thatexlends beyond these factors, it is unclear whatcardiologists can do to reducethis extra risk. lt is likelythatcardiologists embracing behavioral cardiology will opt touse more conventional direct means of gatheringpsychosocial risk informalion than personality tests,unless the data becomes overwhelming such thatpersonality predicts significant risk that extends beyondadverse lifestyle behaviors, self-management behavior,emotional factors, low social support and chronic skess,Financial disclosureThe aulhors have no relevant financial interests incl{.idingemployment, consultancies, honoraria, stock ownership

Bibliography

1. Ozer DJ, Benet-Martinez V: Personalily and theorediction of consequential outcomes. Ar?na. ReuPsychol. 57, 4O1 421 (20OG).

2. Smiih TW lracKenzie J: Pe rsonality and riskofphysicaf illness. Annu. Reu Clin. Psychol.2,435467 (2006)

3. SmithTW. Ruiz JM: Psychosocia I infl uences onthe development and courseofcoronary heartdisease; cunent status and implicationsforresearch and practice. J. Consult. Clin. Psychol.70(3).548568 (2002).

4- Friedman M, Rosenman RH:Association ofaspecificovert behaviour patlern wth increases inblood cholesterol. blood clotting time, incidence ofarcus senilis and clinical coronary artery disease.JAMA 169, 12861296 (1959).

5. RozanskiA, Blumenthal JA, Kaplan J: lmpactofpsychological faclors on the palhogensis ofcardiovascular disease and implications forIherapy. Ciculation 99(16), 21 S522 1 7 ( 1 999).

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SYMPTOMS OF DEPRESSION, ACUTE MYOCARDIAL INFARCTION,ANTI TOTAL MORTALITY IN A COMMUNITY SAMPLE

John C. Baretoot. PhD: liarlanno Schroll, MD, DM Sc

fcrl.curatbn. 1 3S6;93:1976 1980)From the Behavioral Medicine R€search Center, Duke Universit Medical Center, Durham, NC: the

Institute ot Preventive Medicine, Copenhagen (Denmark) Municipal Hospital (J.8.)t and Glostrup Population Studies,Copenhag€n County Hospital (M.S.), Gloshup, Denmark.

Backgrcund Depression has been shown to adversely affect the prognosis of patients with establishedcoronary artery disease, but thore is comparatively little evidence to document the role of depression in the initialdevolopment of coronary disease.

Methods and Resu/ts Study padicipants were 409 men and 32t women who were residents of Glostrup,Denmark, bom in 1914. Physicaland psychological examinations in 1964 and 1974 established their baseline riskfactorand disoase statusand their level of depressive symptomatology. Initial myocardial infarction (Ml) was observedin 122 participants, and there wero 290 deaths during follow-up, which ended in 1991. A2-SD difference in depressionscor€ was associated with rolative risks of 1.7'1 fF=.005)for Mland 1.59 (P<.001) fordealhs from allcauses Thesefindings were unchanged after we controlled for risk factors and signs of disease at baseline. There were no sexd ifierences in efiect sizes.Conclusions High tevels ofdepressive symptomatology are associated with increased risks of Ml and mortality. Thegraded relationships betw€en depression scores and risk, long-lasting natlre of the effect, and stability of thedepression measured acrosstime suggestthatthis risk factor is bestviewed as a continuous variable that represents achronic psychological characteristic rather than a discrete and episodic psychiatriccondilion-

KeyWords:depression'epidemiology'mortality*myocardialinfarction"riskfactors

GENDER, DEPRESSION, AND ONE.YEAR PROGNOSISAFTER MYOCARDIAL INFARCTION

Nancy Frasure-Smith, Phd, Francois Lespirance, MD,Msrtin Juneau, MD, Marlo Talajic, MD, and Martial G Bourassa, MD

Obi.ctive: The purpose ofthis study was to assess gender difJerences in the impact of depression on 1-yearcardiac morlalityin patients hospitalized foran acute myocardial infarction ([,4]).

Melhods: Secondary analysis was performed on data from two studies thal used the Beck DepressionInventory (BDl) to assess depression symploms during hospitalization: a prospeciive study of post-lvll risk and arandomized trial of psychosocial intervention (controlgroup only). The sample included 896 patients i283 women) whosurvived to discharge and received usual posthospital care. lvlultivariate logistic regression analysis was used toassessthe risk of'1-year cardiac mortality associated with baseline BDlscores.

Results: There were 290 patients (133 women) with BDI scores >=10 (at least mild to moderate symptoms ofdeprcssion)i 8.3% of the depressod women died of cardiac causes in contrast to 2.7o1 of lhe nondepressed Fordepressed men, the rate of cardiac death was 7:0% in conkast to 2.4olo ofthe nondepressed. Increased BDI sco@swere significantly related to cardiac mortality for both genders lthe odds ratio for women was 3.29 (95% confldenceinterval (Cl) = 1.02-10.59); for men, the odds ratio was 3.05 (95% Cl = 1.29-7.17)1. Control for other multivariatepredictors of mortality in the data set (age, Killip class, the interactions of gender by non-Q wave N,'ll, gender by leftventricularejectionfraction, and genderbysmoking) did notchangethe impactofthe BDI for either gender'

Conclusions: Depression in hospitalafter Mlis a significant predictorof 1-yearcardiac rnortality forwomen aswellasfor men, and its impact is largely independent ofother post-Ml risks.

Key words: depression, myocardial infarction, women, prognosis.

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PROSPECTIVE STUDY OF A SELF-REPORT TYPE A SCALE ANDRISK OF CORONARY HEART DISEASE

(C irculation. 1 998;98:405.)Test of the M[4Pl-2 Type A Scale

lchiro Kawachi, l\4D David Sparrow, DSci Laura D. Kuhzansky, PhD;Avron Spiro, lll, PhD: Pantel S. Vokonas, l\4Dt Scott T. Wei$. MD, N4S

Background - Soverd methods exist by which to assess type A behavior (TAB). Although the videotapedclinical inleNiew is regarded asthe"gold standard,'self- report measures have also proved usefulin assessingTAB inlarge population studies. The purpose of this study was to examine prospectively the relationship of TAB to risk ofcoronary heart disease (CHD) incidence with the use of the revised Minnesota l4ultiphasic Personality Inventory(l,,lMPl-2) Type A Scale. To the best of our knowledge, lhis is the first test ofthis scale in the context of predicting CHDincadence.

Methods and Resulb-The studywas performed in the VA Normative Aging Study, an ongoing cohorl ofolder(mean age, 6'1 years) community-dwelling men. A total of 1305 men who were free of diagnosed CHD in 1986completed the MldPl-2 Type A Scale. During an average 7.0 years of follow-up, 110 cases of incident CHD occurred.Compared with men in the lowestquartileoftypeAscores, men in the highest quartile had multivariate adjusted relativerisks ot2.86 (95% Cl, 1.19 to 6.89; Pfor lrend=O.016) forcombined CHD death and nonfatal myocardial infarction (Ml)and 2.3O (95% Cl, 1.32 to 4.01i P for trend=o.Oo1) for combined CHD death/nonfatal Ml plus angina pectoris. Therelationship of TAB to CHD was independenl of measures of angerand cynicism.

Corclusions- The MMPI2 TypeAScale predicts CHD incidence. Further research is warranled to examinethecorrelation, ifany, between thisscale and the videotaped clinical interview.

IS WORRYING BAD FOR YOUR HEART?A PROSPECTIVE STUDY OF WORRY AND CORONARY HEART

DISEASE IN THE NORMATIVE AGING STUDYLaura.D. Kubzansky, PhD lchiro Kawachl, [{D Avron Spiro, lii,

PhD: scon rweiss. MD, Msi#:.lr:.""rt316:dll3 "avid sparrow. DSc

Background-Wotry is an important component ofanxiety, which recentwork suggests is related to increasedincidence of coronary hearl disease (CHD). Chronic worry has also been associated with decreased heart ratevariability. We hypothesized that high levels ofworry may increase CHD risk.

Method and Resu/as-We examined prospectively the relationship of worry with CHD incidence in theNornmative Aging Study, an ongoing cohort of older men. In1975, 1759 men free of diagnosed cHD completed aWorries Scale, indicating the extent to which they worried about each of five worry domains: social conditions, health,financial, self-definition, and aging. During 20 years of follow-up, 323 cases of incident cHD occurred: '113 cases ofnonfatal rnyocardial infarction (l\41); 86 cases of fatral CHD; and .1 24 cases of angina pecloris. Worry about socialconditions was the domain moststronglyassociated with incidentCHD. Compared with men reporting the lowestlevelsof social conditions worry, men reporting the highestlevels had multivariate adjusted relative risks of 2.41195%Cl,1.40to 4.'13) for nonfatal Ml and 1.48(95% Cl, 0.99 to 2.20) for total CHD (nonfatal Ml and faial CHD). A dose-responserelation was found between levelofworryand both nonfatal Ml (Pfor trend, .002) and totalCHD (Pfortrend, .04).

Corclusiors- These results suggest that high levels ofworry in specific domains may increase the risk ofCHD in older men.

it(u,tw095tjwo enle aine'a wfu uzxe o al uotft f4lud &4duel.uz6 et tfr2 tetn2 b.Ali in & @ttasotl.

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Shpt &. uxfarN lall4. Wfu& il: ioet a$in, .1 uW @gak &t audirn e witlr j4fte6,IA2n tA4 surain l4ll", and ufiq. il tuea, J'U 6z t fue again h. p,t2'tQnt e. ,iuggliog a4.. .?

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Depressive Symptoms and Risks of Coronary Heart Diseaseand Mortality in Elderly Americans

Abraham A. Ariyo, MD, MPH lrary Haan, MPH, PhDa Calherinem. Tangen, PhD John C. Rutlodge, MD llary Cu3hman, MD MS Adrian Dobs, MD, l\,4HSa

Curt D. Fulborg, MD, PhD;forthe Cardiovascular Health Sludy Collaborative Research Group(Circulation 2000; 102i 17731779)

Backgnturd-several epidemiological studies have associated depressive symptoms with cardiovasculardiseas€. We investigated whether depressive symptoms constituted a risk for coronary heart disease (CHD) andlotal mortality among an apparenfy healthy elderly cohort

Methods end R6!tut'l'- In a orospective cohort of 5888 eldedyAmericans (65 years) who were enrolled in the

Cardiovascular Health Study,4493 parlicipants who were free of cardiovascular d isease at baseline provided annualinlomation on lheir depressive status, which was assessed using the Depression Scale of the Center forEpidemjologicalstudies. These 4493 subjects were followed for6yearsforthe development ofCHD and monality. Thecumulative mean depression score was assessed for each participant up to the time of event (maximum 6_yearfollow-up). Using timedependent proportional-hazards models, the unadjusted hazard ratio associated with every s_unitincrease in mean depression score for the development of CHD was l.15 (P<O.006);the ratio for all-cause mortalitywas 1.29 (P<O.OOol). tn multivariate analysesadjusted for age, race, sex, education, diabetes, hypertension, cigarettesmoking, total cholesterol, triglyceride level, congestive heartfailure, and physical inactivity, the hazard ratio for CHDwas.l.15 (P=O.OO6)and thatforallcause mortality was 1.16 (P=0.006).Among participanlswith the highestcumulativemean depression scores, the risk ofcHD increased by40% and riskofdeath by 600/0 compared with those who had thebwestmeans@res.

Conclusions-Among elderlyAmericans, depressive symptoms constitute an independent risk factor for thedevelopment of CHD and total mortality-

MENTAL STRESS INDUCES PROLONGED ENDOTHELIAL DYSFUNCTIONVIA ENDOTHEIIN-A RECEPTORS

Luka3 E. Spiak€r, MD; O.vid Hurlirnann, MD; Frank RuschiEka, l{D Roberlo Coni, t\'lDiFrank Enseleit, MD Sldney Shaw, PhD; Daniel Hayoz, MD John E. Deanfield, t!4D

Thomas F. Luscher, MD; Georg Noll, MD(Circulation. 2OO2; iO5:28172820 )

Backgtound-Mental stress is a risk factor tor atherosclerosis and may precipitate myocardial ischemia andinfarction. Because endothelial dysfunction is an early manifestation of atherosclerosis, we investigated the impact ofmental stresson endothelial function.

Methods and Resurts- The efiects of a 3_minute mental stress task on endothelium-dependentvasodilation were studied n healthy subjects withoutcardiovascularriskfactors. FIow-mediated (FN,'lD) and nitroglycerin(0.4 mg sublingual)-induced vasodilation were studied before and after mental stress by high-resolliion ultrasound ofthe radial artery. Additionally, FMD was assessed before and 10 to 45 minutes after mental stless duing intraarterialinfusion of a selective endothelin A receptor antagonist (BQ-123, I nmol/rnin) or saline, respectively. Endothelium_dopendent vasodilation was reduced by half for about 45 minutes (8 011.'l% versus 4 1+l0o/o; P<0 002)' whercasendothelium-independent vasodilation to nitroglycerin remained unaffected (1561 1 6 versus 14.3 t1-3%; NS).lntraarterial infusion ofBQ-123, a selective endothelin-Areceptorantagonist, but not saline prevenied the impairmentofendothefium-deDendent vasodilation (8.6t 1.2 versus 9.4! 1 .3yo, NS). In contrast, intraaderial infusion of norepinephrifl e of similarduration as mental stress did not inhibit F[4D

Concrusions -l\4€nta1 stress induces prolonged endothelial dysfunction, which is prevented by selectiveendoihelin-A receptor antagonism. This represents a novel and important link between mental stress andatheroscleroticvasculardisease.

WuL ePil hicn"d and gtitn uout

Mind Body MedicineMind & Emotions -Body & Diseaso . irlnd Therapy - Body Therapy

Rudolf Kllme3,Phd. (lndiana University), MPH (Johns Hopkin University),

Adjunct Prot. at Folsom Lake College, CA

"The mind st€adfastly refuses to behave locally,

as contemporary scientific evidence is beginning to show.We now know for example, that brain like tissue is foundthroughout the body.... So, even from the conservativepercpective of modem neurochemistry it is difiicult if not

impossible to follow a strictly localview of the brain.'LarryDossey, MD

Mind/body medicine is based on the recognition of

the relationship between mindand body, the body's innatehealing potential, and th€ partnershipof patientand healer

in restoring the body to health.lvlind/body medicine is an approach to healing

that uses the power of thoughts and emotions to influencephysical health. As Hippocrales once wrote, ''The naturalhealing force within each one of us is the greatest force ingetting well." This isthe essenceofmind/body medicine.

While phrases such as "mind over matte/' have

been around foryears, only recently have scientistslound

solid evidence that mind-body techniques actually docombat disease and promote health. In 1989, a landmark

studybyDavid Spiegel, M.D. at Stanford University School

of Medicine dramatically demonstrated the power of the

mind to heal. Of86 women with late-stage breast cancer,half received standard medical care while the other half

received the standard care plus weekly support sessaonsin which lhe women were able to share both theirgriefand

their triumphs. Spiegel discovered that the women whoparticipated in the social support group lived twice as long

as thewomen who did not.

"A relaxed attitude lengthens life. jealousy rots at away."Proverbs l4:13, NLTMind and Body lredicine is the subject of the Mind/Body

Ivledicallnstitute:

The Mind/Body Medical Institute is a non-profil

scientific and educational organization dedicated to thestudy of mind/body interactions, including the relaxation

response. The Institute will use its expertise to enhance

tho recognit ion and understanding of mind/body

medicine's role in the oractice of medicine, to toster and

expand the uses of mind/ body interactions in healthcareand other appropriate settings, and thereby, to advanc€health and well-being throughout the world. l taccomplishes these objectives in a variety of ways,

including:

. documenling and furthering the understanding ofthe

scientific bases ofmind/body medicine, including therole of belief, and exploring their uses by conductingbasic and clinical research, both independently andcollaboratively,

. disseminating its knowledge and experience and the

results of its findings through medical and generalpublications, leclures, symposia, continuing medical

education programs and olher appropriate media,. quantifying the benefits and costs of mind/body

programs,. teaching medical students and training post'

docioral fellows and other researchers,. training health care and olher professionals and

helping them integrate mind/body interactionsintotheirwork, and

. fostering the establishment of clinical and

rcsearch programs in institutions that provide

healthcare.

Note: The mind affects the body and the body affects themind. Thus it may not be possible to clearly divide lvlindand Body Medicine into mind therapy and body therapy.There is an overlap that makes it attimes difficult. Thus the

areas should be seen as ageneralaid for the presentation

ratherthan a definite taxonomy.

1. Mindand Emotions1. 1 Positive Emotions and Feelings: joy, interest,

contentment, optimism, love, serenity, enthusiasm,laughter, empathy, action, curiosit, etc.

1.2 Negative Emotions and Feelings: anger, fear,anxiety, alienation, hopelessness, apathy, grief, halred,

shame, blame, regret, resentment, hostility, etc.

I

Emotions Anonymous has been known to work

miracles in the lives ofmanywho suffer from problems as

diverse as depression, anger, broken ol stralned

relationships, grief, anxiety, low self-esteem, panic,

abnormal fears, resentment, jealousy, guilt, despair,

fat igue, tension, boredom, loneliness, withdrawal,

obsessive and negative thinking, worry, compulsive

behavior and a variety ofother emotional issues.1.3 Emotions and Disease.

This story begins as did so many othercomponents ofour

culture, in Grcekand Roman antiquitywhere medicine first

emerged as a secular activity independent of religion.

There Hippocrates (ca.460 B.C.Bca.370 B.c.) and his

followers combined natulalistic craft knowledge with

ancient science and philosophy to produce the firsl

systematic explanations of the behavior of the human

body in health and illness- Distant ancestors of modern

biomedical scientists began to explore the solid and fluid

parts ofthe human organism for keys to unlock the hidden

mechanisms of disease. They made the first attempts to

understand emotions as mental phenomena which had

surprising and complex connections to physiological ord er

and patholog ica I diso rd etEarly Western physicians lecognized that emotions

were of essential signiflcancel however their medical

systems were actually weighted more heavily on the body

side of the mind-body balance. The dominant theory of

Hippocrates and his successors was that of lhe four"humors": black bi le, yel low bi le, phlegm, and blood. When

these humors were in balance, health prevailed; when

they were oul ol balance or vitiated in some way, disease

took over. The goal of an individual's personal hygiene

was to keep the humors in balance, and the goal of

medical therapy was to restore humo€l equilibrium by

adjusting diet, exercise, and the management of the

body's evacuations (e.9.: the blood, urine, feces,

perspiration, etc.). The bedside scene from Walter Ryffs

Spiegel und Regiment and the diagram from Johannes de

Ketham's Fasciculus Mediclnae, although both from later

periods,clea yillustratetheseclassicalthemes.

1.4 Copingwith NegativeemotionsNegative Emotions can be described as anyfeeling which

causes you to be misemble and sad. These emotions

make you dislike yourselfand others, and take away your

confidence.Emotions which can become negative are hate, anger,jealousy and sadness. Yel, in the right context, these

feelings are completely natural. Negative emotions can

dampen our enthusiasm for l i fe, depending on how long

we let lhem afJect us and the way we choose lo express

them.Holding onto negative emotions causesa downward spiralNegative emotions stop us from thinking and behaving

rationally and seeing situations in their true perspective.

When this occurs, we tend to see only we want lo see and

remember only what we want 1o lemember. This onlyprolongs the anger or griefand prevents us frcm enioying

life.The longerthisgoes on, the more enttenched the problem

becomes. Dealing with negatve emotions inappropriately

6an also be harmful - for example, expressing anger with

Emotions are comp ex reactions

Emotions are psycho ogica (whatwe think) and brological

(what we feel). Our brain responds to our thoughis by

releasing hormones and chemicals whlch send us inlo a

stale of arousal All emotions come about in thrs way,

whelher posiiive or negalive

It is a complex process and often we don't have the ski ls to

deal with negative feelings. That's why we fnd it hard to

cope when we experience them.

H o w t o d e a l w i t h n e g a t v e e m o t i o n s

There are a number of coping strategies io deal with

negative emotions. These include:. Don't blow lhings out of proportron by gorng over

them time and again ln your mind.. Tryto be reasonable accept that bad feelings a re

occas onally unavoidable and think oi ways to

makeyourse f feel beiter.. Relax - use p easanl aci ivt ies lrke reading,

walking ortalking to a frrend.. Learn notice how griet, loss and anger make you

feel and which events trigger those ieelings soyou can prepare In aovance.

. Exercise - aerobic activty lowers your level of

stress chemicals and a lows you to cope better

wilh negativeemotLons.Let go of l l"e oast co^stanlly gor'q ove' negalive

evenls robs you ofthe present and makes you feel bad.

2. Body and Oiseaae2.1 Diseases of the head, blood vessets, gut,

immune system, etc2.2 Stress reactions via the hypothelmus (CRH),

pituarity glands (ACTH) and the adrenal glands (cortisol

and epinephrine)2.3 The stress response via mind or body real or

imagined stimulation raises blood pressure, pulse,

breathing rate and muscletension.

2.4The relaxation response lowers blood pressure,

pulse, breathing rate and muscletension.

2.5 Mind/Body Communication

Our thoughts and feelings influence the body via

two kinds of mechanisms: the nervous system and the

circulatory system. These are the pathways of

communication between the brain and the restofthe body.The brain rcaches into the body via the nervous

system. This allows it to send nerve impulses into allthe

body's tissues and influencetheir behavior. The brain can

thus affect the behavior of the immune system with its

nerve endings extending into the bone marrow (the

birthplace of allwhite cells), the thymus, the spleen. and

the lymph nodes.It also rcaches into allthe glands of the endocrine

system, allthe bones, muscles, allthe internalorgans, and

even the walls of veins and arteries. lt can influence the

behaviorofthe heart with its neNes penetrating the heart

tissue, affecting heart rate and othef aspecls ofthe heart's

functioning. The entire body is literally "wired" bythe brain.The brain is also a gland. lt manufactures

thousands of dlfferent kinds of chemicals and releases

them into the bloodskeam. These chemicals circulate

throughout the body and influence the activity and

behavior of all the body's tissues. The brain could be

described as the ultimate apothecary, producing many

more drugslhan science has ever invented,The cells of the body have receptors on their

surfaces that function somewhat like satellite dishes.

These receptors receive the chemacal messages being

released bythe brain and respond accordingly.Finally, the mind/body connection is a two-way

street. In addition to sending messages into the body's

tissues. italso rec€ivesfeedback. both in theform of nerue

impulses and its own receplors that sense whatchemicalsare being released by othertissues in the body.

Research into how the brain can influence

immune responses has given rise to the new tield calledpsycho-neuro-immunology (PNl). Findings in this field

have brought great hope to people dealing with such

difficull illnesses as cancer, AIDS, cFIDS (chronicfatigue

immune dysfunction syndrome), and other immune-

related diseases.It is only a matter of time before similar acronyms

are defined for other fields such as psycho-neuro-

cardiology (PNC), the study of the mind-heart connection,

or psycho-neuro-hematology (PNH), the study ofhowthemind can influence bloodrelated disorders, such as

clotting problems in hemophilia.

3: MindTh€rapy3.1 Spkitual: Prayer, medilation, spiritlality, music, humor,

cheerf ulness, biblio-therapy, forgiveness.

3.2 Posit ives: Guided amagery and visualization,positivasm, cognitive behavioral therapy, journaling.

3.3 Easlem: Ivlindfulness, yoga,lai chi, qigong.Yoga: EffectonAttention inAging & t!4ultiple Sclerosis,

National Center for Complementary and Alternative

Medicine (NCCA[,4)Purpose

Changes in visual attention are common amongelders and people with multiple sclerosis. The visualattention changes contribute to difficulty with day to dayfunctioning including fal ls, driving and even f inding one'skeys on the kitchen counter as well as coniributing todeficits in other cognitive domains. Yoga emphasizes lheability to focus attention and there is some evidence thatthe practice ofyoga may improve one's cognitive abilities.Additionally, yoga praciice may improve cognitive functionthrough other non-specific means such as improvedmood, decreased stress ordeclines in oxidative injury. Wepropose a randomized, controlled 6 month phase lltrialofyoga in two separate cohorts: healthyelders and subjectswith mild multiple sclerosis. We will determine if yoga

intervention otoduces imorovements on a broadattentional battery that especially emphasizes attentionalconlrol. To further understand the reported beneficialeffect of yoga on its practitioners, we willalso determine ifthere is a positive impact on measures directly relaled to

yoga practice (fexibility and balance) as well as mood,quality of lite and oxidative injury markers. The yoga

intervention consisls of a Halha yoga class meeting twiceper week. The class is taught by expedenced yoga

teachers who are supeNised by a nationally known yoga

instructor. There are lwo controlgroups. An exercise group

will have a structured walking program prescribed by a

certified Health and Fitness Instructor and PersonalTrainer The program willattemptto match the Hatha yoga

class for metabolic demand. The second control group willbe assigned to a 6 month waiting list. The outcomemeasures are assessed at baseline and after the 6 monthperiod. The primary oulcome measures are alertness(quantitative EEG and self-rated scale), ability to focus

attention (Stroop) and abil i ty to shift attention(ext€dimensional set shifting task). Secondary attention

outcome measures include the ability to sustain attention(decrement in reaction time) and ability to divide aftention(Useful Field of View). Other secondary outcomemeasures include flexibility, balance, mood, quality oflife,fatigue (in MS cohort) and decreased markers of lipid,protein, and DNAoxidative iniury.

3.4 Social: Relationships, suppod groups, talktherapy, connections, f riendships.

3.5 lvlind-Body Interventions for GastrointestinalCondil ions

The objective of this evidence report was to

search the literature on the use of mind-body therapies for

the treatment of health conditions and, on the basis ofthissearch, to choose eiiher a condition ormind-body modalityfor a comprehensive reviewAbroad search of mind-body therapies showed thattherewere suff icient studies regarding their use forgastrcintestinal (Gl) conditions to warrant a detailedreview. Gl conditions pose a significant health problem,

and theycan be challenging to manage.

They also have been the focus of mind-bodyinterventions, including:

. Behavioral therapy.

. Biofeedback.. Cognitive therapy.. cuided imagery.' Hypnosis. tuleditation.. Placebotherapy used asan intervention.

. Relaxation thera py.

. I\,4ultimodaltherapy.However, no studies of medilation were found thal used acomparative treatment design. Therefore, this reportreviews the use of behavioral iherapy, biofeedback,cognitive therapy, guided imagery hypnosis, placebo

therapy, lelaxation therapy, and multimodal therapy for thetreatment of Gl conditions.Findings. The five most common body systems/condalions

for which mind-body therapy literature was found are:neuropsychiatric; head/ear, nose, and throat (head/ENT);

Gl; circulatory; and musculoskeletal.. The trials that exist on Gl conditions are seriously

l imited by methods problems (small sample sizes,lack of randomization, and clinical heterogeneity).

. The greatest number of lrials of a mind-body

thera py for G I cond itions in trialswas biofeedback(n=17) .

. There are fewer contfolled trials in the Gl studies

thal assess other mind-body therapies: hypnosis(n=8), relaxation (n=8), behavioral iherapy (n=8),multimodal therapy (n=4), cognitive therapy(n=4), imagery (n=2), and placebo (n=1).

. The most commonly studied Gl conditions were

i r r i t ab le bowe l synd rome (n=15) , f eca lincontinence/encopresis (n=11), constipation(n=10), vomit ing (n=8), nausea (n=7), andabdominal pain (n = 5).

. There is no evidence to supporl the efficacy of

biofeedback therapy for children.There is l imited ev dence (i .e., at least one tr ial

whose q ua llty score characterized il as "good" thatreported statistically significant benefits and themajority of other studies also fepod statisticallysignificant benelits) lo support the efficacy of thefollowing m ind-body th era pies:Behavioral.

o Cognit ive.o Guided imagery.o Relaxation.The methodological shortcomings of studies

report ing benefrcra effects of hypnosispreclude drawing conclusions about i tsefflcacy.Results are mixed regarding the use of

biofeedbackin adultsSourcelhttp://www.ahrq-gov/clinic/epcsums/rnindsum.htm

OPENTNG THE MINDCommentary - Realizing Negativity and Developing Positivities

BK Bala GuPtaResearch Associate, CAD Research Prcject, Global Hospilal & Research Centre

what is Mind? lrind is meiaphysical. lt has tuur aspects :T - Thoughts, E - Emotions, A . Attitudes, lil - Memories (TEAM)

This world is a drama... that is who themselves crushed my feelings and imposed their

unique, mostwonderful, etemaland never ending desires and opinions on me and lhese

complete in al' aspects... lt's havebecome myfate-.. myfreedom ie. my original nature

Creatorand Diector is Almighty, the and virtues (ofbeing peaceful, loving, blissfuland happy)

Father of all Souls, God Shiva who is the benefactor and were replaced by negatives (like peacelessness, anger'

forever pure and supreme... I, the soulam Hiscreation . sadness and despair...) the lack of Truth' SupPort and

He has created meforwithout me His creation, this World Love have filled my life with criticism' tension' hurry-

Drama. is incomplete..... I am the luckiest and most sickness, worry and responsibilities which have burdened

fortunate asthe creator offate has Himselfselected me to my life... most natural duties towards family and society

be pad of His creation... though my role is hut a small seemed to me like a heavy burden

scene of this huge world drama, it is complete in allrespects and so am 1... there are no defects, noshortcomings in me.... t!4y part is unique and perfect,

which no one else can play.... Without me this worlddrama. the creation of Supreme Being is incomplete andthis cannot be for Almighty Authority is perfect.... TheUltimateTruth. llove the role given to me by Him... for onlyI am capable of playing this role... I like my Father, andunique, wonderful and complete.... I have to play my part

with utmost devotion, and at the same time relish itto theextreme... for it is mine... Only bydoing as above, I can dojustice to my Father (Supreme Being), myself and myrole... The roles and expectations of other souls whenimposed on my role, effect my role... The roles andexpectations of other souls when imposed on my roleeffect my performance and fill my life with negativeattitude... I am caught in the monstrous waves ofjealousy,hatred etc. (the negative attitudes)... whenever I havetried to go beyond the effect of these tendencies, thefailureto do so has resulted in the getting more entangledin this vicious web... The reason of this failure is the factthat lhave always looked for support and strength inthose

But now I have the creator, truthful Father,Teacher, Liberator (Sat Guru), Friend and Lover,with Him Iam not alone and fully capable offreeing myself from thevicious web of vices or negative tendencies... I am thechild of Almighty authority and therefore I too am masterAlmighty. Now I am the happiest... not even the slightesthace ofnegativities c€n touch me... theyjust cannot affectme for I am protected under the canopy ofAlmighty... mylrue form and nature are coming forth.-- knowledge, purity,peace, tove, happiness, bliss and power arc flowing outofme like a foundation... every organ of my body, every cellis saturated with vibrations of knowledge and purity-.. l.the soul, am geti ing healed... aaha...what bl iss lamexperiencing in myfree originalform... Baba... oh sweetBaba... lam blessed with yolr companionship... Babayou arc the greatest magician... how may lthank you...my losl selfrespect, mydestiny, my destiny, myfate. I havegotthem allback... now l(soul)am completely healthyandfull of my strength and vitality... wah Baba wah... OmShanti.

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e.xamplz, u'hrt tinc da J gt b pic& u? ,na ftiAa fun o&u$

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ttuugAto al tAe paat o'r fulla@: " 4 o'11r. . ." A " J Aope oo" .

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&t lead t4 aW-Aeallh a d nenlal6'.eaAd4!aa-

4- gotitiac nfuuSAL: 1fre* arc tfuqAla tAal uplilt.fa&, enngtuq.falL iW ad fta'ppinan..

FOOD, MOOD AND HEALTH: A NEUROBIOLOGIC OUTLOOKsection of Endocdnorosy & uetaoorism, oepartmecnilli,X"i","., a"u ""0,"", "enter, New oneans, LA, usA

Hippocrates was the first to suggest the healingpower oftood; however, it was not untilthe medievalagesthat food was considered a tool to modify temperamentand mood, although scientific methods as we know themtoday were nol in use at the time. Modem scientificmethods in neuroscience began lo emerge much later,leading investigators to examine the role of diet in health,including mental wellbeing, with greater precision. Thisreview shows how short- and long- term forced dietaryinierventions bring aboul changes in brain structure,chemistry, and physiology, leading to altered animalbehavior Examples will be presented to show how dietsalter brain chemistry behavior, and the action ofneuroactive drugs. lrost humans and most animalspeciesexamined in a controlled setting exhibit a fairlyreproducible pattern of what and how they eat. Recentdata suggest that these patterns may be under theneurochemical and hormonal control of the organismsthemselves. Other data showthat in many insliancesfoodmay be used unconsciously to regulate mood byseemingly normal subjects as well as those undergoingdrug withdrawal or experiencing seasonal affeclivedisorders and obesity-related social withdrawal. We willdiscussspecif icexample6lhati l luskatethatmanipulal ionof dietary prefercnce is actually an attempt to correctneurcchernical make-up.

K€y wordsFood peptides Dietary carbohydrate and serotonin

Neu rolra nsmitter precursors

lntroductionl\4odem medical science has made imposing

progress in understanding the role of dietary nutrientsboth macro- and micronutrients in the maintenance ofnormal health and in the orevention of diseases likescurvy, pellagra, marasmus, Kwashiorkor, and manyothers. In the lasl few decades, an impressive volume ofresearch has been performed and scholarly articles havebeen written on the role of nulrition in brain developmentand mental health. 1 doubt that many scientists todaywould disagreethat nutrition plays a criticalrole in prenataland early postnatal development ofthe brain at alllevels,including structural, chemical, pharmacologic, andfunctional. This review bypasses discussions related tothe role ofnutrition in the developmental maturation ofthebrain and focuses instead on the role nulrition may play inthe restrucluring and functional modulation of the adultbrain.

When we speak of nutrition and health, wegenerally think ol nutrition in relation to the prevention oreven tr€alment ot cancer or ot obesity and relateddisorders. This is merely a refl€ction of the fact lhat notonly hav6 we leamed a great dealaboutthe role ofdiet in

cancer and obesity, but that such discoveraes make forpopular reading and that the news media are veryinterested in them. Most of us, however, rarely relate dieland nutrition to mental health. Only recenlly have werealized the potential of certain dielary nutrients andsupplements (macronulrients, antioxidant vitamins, andminerals) in the control of bodily functions, includingmental performance . This is supported by the fact that inlhe Western world alone, contemporary interest inmaintaining and enhancing both body and mind throughdiet and dietary supplementation has generated amultibillion dollar industry.

However, the use of diet to enhance mentalfunclion is not a recent phenomenon. The concept thatfood can help or hinder health was known and used byphysician priests atthe time ofAesculapius and centuriesbefore . The use of nutrition in patient care also was acommon practice at lhe time of Hippocrates. This isevident from one version of the physician's oath byHippocrates, pad of which reads as follows: 'l will applydietetic measures for the benefit of the sick according tomy ability and judgment; I will keep lhem from harm andinjustice". l\4edical nuvilion was at its pinnacle during theMiddle Ages, when il was common to prescribe diettherapyas the solelreaiment oras an adjuvantto standardmedication and surgery tor a disease. Maimonides orMoses ben N,faimon (1135-1204),Ihe philosopher, rabbi,and physician, advocated that any illness curable by dietalone should not otherwise be treaied . In the medievalholistic view of nature, mood wasthoughlto be modulatedby foods. The assertive relationship between food andmood is documenled in many medical culinary textbooksof the period; unfortunately, most are written in NredievalLalin, Hebrew,Arabic, and early English dialects, with fewEnglish translations. For medieval man, every tood itemwas important since il was associated with good or badefiects that might be immediate or delayed. S|rch effectswere related to the food itself rather than to its caloricdensity and composition. For example, some foods wereconsidered erotic stimulants (eggs, pea- cock, beef,pomegranates, apples); others were used as moodenhancers (quince, dates, elderberries) or tranquilizers(lettuce, purslane, chicory).

Twentieth century literature on the impact of dietand nutrition on mental health and behavior is laced wilhcontroversial reports, particularly when they involveinvestigations on human subjects. The reasons for suchcontroversies are many. Often, overenthusiastic scientistsand news-starved media are too eager to jump to far-reaching conclusions based on oflen soft or preliminarydata. Many times, anecdotal data creep into scientificliterature and with time come to be viewed as huth.Additionally, it is ofren expensive and difficult to run well-

designed long-term human nutritional trials, making itdifficult to suooort or refute anecdolal obse ationsckculating in the literature. I must mention, however, thatthere are some excellentshort-term human trialsthat haveexamined the rolo ofdiet in human behaviot lwill discusssome of these studies later in this review. On the otherhand, a wealth of information emerging from animalstudies unequivocally suggests a role for diet, nutdtion andnutritional supplements in modulating not only brainchemislry and behavior but possibly the structuralelementsofthe brain.

Dietary influences on brain chemistry

Neurokansmitters and neuromodulators arebasic units of chemical communication within the nervoussystem. These include a variety of phenethylamines andtheir derivatives (dopamine, norepinephrjne, epanephrine,tyramine, octopamine, and tetrahydroisoquinolines),indoleamines (serotonin, melatonin, and tryptamine),cholinergics (acetyicholine and choline), amino acids andtheir derivatives (glutamate, aspartate, glycine, taurine,histamine and gamma-amino butyric acid), nucleosides(adenosine and inosine), hormones (prostaglandins,corticosteroids, estrogen, testosterone, thyroid hormoneand many others), and peptides (enkephalin, endorphin,substance P, cholecystokinin, somatostatin, cyclo (His-Pro), thyrotropin releasing hormone and manyothers).

irost of these are synthesized de novo usingprecursors provided by the food that we eat and thus areunder direct influence of the diet. As an example, I willdiscuss the role ofdietary protein and carbohydrate in thesynthesis of serotonin, a neurohansmatter ubaquitousthroughoutthe nervous system.

A carbohydrate-rich/protein-poor diet increasesand a protein- ch diet decreases brain serotoninsynthesis. The following is an explanation of thebiochemical basis for the dietary control of serotoninsynthesis.The synthesis of serotonin in the brain is limitedby the availability of tryptophan. The large neutral aminoacids (LNAA), tryptophan, valine, leucane, asoleucine,methionine, phenylalanine, and tyrosine, share the sametransport canier across the blood-brain barrier. Atphysiologic blood amino acid concenkations, there iscompetition for available carrier sites. Therefore, thetransport of blood tryptophan into the brain is proportionalto the ratio of its concentration to lhat of the sum total ofolher LNAA. Con- sumotion of a orotein-rich meal raisesthe blood levelofmany amino acids. Tryptophan is one ofthe least common amino acids in dietary protein.Therefore. a protein-rich meal contributes proportionatelymore competing LNMS than tryptophan, resulting inreduced entry of lryptophan into the brain and reducedserotonin synthesis.

Conversely, a carbohydrate-rich meal can alsoalter blood amino acid levels . This effect is mediated by

the action of insulin. which promotes the uptake of mostamino acids by muscle, which accounts for >45% of leanbody weight. Muscle metabolizes branch-chain aminoacids, lhereby loweing their concentration in the blood.Plasma tryptophan levels are unaltered by carbohydrateconsumption, and insulin does not promote the netuptakeof tryptophan into muscle because this amino acid islargely bound to low-affinity, high-capacity sites onalbumin. Normally, 75 to 85% ol plasma tryptophan isbound to albumin. When insulin is secreted. the olasmalevels of nonesterified fatty acids (NEFAS) fall becauseinsulin promotes up-take ofNEFAS byadipocytes. NEFASalso are adsorbed on circulating albumin, therebyincreasing the number of sites available on albumin forbinding tryptophan. This rise in bound tryptophancompensates for the slight fall in plasma free tryptophancaused by insulin-mediated uptake of amino acids bymuscle. The totalamount oftryptophan in plasma (boundplus free) determines the rate of hansport of tryptophaninto the brain because the affinity ofthe kansport systemfortryptophan is much greater than the affinity ofalbuminfo r t r yp tophan- Thus , i nges t i on o f a h igh -carbohydrate/low-protein meal facilitates entry oftryptophan into the brain.

Once in the brain, tryptophan undergoes a seriesof enzymatic reactions, resulting in the synthesis oftheneurotransmitter serotofin. The first (and the rate-limiting)step in the conversion of tryptophan to serotonin ishydroxylation of tryptophan by the enzyme tryptophanhydroxylase, a low-affinity 6. 0.4 m[.4) enzyme that isabundant in the brain. Accordingly, whenever the brainlryptophan levelises, more serotonin is produced - Ratsfed orinjectedwith tryptophan have higherbrain serotoninlevels than do conkols. Conversely, rats fed a corn diet(tryptophan-poor) have low levels ofbrain serotonin.

Neuroactive substances in food l\,4any of theneurotransmitter substances discussed above arepresent in ourfoods and, therefore, can directly influencebra in chemisky . Here l l a l k abou t f ood -bo rneneuro t ransmi t te rs /neu romodu la to rs . Long ago ,Hippocrates. the fatherofmedicine, said, "Let yourfood beyour medicine, and your medicine be your food". Thecoming cenlury holds great promise and the opportunitiesto test the accuracy of this slatement. Epidemiologicstldies over the last sixty years have clearly linked dietand lifestyle with cancer and cardiovascular diseases . Inthese studies, the disease-modulating activity of food hasgenerally been associated with caloric density ormacronutient corn- position. For example, a diet high infat has been associated with an increased risk of breastcancer and atherosclerosis. However, new knowledge,some anecdotal and some scientific, aboui mental healthand foods hasjust begun to emerge ; antioxidant vitaminsand minerals, for example, are thought to attenuateprogression of neurodegenerative diseases and seizure.Such effects offoodsarc more likelyto beassociated with

the presence of neuroactive substances in foods ratherthan with their caloric density. This section will provide avery brief over- view of the types of neuroactivesubstances found in food.

Serctonin

Serotonin is a chemical the brain Droduces fromtryptophan. Where do we get tryptophan? From theprotein in our food. Brain serctonin conlrols manydifferenttypes of bodily functions, including appetite, bodyt€mperature, libido, and mood, to name a few Some of thefoods rich in sorotonin and tryptophan include clams,oysters, escargots, octopus, squids, banana, pineapple,plum, nuts, milk, and turkey.

Cyclo(His-Pro)Cyclo(His-Pro) or CHP has profound effect on

satiety, hunger, and behavior . Chemical substances likeCHP are common in fermented foods or foods containinghydrolyzed proteins. For example, high levels ofCHP arefound in nukitional suoolements derived from thehydrolysis ot casein, a milk protein, and from soy protein.During a search for CHP in food, we found that many pro-tein-derived processed foods contain copious levels ofCllPThese included nutritionalsupplements(e.9., EnsurePlusand TwoCalRN), sh mp, tuna, and a varietyofotherfood products . Other foods rich in CHP include milk,yogurt, and buttermilk

Cholecystokinin

Like cHP, cholecystokinin (CCK) is also foundnatlraily in our brain and gut. Soon alter we begin to eat,CCK begins to be released from ourgut. When the bloodlevel of CCK rises to a critical level, we feel satiated andstop eating - The release of CCK after satiety has beenachieved is lem inated bythe action of trypsin on gut. Forthat reason there is now substantial interest in developingCCK as a drug for appetite control. Unfortunately, largedoses ofCCK act on sites in the brain thal controlanxietyand panic behavior. One solution to this problem might bethe use otfood rich in CCK. Unfortunately, to date we knowof no such naturalfood. This does not mean CCK does notexist in natural foods, only that no one has traken time toscreen mmmon foods for this peptide. Meanwhile, thereare data to suggest that the use of certain foods toincrease blood CCK levels may be possible. Forexample,many animal and human studies show that a dietconlaining soy protein, a ri6h source of trypsin inhibitor,may increase circulating level of CCK. Actually, any foodrich in lrypsin inhibitors should result in increased CCKSecretion and early satiety.

Two oth€r foodderived substances must bementioned here. The first is peptone broth, a greatstimulusfor CCK secretion. The second is phenylalanine,a natural amino acid that comes from digestion of proteindch foods such as casein or soy protein. Phenylalanine

has been shown to be a potent stimulant of gut CCKreleasein humanand animalstudies, as wellas a powerfulinhibitorof food intake in hungry human subjects.

Exorohins

Exorphins (exo exogenous or from ouf side,orphan=morphin, an opium), the opposite of endorphins,are a family of foodderived peptides that act on brainopiatereceptors. DrWernerKleeof theNational InslitutesofHealth has shown thatwhen pepsin, an enzymefound instomach, acls on casein (a milk protein), it generatesmany peptides, some of which interact with opiumreceptors in the braini he called these peptides"casomorphins" . Today we know of many peptides thatcome from gluten (a wheat protein), zein (a corn protein)and casein and act as opium antagonists, which, inaddition to being appetite suppressants, affect a variety ofother central nervous system functions, including mood.Heterocyclic aminesThese amines comprise a family of bioaclive substancesin food that are not endogenous to food but are producedduring its preparation or processinq. Earlier I talked aboutthe high levels of CHP in protein- derived nutritionalsupplements like Ensure Plus ihat are produced by acombination ofenzymatic hydrolysis of proteins and heatlrealment. I also must menlion two helerocyclic aminesthai are products of tryptophan pyrolysis and that areoresent in meat and fish cooked on an open flamet thesewere identified as 3-amino-'l,4-dimethyl-sH- pyridoll4,3-bl indole(Trp-P-1) and 3-amino-1-methyl-sH-pyridoll4,3-bl indole (Trp-P 2) These compounds are related to 13-carbolines with slruclures similar to 'l-methyl-4-phenyl' 1,2,3,6{etrahydropyridine (N,,|PTP), a man-made agentknown to cause Parkinson's disease. Functionally,however, they are quile opposite to MPTP Systemicadministration of Tro-P- 1 and TrD-P-2 to mice calsed amarked increase in the neurolransmitter dopamine (DA)and a decrease in DAmetabolites in the brain, suggestinginhibition of enzyme monoamine oxidase in vivo. Thesedata suggest the possibility of altering DA-dependentbehaviors following consumption of foods containingthese heterocyclic amines.

Human sludies -from anecdote to sound science

Since long{erm controlled clinical siudies on theeffects ofdiet on human behavior are logistically difficulttoconduct, most published studies are either anecdotal annature or epidemiologic and plagued with poor design.Epidemiologic studies generally requhe subjects orsometimes an acouaintance of lhe subiect to fill outquestionnaires that involve recalling pasl events, apotential source of enor This is the major reason forinconsistencies in the conclusions of different reports.Despite these problems, a careful meta-analysis of suchrcsearch ot ten yields a fairly accurate idea ofthe role dietmay play in human behavior. Lel's l,ake a specificexample: much has been written about the alleged

relationship between refined sugars in the diet andhyperactivity in children and criminality in adults. Some ofthese studies suggest that excessive ingestion of simplesugars (i.e., sucrose and glucose that can be present angranllated sugar, cookies, cereals, chocolates, andsweets) has profound efiects on human physiology,behavior, and intellectual functions. Other studies havefound no effect on blood glucose regulation, mood, bodilysymptoms, or cognitive function in persons reporting twoor more years of heavy consumption of refined sugat Thetruth probably lies somewhere between these extremesThe behavioral sensitivity to sugar and other dietaryconstituents may vary from individualto individual, and theeffects on behavior may be more subtle than manyinvestigators teal ize or wish to acknowledge.ln contrast, dietary supplements capable of having directeffecls on brain neurotransmitter make-up may exertprofound efiects on human behavior. These inclldesubstances that act as neuotransmitter precursors (e.9.,tyrosine, tryptophan, choline, and lecithin) or modulatorsof poslreceptor events (e.9., caffeine). The differentbehavioral effects of diet and dietary supplements onhumans involve changes in sleep pat-lerns, perception ofpain, and mood, to namea few.

SleeDThe amino acid composition of a single meal

designed to affect brain tryptophan availabilaty has beenshown to modulate sleep behaviorin newborns. Similarly,many studies conducted on adult humans receivingvarious dosages of tryptophan by different rolltes ofadministration (10-500 mg/kg, orally, to much lowerinkavenous doses) show that tryplophan increasesd rowsiness and feelings of fatig ue and lethargy . In healthyfemale adult humans, oneweek ofdaily consumption ofalow-carbohydrate diet (50 g/day) caused a significantincrease in REM sleep latency (66 1 I to | 1 1 i 38,P<O.05). In contrast, when the relation-ship between a 5-day self reported dietary history and the response to asleep questionnaire was analyzed, no link between sleepand dietwasfound in adults. This suggests that it may benecessary to use high levels oIa dietary supplementortoinstitute major dietary changes to see an effect onbehavior.

PainperceptionIn a controlled double-blind crossover study, 50

mg/kg oral tryptophan reduced pain sensitivity tomoderate but not to very mild or very painful stimuli. In adouble- blind study, patientswith chronic maxillofacial painreported a 50% reduction in pain afler 4 weeks of a high-.carbohydrate dietand 3 g oraltryptophan daily;in contrasl,the placebo group reported only a 20% reduction in pain.In another study, tryptophan{reated patients undergoingrhizotomy and cordotomy also reported a reduction inchronic pain- In a preliminary study, tryptophan has alsobeen shown to potentiate electrically induced endorphinanatgesra

Mood

The association between food intake or eatingpatterns and mood is ofgreat interestto scientists and laypersons alike. In addition to an abundance of anecdolalreports in the literature, there is considerable scientificevjdence demonstrating that food influences mood andperformance. lt has been suggested that many patientsconsume large quantities of carbohydrate-rich food toelevate their mood; these incllde those diagnosed withconditions with a significant depressive component suchas seasonal affective disorder (or winter depression),premenstrual shess syndrome, or nicotine withdrawal.Consumption of carbohydrate-rich food may elevate moodin such individuals by raising brain serotonin levels.Dexfenfluramine, an agent known to facilitate brainse.otoninergicactivity, is also known to elevate mood statein all of the above mentioned condilions. Incidentally,vitamin D3 has been shown to enhance mood in healthysubjects prone lo winter depression. lt remains to be seenwhether vitamin D3 acts by raising brain serotonin levelsorthrough some othermechanism.The relationship between food and mood in seeminglynormal individuals is not a simple one but instead dependson the time of day, the type and macronutrientcompositionof food, the amount of food consumed, and the age anddietary history ofthe subject. Forexample, while skippingbreakfast impairs cognitive performance, a larger- than-normal breakfast improves recall performance but impairsconcentration, Fudhermore, changes in ihe macronutrientcomoosition ofbreakfast have differential effects on mood.Forexample, changes in mood have been producecl mosteffectively by raising brain serotonin levels byadministering kyptophan or by supplementlng acabohydrate-rich/protein-poor diet with iryptophan. Ihave discussed the theoretical basis for lhis approach ingreater detail earlier.

Dietary influences on animal behavior - a road tohuman studies

While there is no doubtthatour ult imate goalis toundorstand how dietand nuhition can affect human moodand health, such knowledge is difllcull to come by forreasons discussed eadiet Animal studies designed tostudylhe effect of food on mood, then, are the gateway tofuture human study. Here, lsummarize the results ofsomeof the animal studies conducted over the years in mylaboratory on the role of dietary macronutrients in brainstruclure, chemistry and behavior in adult animals.Both undernukition and overnutrition in preweaning ratsresult in long-lasting functional changes in the brain. Theeffects of protein undernutrition on behavior, braindevelopment, and intellectual function are well known.Unfortunately, there are far fewer studies on the efiect oflong-lerm excess consumption of any macronuhientparticularly protein on the brain. Some reported studieson the efiect ofDrotein overnutrition on behavior are notrigorous in design and data analysis. For example, it has

been reported thatadultrats consuming a high-prolein dietbecome more easily frightened and "snappish". A fewyearsago, we undertooka seriesof studiesto evaluatelheeffect of long-term(20-36 weeks) consumption ofisocaloric high (50% oftotal calories; HP)-, moderate (20oloof total cabries; lrl P)-, and low-protein (5% of total calories;LP) diets on a variety of behavioral measures. Theseincluded the adhesive patch test and negative geotaxiscommonly used to evaluate sensorimotot functaon;locomotor activity and stereotypy as measures ofambulalory and searching behavior; the tailflick test fornociception, and lhe elevated plus- maze test as ameasure ofanxiety and aversive behavior. The HP groupwas more responsive compared with the MPor LPgroupsin sensorimotor function, negative geotaxis, andspontaneous locomotor activit. In addition, the HP groupexhibited reduced aversion as measured by the elevaledplus- maze test of anxiety and hyperalgesia as shown bytail-flick reaction time. These daia suggested that long-term consumption of an HP diet may lead lo hyperactivityand hyperresponsiveness to the envilonmenl, a changethat may not always be deshable. In a separate study, weexamined whetherthe HP diet had any effect on learning,memory, and sensory discrimination. The results ofthesestudies showed the following: in the swim cylinder ofPorsolt, which tests adaptation to stress, HP rats weresignificantly less ablethan was thecontrolgroup (lvlP rats)to develop an effective coping strategy; during therecording of auditory-evoked responses to deviant tones,short-term auditory memorytraces degraded more quicklyin the HP rats, and finally, in the l\,'lorris water maze, diethad no signillcant effect on acquisition and recallofspatialinformation. These data suggest that a long-term HP dietmay precipitate a dellcit in short-ierm but not long-termmemory and a diminution in the ability to cope with acutestress.

A review ofthe literature indicates that a numberof food constiluents (e.9., dietary macronutrients andneurotransmitter amino acid ptecursors) as well as fooddeprivation may modulale developmenl of tolerance andphys ical d ependen ce and infl uence self-ad- nin istration ofseveraldrugs ofabuse in animals. In an effort to examinefurther the nature of neuronal changes responsible forpefturbation of spontaneous unprovoked molor behaviorin animals consuming lhe HP diet, we examtned thesensitivity of HP, l\rB and LP mice io a variely ofneurotropic agents such as amphetamine, apomorphine,haloperidol, etc. Thefollowing is a summary ofourstudieson amphetamine. Adult ICR mice were put on HP, 1,4P, orLP diets for 35 weeks. At the end of this period, all micewere tested for spontaneous locomotor aclivity (SLA) andstereotypic behavior (SB) after administration ofvehicle oramphetamine (0. 1 or 1 .0 mg/kg). Both SLAand SB, in theabsence of amphelamine, increased with increasinglevels ofprctein in the diet. N4ice on the LP but not the N,'lPor HP diets increased SLA and SB on low-dose (0. 'l

mg/kg) ampheiamine. Mice on HP but not LP or MP diets,however, failed to respond to high-dose amphetamine (1

mg/kg). These data suggest that long-term consumptionof an HP diet not only may lead to hyperactivity andhyperresponsiveness to the environmenl bul mayattenuate neuronal sensitivitv to amDhetamine andpossiblyotherdrugs of abuse. l t is general ly accepled thatamphetamine-induced locomotjon is mediated bymesolimbic DAergic neurons, whereas stereotypy lsassociated with nigrostriatal neurons. Furthermore, thereis abundant evidence ihat DAalone is largely responsibleforthe effecl ofamohetamine on SLAand SB. Therefore, ilseems thal a long- term HP diet may modulaie multipleDAergic pathways in the brain; it rs nol clear how the HPdiet may affect olher neuronal systems. To gain furtherinsight into the effecl of dietary protein on theneurochemical makeup of ihe brain, we exam ned thedisiribution of DA, DA-melabol tes (dihydroxyphenylacetica c i d ( D O P A C ) a n d h o m o v a n r l l i c a c i d ( H V A ) ) ,norepinephrine (NE), serotonin (5- HT), and 5-hydroxyindolacetic acid (5- HIAA) in the brains of ratsconsuming LP, NrP, and HP diets for 36 weeks. Here Idiscuss only ihe data on DA and its metaboliies.In the substant ia nigra, the slr ia ium, and the dentategyrus, DA evels decreased and rncreased, respeclrvely,wi lh a decrease and increase in dietary protein (P<O.05corn- pared wiih the M d et The nigroskiata system isimporlant to a number ofbehavrors relaled to sensorlmotori n t e g r a t i o n a n d r e s p o n s e i n i t i a t i o n , i n c l u d i n gextrapyramidal movement, aphagia and adips a, emesis,and stereotypy. Ourbehavioral studies have shown thatthe HP diet produces hyperact viiy. These neurochemicaldata suggest that an ncrease n DA in the nigrosiriatalsystem may contribute to behavioral hyperactjvly in HPrats. In the mesol imbic system, dietary manipulat ion hadthe most marked effect on DA metabolism. There was adiminution in amygdala DOPAC/DA and HVA/DA raiios inthe rals on the HP diet, suggesting a decrease in the firingof DAerglc neurons nthisregion DAiransmission in thisregion is impl icated in emotion, sexual behavior, and thereward propedies of many drugs of abuse (56-59).Therefore, rt is conceivable that reduced sensitivityto SLAand SB after amphetamine admlnistrat ion to HP rais mayb e r e l a t e d l o c h a n g e s i n D A m e t a b o l s r n .In addition to its neurochemical and behaviora I effects, lhelevel of prote n 1n ihe diet has also been shown to have aprofound effect on food iniake, body weight, and bodycomposit ion. For example, White et al . have recentyshown that rats given a low- prolein (5olo) diet for only 1 1days, compared with those on a 20"/o-protein diei,increased NPY gene expression n the hypothalamus,result ing in augmented calor ic intake. In rats on 5%protein, whi le their average dai ly food intake wasincreased by 20%, their body weight gain was severelyattenuated, and body composiiion analysis revealed increased water retention decreased body protein, andincreased body fat. while ihese studies underscore theeffectofa low-protein diet-mediated increase n NPY geneexpression on appetiie, other behavioral con sequencesassociated with increased NPY femain to be e ucidaied.

Concluding remarks

Proteins, carbohydrates and fats the maiorconstituents ofourdiet serve notonly as an energy sourcebut as precursors to a variety of neuroactive substances.The so- called minor constituenls of food minerals andvitamins are just now being recognized for their manynontraditional functions (e.9., as antioxidants) in healthmaintenance and promotion- ln addition, food is a richsource of many bioactive substances like amino acids,peptides, and others. While some of these bioactivesubstances (CHe casomorphins, and a variety of othersub- stances capable of interacting directly withneurotransmitter receptors) can have a direct effect onneuronal functions, others serve as precursors(tryptophan, tyrosine, etc.) or modulators (heterocyclica m i n e s , p h e n y l a l a n i n e , e t c . ) o f c l a s s i c a Ineurotransmitters (DA, norepinephrine, serotonin,acetylcholine, endorphin, etc.). Furthermore, the use ofneurctransmitter prccursors as dietary supplements inboth humans and animals has shown profound effects onneurochemistry and behavior.

Food and dietary supplements, if used properlyand wisely, may help us live healthier lives. Althoughingestion of minute amounts of any given compoundthrough food may not have any good or badconsequences, a variety of foods in combination mayindeed affect mood and health. Some of thesesubstances, such as peptides, are naturally present infood (e.9., CHP in shrimp andtuna), whereasothers arisefrom in v,vodigestion of food (e.9., opiate antagonists fromcasein in milk) or from the use of protein hydrolysates asfood (e.9., Ensure from casein and soyprotein).

References1. caller JR & Ross R ('1993)- lvlalnutrtion and mentaldevelopment- In: Suskind RM & Lewinter-suskind L(Editors), Textbook tr Pediatric Nuhition. Raven Press,New York, 173-179.2. Zeisel SH (1986). Dietary influences onneurotransmission. Advances in Pediatrics, 33: 23473. Cosman MP (1983). Alapius: Historical dietssexual pleasure. Annualt i on ,3 :1 -33 .4. Pardridge WN4 (1977). Regulation ofamino acidavailability to the brain. In:Wurtman RJ & Wurtman JJ (Editors), Nutrition and theBrain. Raven Press, New Yotk,141-204.5. Adibi SA, l4orse EL & Amin PM (1975). Role of insulinand glucose in the induction of hypoaminoacidemia inmani Stud- les in normal, juvenile diabetic, andinsulinoma patients. Journal of Laboralory andClinical Medicine. 86: 395409.

The influence of diet on cognitive function,appetite and mood

6 March 2007 sainsbury's Business centreorganised byThe British Nutrition

Foundation The conference opened with awelcome speech and inkoductory remarks fromProfessor Robert Pickard from the British NutritionFoundation. He briefly discussed the work of the BritishNutrition Foundation over the pasl 40 years and thepurpose ofthe day's conference in bringing attendees upto datewith the latestinformation on the topical issue oftheinfluence ofdieton cognitivefunction appetite and mood.The first presentation of the day was given by ProfessorLary Chistensen from the University of South Alabama,USAon cravings for sweet carbohydrate and fat rich foods.He began by discussing the current definitions andcomponenls of food cravings and the difJiculties ofmeasuring them. He then went on to talk about thevariability of food cravings, with prevalence typically beinggreatesl in younger people ratherthan olderpeople and inwomen rathea than men. He discussed how sweetcarbohydrate and fat-rich foods e.g. ice cream, tend to bethe most commonly craved foods and how most studies inthe field havefocused on the effect of negative mood as atriggerforfood c€vings. Finally he discussed the impacl ofcravings on nutrient intake. Preliminary data indicated atleast in older oeople- that cravers' nutrient antake mel orexceeded the recommended daily amount (RDA'S) formost nuhients unlike the non cravers who had intakesbelow the RDAfor all nutrients except iron, phosphorousand selenium. He concluded that these studies suggestthatcravings and the subsequent increased intake in foodmayassist in ensuring adequate nutrient intake In cravers,allhough further research is req uired.

France Bellisle from the Inslitut National de LaRecherche Agronomique (INRA), France gave the nextpresentation. She began by discussing the popllar ideathat sweetness is "addictive" and how this is an area thathas been widely studied- She then went on to describehowwe are allborn with a naturalpredisposition to accePtsweet tasting foods over sour tasting food, but anacceptance, preference or craving fora certain food is notthesame as an addiction. The claim thatcerlain foods canbe addictive has had implications for obesity-relatedlawsuitsi however at present there is no evidence tosuggest that sweetness perse has addictive properties. Inconclusion she discussed that although "addictions" tosweet foods may not be the problem, 'preferonces" forenergy dense, sweet and fat rich foods certainly are, andthat this is contributing to the prevalence of conditionssuch as oveMeight, diabetes and metabolic syndrome.

Dr Diane Bamber and caroline Stokgs bothfrom the University of Cambridge, UK gave the nextpresentation on the role of diet in the prevention and

management of adolescent depression. Dr Diane Bamberb€gan bydescribing howadolescentdepression is a majorpublic health concern. Shethen discussed how improvinglhe diet could ofier an inexpensive, safe and acceptableoption tor the prevention and lreatment of depression, butlhata lack ot evidence and knowledge has limited currentprog.ess. At present, the available evidence suggests thatomega 3fish oils, folic acid and possiblyzinc, thiamin andchromium picolinate can ofier some benefit. Levels ofthese nulrients are commonly found to be low in peoplesuffering with depression and studies suggest thatsupplemenlation (particularly of Omega 3's and folicacid)may be able to produce some behaviourulimprovement.

Professor Joanne Salvin from the lJniversity ofMinnesota, USAthen gave a presenliation on the role offibre on satiety (the feeling of fullness). She began bydescribing how the importance offibre in the diet has beenrecognised from as early as 400 BC. She then went on todiscuss some of the recognised health benellts of thedifferent forms of dietary fibre e.g. protection againstcoronary heart disease and obesity. Generally a diet highin fibre tends lo be lower in overall energy since it isthought to make foods more filling or satiating, thereforereducing the quantity consumed. Fibre improves thesatiation ofloods by adding volume (bulk) and viscositytofoods which increases the work and lime taken to eatthem, all of which are linked to enhancing the feeling offullness. Not alldietary fibre has an impacton satietywithviscous and non fermentrable fibres such as that foundinside fruits etc being the most satiating and resistantstarches such as thatfound in whole gmins,legumes andseeds(even in high doses) notsatiating.Professor Margriet Westerterp-Planlenga froml\4aasricht University gave the next presenlation on therole ofprotein in bodyweight management. She began bydiscussing how recentfindings suggestthat an increasedprotein intake seems to play an important role inbodyweight management through various possiblemechanisms. For example, a high protein diet mayincrease feelings of fullness, therefore leading to lowerintake of food (and therefore energy) overall. In addition itis suggested thatsome proteins may increase the amountot energy used bythe body compared with other nutrients.Whatever the mechanism, studies have shown that highprotein diets appear to improve loss of body weight andhelp to ensure more slable weight maintenance afterweightloss.

The next presenliation was given by ProfessorPeter Rogera from the University of Bristol, UK andcovgrod the toDic of the influence of cafeine on mood andmental performance. He began by discussjng howcafieine is the most popular drug in the world and isconsumed by millions in order to improve attontion andp€rformanc€. However, recent evidence suggests thatactually lit{e or no acute benefit is gained trom regularcafieine consumption. This is because withdrawal of

caffeine (e.9. overnight) lowers alertness, performanceand mood, and thatconsumption of caffeine in the morningsimply reverses the effect rather lhan boost functioningabove "normal" levels. Proff Rogers lhen went on todiscuss how new evidence also suggests that caffeineconsumption may lower the risk of mental decline anddementia in older age, however further research isrequired inthisarea.

Dr Leigh Gibson from Roehampton ljniversity,L,K gave the penultimate presentation on the topic ofcarbohydrates and menlal function. He began bydiscussing how despite 25 years of research antocarbohyd rates and menta I fu nction, current u nderslandingis still unclear In general, it is thought that numerousdifferent factors influence the performance ofthe brain e.g.age, effort, personality, time of day, type and amount ofcarbohydrate given and the ability to regulate glucoselevels in the body. lt is also ihought that the release ofcertain hormones e.g, cortisol can also have a significantimpact. Forexample, studies suggestthat high glycaemicindex (Gl) carbohydrates (rapid release energy sources)cause a greater release ot cortisol which can negativelyinfluence brain function, especially memory funclion. Thismightalso help to explain why studies suggestthat lowGlcarbohydrates (slow release energy sources) providemore benefit to mental function than high Glcarbohydrates. He concluded by desc bing how furtherresearch is reou ked to better understand this a rea.

The last presentation of the day was given byDi Harris Lieberman from the US Army ResearchInsti t l te of Environmenlal N4edicine USA. ln hispresentation he dascussed how djetary supplements andspecial diets that supposedly enhance cognitive functione.g. improvements in memory and alertness and relief ofstress and depression are widely promoted across theglobe. However despite this, there are limited regulatoryrequirements for markeling dietary supplements incomparison to drugs. This places great responsibility onrosearch scientists to ensure thal these producls are safeto use. Dr Lieberman suggested that a solution to thisproblem would be to gain scientific consensus onprocedures and melhods used to assess efficiency andsafety in order lo help prevent ineffectave or evendangerous productsfrom reaching the shelf-

Conference summary

The BNF conference provided an interestingselection of presental ions based upon recenldevelopments in the understanding ofthe inlluence ofdieton cognitive function, appelite and mood from around theworld. This appears to be a complex topic to study due tothe many additional factors lhat influence the way inwhichthe brain functions. As with all areas of science andespecially nutrition, further work is rcquired to improveunderstanding, however knowledge of this area hasrapidly expanded in only a relatively short space of time,and the future looksvery positive.

SLEEP.DISORDERED BREATHING AND CARDIOVASCULAR DISEASERobertWolk, MD, PhD; Tomas Kara. MD: Virend K. Som6rs, [,1D, PhD

From th€ Mayo Clinic, Roch€ster, Minn.Conespondence lo vlrend Some6, lvlD, PhD,

Divisions ofCadiovascular Diseases and Hype(ension, Departmsntof l edicine,Mavo Foundation.200 Firsl S't SW Rochester MN 55902.

lntroduclion

Sleep apnea is defined as repetitive episodes ofdecreased ortotal cessation of respiratory airflow duringsleep, leading to a fall in oxygen saturation of =47o andsleep fragmentation. Sleep apnea can be central orobstructive. Central sleep apnea (CSA) is characterizedby apneas secondary to diminution or cessation ofthoraco-abdominal respiratory movements (due todysfunction of central respiratory control mechanisms).Obstructivesleep apnea (OSA) is caused by lpper airwaycollapse during inspiration and is accompanied bystrcnuous breathing efiorts.When defined as >5 episodesofapnea or hypopnea per hourofsleep, OSA is relativelycommon, affecting 24olo and 9% ofmiddle-aged men andwomen, respectiv€ly.! CSA is primarily seen in patientswith congestive heart fai lure (CHF), although itoccasionally may occur in healthy normal subjects, inpeople at high altitudes, and in association with centralneural lesions. Sleep apnea constitutes a major publichealth problem because of its hagh prevalence and itsemerging association with cardiovascularmorbidity.

Cenlral Sleep ApneaCSA is especial ly relevant to CHF. The

prevalence of CSA in CHF patients is dependent onvariousfacto16, such as heartfailure etiology, gender, age,ejection fraciion, and hemodynamic status, and has beeneslimated at 40% to 60%.43 Cheyne-Stokes respirationoccurs during CSA and is a distinct pattern of periodicbreathing with alternaling crescendo-decrescendosequences of hyperventilation and apnea (ie, completebreathing cessation ).

CSA may have an important influence onprognosis, in thatitspresence is associated with increasedmortality in CHF patienls.s This effect appears to beindependent of other known risk faclors, such as leftventricular ejection f raction or peak oxygen consumption.

Although the association of CSA with CHF hasbeen recognized for decades, it is unclear whether cSAdirectlyaffecls CHF pathophysiology and can therefore becausallyl inkedtoprognosis,orwhetherit isratheran indexof the severity of CHF. Evidence implicating CSA in CHFprogression includes the fact that CSA in CHF isassociated, first, with increased sympathetic nerveactivity,higher urinary and plasma norepinephrine concentration,and oe rhaos e leva ted endo the l i n . E leva tedcalecholamine and endothelin levels are associatod withpoorer prognosis in CHF. Second, CSAmay also be highlyprevalent in patients with asymptomatic lefr ventricular

dysfunction, where it is associated with impaired cardiacautonomic contrcl and increased cardiac arrhythmias,suggesting that CSA may precede the development ofovert heartfailure. Third, prevention of CSAby continuousposilive airway pressure (CPAP) may contribute toimproved outcome in CHF. On the other hand, CHFpatients with CSA are characterized by lower exercisecapacity and ejection fraction, increased leff ventricularvolumes, elevated pulmonary capillary wedge pressure,and a higher prevalence of cardiac arrhythmias.Therefore, CSA may indeed also be an index of moresevere CHF The most likely scenario is that CHFpredisposes to CSAand, in turn, CSA contributes to CHFprog ression.

Teatment

H e m o d y n a m i c i m p r o v e m e n t a f t e rpharmacological therapy of CHF is often associated with asignificant decrease in CSA. However, persistent CSAdespite optimal pharmacological therapy (especially ifaccompanied by severe oxygen desaturation andrefractory CHF) should be keated more aggrcssively.CPAPtherapy has beenfound to improve ejection fractionin CHF patients with CSAand has been associated with atendency to enhanced lransplant-free survNal (Figure 1).'Othertherapies,suchastheophyll ineornocturnaloxygen

E

!

til

t

!

a i t r a r . ! t a a : t a aur ar-r r..r-i.r6 I'i.n-l

Figure 1. Transplanlfree survival in CHF pat ientswith CSA treated (and compliant) or not treatedwilh CPAP The difference was not significant

(P=0.1) in intent ion{o-treat analysis. CPAP alsoincreased eiection fraction. Reorinted with

permission from reference 4.

supplementation, have been shown to decrease lheseverity of CSA, but their eflects on long{erm pognosisare notknown.The efficacy of CPAP in CHF patients with CSAmight be

related to a decrease in the obskuctive componentaccompanying csA or may be due io some directhemodynamic effects of CPAP An intriguing finding is thatoverdrive atrial pacing may decrease CSA in selecledpatients with symptomatic sinus bradycardia and mightperhaps also be related lo improved hemodynamics.

Obstructive Sleep Apn€a

OSA has been associated with severalcardiovascular diseases, most notably hypertension,ischemic heart disease, heari failure, stroke, cardiacarrhythmias, and pulmonary hypertension. With theexception of hypertension, evidence implicating OSA inthese disease conditions is presently circumstantial, andcause-effectrelationships remain to be proven.

Hypertension

The evidence supporting the causal associationbehveen OsA and hypertension is compelling. TheWiscons in S leep Cohor t S tudy p rospec t i ve l ydemonstrated a dose-response association betweensleep-disordered breathing at baseline and the presenceof hypertension 4 years later.! This association wasindependent ofother known risk factors, such as baselinehypertension, body mass and habitus, age, gender, andalcoholand cigaretteuse.

The mechanisms underlying the hypertensiveeffecls of OSA are multifactorial. Nocturnal chemoreflexactivation by hypoxia and hypercapnaa, with consequentsympathetic activation and increased blood pressure(EiqU9-2),6 might carry over into excessive sympatheticactivity and higher blood pressure even during daytimenormox ia - Chemorecep to r rese t t i ng and ton i c

lschemic Heart DiseaseThe clinical importance of OSA ln ischemic heart

disease is twofold. First, epidemiological evidencesupports the conceptof OSA being eiiologically linked tothe development of atherosclerosis. There is a highprevalence of OSA in patients with coronary arterydisease, and several case conlrol or prospective studiessuggest OSA as an independent predictor of colonaryartery disease. Although the exact mechanisms of anyatherogeniceffects ofOSAhave not been established, oneintriguing possibility is lhe involvemeni of inflammatoryprocesses. C-rcactive protein (CRP), a biomarker ofsystemic inflammation and of an increased risk forcorcnary events, may also play a direct role inatherogenesis. CRP is elevated ln OSA,' a finding thatsuoDorts lhe role ofinflammation as a mechanism ofOSA-related atherogenesis. Consistent with this hypothesis,elevaled plasma levels and cell expression of severaladhesion molecules. as well as evidence of increasedoxidative stress. havealsobeen noted in OSA.

Second. there is evidence that. in patienls with orwithout a history of coronary artery disease, OSA maytrigger acute noctu rnal ca rdiac ischemia with ST-segmentdepression that is oflen resistant to traditional therapy.Several OsA-related mechanisms, such as oxygendesaturation, high sympathetic activity, increased cardiacoxygen demand (due to lachycardia and increasedsystemic vascular resistance), and a prothrombolic state,may contribule to the onset of these ischemic episodes.Whetherthe same mechanisms may also lead to coronaryplaque ruptureand an acute coronary event rema ns to beestablished.HeartFailure

OSA has also been reported in association withCHF, with a prevalence up to 11%.? Soft tissue edema(which would increase while supine during sleep) andconsequent increased aiMay resislance may lead toincreased insplratory force and collapse of the upperairway, thus increasing the risk of new-onsei OSA.Converse l y , ep idemio log i ca l da ta sugges t i ha t ,independent of other riskfactors, OSA is associated wiihan increased risk for CHF.sOSAcould predispose to CHFby virtue of its effects on sympalhetic drive, endothelin,endothelial function, hypertension, and ischemic heartdisease. which are known to be important risk factors forCHF, Ivloreover, OSA may potentiate acute ventficulardysfunction by increasing transmural pressures andventricular wall stress. The coexistence of CHF and OSAmay therefore create a vicious cycle of progressing CHF,with OSA causing deterioration of cardiac function, andwith subsequent exacerbation of OSA.

Slroke

The prevalence of OSA is increased in patientswith stroke. but it is debatable as to what extent stroke-indlced breathing abnormalit ies contribuie to thisassociation. The factors that maY increase the risk ol

turlArr-.r1Arr-

- ia-{ral ------.l *. .-- .w..,,r1'^,11,^e!'.!.'. ^.r.'dd.r,.''..

.^..

Figure 2. Recordings of the electrooculogram (EOG),electroencephalogram (EEG), electromyogram (EMG),

electrocardiogram (EKG), sympathetic nerve activ ty(SNA) respirat ion (RESP) and blood pressure (BP)ina pat ient w th OSA durinq rapid eye movement s eep.BP surges ai the end of the apneic perrods Reprinted

wrlh permrss on lrom refF'ence 6

chemoreceptor activation may also contdbute to daltimeinqeases in sympathetic activity and blood presslre.Pati€nts with OSA also have endothelial dysfunction,Increased endothelin, and lower nihic oxide levels, all ofwhlchwould oot€ntialevasoconstriction.

skoke in OSA include blood flow reduction with individualapnea episodes (caused by negative intrathoracicpressures and increased inkacranial pressure), aprothrombotic state, atherosclerosis, and hypertension.From a clinical standpoint, it is an imoortant observationthat OSA in stroke survivors may be associated withincreased mortality and a worsened long-term funclionalotltcome,Pulmonary Hypertension

Some preliminary studies have suggested thepresence of mild{o-moderate daytime pulmonaryhypertension (and even right ventricular failure) in OSApatients in the absence oflung and heartdisease. Insomestudies, pulmonary hypedensive OSA subjects tended tohave a greater body mass and lower daytime arterialoxygen saturation compared with those without pulmonaryhypertension, so lhat some contribution of the obesity-hypoventi lat ion syndrome to elevated pulmonarypressures in OSAcannot be excluded.CardiacArrhythmlas

The most frequent arrhythmias reported inassociation with OSAare sinus arrest, sinoakialblock, oratrioventricular block, all ofwhich may lead to ventricularasystole. The mechanism of these bradyarrhythmias isusually a reflex increase in vagal tone triggered by acombination of apnea and hypoxemia (diving reflex).Therefore, before pacemaker therapy is recommended inpatienls with noctumal bradyarrhythmias, the diagnosis ofOSA should first be considered and, if present, CPAPtherapyshould be tried. Because OSA patients sometimesfall asleep d uring the day, even daytime bradyarhlhmiascould be atlributed to sleeo aonea.Severalreports also suggestthat OSAmay be associatedw i t h b o t h s u p r a v e n t r i c u l a r a n d v e n t r i c u l a riachyanhythmias, although the latter are more likely looccur in the setting of other cardiac comorbidities, such asischemic heart disease or heartfailure.Treatment

Behavioral and lifestyle modifications, such asweight loss, avoidance of sedatives and alcohol, andavoidance of sleeping on the back, will offen attenuateOSAseverity.

The treatment of choice in OSAis CPAP Althoughit is generally accepted that patients with moderate tosevere OSA and daytime somnolence should be treatedwith CPAP, less clear is whetheror not to treat mild OSAinthe absence of daytime somnolence. In the shod-term,effective CPAP heatment (ie, treatment associatedwith asignificant reduction in apnea severity) may reducesyslemic (Ejg!ql3)' and pulmonary pressures, prevenlnoctu rnal ST-segment depression, improve left ventricularejection fraction and functional class, and decreasecardiac arrhythmiaso in patients with CHF. Troatment forOSA has also been shown to reduce th€ risk for motorvehicle accidents, probably by lessening daytimesomnolence. However, no clear data showing long termbenefitwith regardto cardiovascularend points with CPAPtherapy are presentlyavailable.

. tIr- r. II

rrt

Figure 3. Changes n blood pressure wrth effect ve(closed bars)and subtherapeul ic (open bars) CPAP n

pat enls w th osA ("P<0 05) MAP ndcatesmeanarter al pressure Reprinted w th perm ssion i rom

reference 9

Conclusions and Recommendations

There is strong evidence for an associationbetween sleep apnea and cardiovascular diseases,pa r t i cu la r l y OSA and hyper tens ion . Fo r o the rcardiovascular diseases, the evidence, althoughsuggestive, remains ckcumstantial.

Although the comprehensive diagnosis andtreatment of OSA and CSA is determined by overnightpolysomnography, a hislory ofwitnessed apneas duringsleep, daytime somnolence, and evidence of oxygendesaturation on overnight oximetry should heighten theindex ofsuspicion forsrgnificanl sleep apnea

OSA should be considered in patients wilhrefractory hypertension, particularly in obese subjectswithout lhe expected noctu rnal decline in blood pressure,and in patients with nocturnal cardiac ischemia, nocturnalarihfhmias, and stroke. Both OSA and CSA should beconsidered in CHF patienls who are poorly responsivetoconventional treatment.

References

'1. Young T, Palta l\4, Dempsey J, et al. Theocclrrence of sleep-disordered breathing amongmiddle-aged adults. N Engl J Med 1993; 328:12301235.

2.

3.

Javaheri S, Parker TJ, Liming JD, et al. Sleepapnea in 8'1 ambulatory male patients with stableheart failure: types and their prevalenc€stconsequen@s, and presentations. Circulator.1998;97:21542159.

Lanfranchi PA, Braghiroli A, Bosimini E, €t al.Prognostic value of noctumal Cheyne.Sokesrespiration in chronic heart tailwe. Circulation.1999;99:14351440.

THREE DIMENSIONAL HEART CARE(HEALTHY & HAPPY LIFE€TYLE (HLS) PROGRAM FOI PTSVENT|ON OIANgiNA & HEAN AttACKs)

Based on Revolutlonary Concept of Soul-Mind-Body Medicine

DL Satish Kr. Gupaa,Sr Consultant P€venlive Cardiology & Cardiac Rehabililation,

JW Global Hospital & Research Centre, N4ountAbu, (Raj)secretary General, wccPc 2007 & wPcHc 2007

Principal lnvestigator& Co-ordinator, CAD Research Proiecl, GHRC

Angina, Hcad attack, coronaryartery disease (CAO): Awarning from Nature:

Angina and Heart-attacksoccur due to blockages Producedby deposition of cholesterol in the

walls of the coronary arteries that

supply oxygenated blood to the

heart muscle. The blockage in a

coronary artery starts early in the

childhood and continues to build

with age. When blockages reach a levelof morethan 70%,

the person starts expe.iencing angina (chest pain in the

centre ofthe chest typically radiating towards the lefrarm),

breathlessnesg or palpitations on physical or mental

exertion. This prccess of blockage due to deposition of

cholesterol in the walls of coronary arteries is called

coronary athelosclerosls or ColonaryArtery Disease(cAD).

Sometimes a block cracks or ulcerates leading to clot

formation thereby causing sudden 100% blockage ofthe

artery leading to heartattack.About25to 30% patienls die

in the first heart atiack even before reaching the hospital. lf

the personwho has suffe€d a heart attack once, does not

change his lifestyle (psychological behavior, diet,

exercise, sleep habits) he or she gets recurrent heart

attacks that lead to many heart-related illnesses and

untimelydeath-

India, tho wodd leader in coronary adery diseaselCAD has assumed epidemic proportions the

world over and more so in India. Heart disease is

considered the number one killer as it is responsible for

about 40% of the deaths alloverthe world.In India, about

10 to 14% (mo.e than 50 million people) of the adultpopulation sufer from CAD. More than 5 million people

sufier ftesh heart attacks every year, out of which 1.5

million die gven before getting any medical assistance.

Morsover, the prevalence of CAD in younger population

(the 20-40 yearsagegroup) is l0t imes more in Indians as

compared to Americans and Europeans. 54% of Indiansget all three coronary arteries diffusely diseased thus

making them unsuitable for coronary bypass surgery or

angioplasty as compared to only 21% in Americ€ns and

Europeans. Asian Indians living overseas have thrace

more orevalence of CAD and 8 times more deaths due to

CAD. lmmig€nt Indian physicians in the United States

have 3-4 times more prevalence of CAO than native lJ. S.physicians. lt is estimated that prevalence ofCAD in lndia

is 6 times more than the chinese and 20 iimes more than

the Japanese- CAD is spreading the world over at an

alarming rate in both higher and lowereconomicslrata.

Coronary Artery Disease (CAD): A challenging healthproblem forthe 21st cenlury

Over the last three decades the progrcss in by-pass

surgery, angioplasty with stenting and cholesterol-

towering drugs like statins have improved the prognosis of

CAD, yet the numberof CAD patients remains enormous-

I\,,loreover, as India is a developing country not everyone

can afford this costly approach. In spite ofthe best efforts

made by medical professionals,lhe facilities have noi yet

reached the masses to combat the menace of CAD

epidemic.Also, these approachesdo notaddress the rootcause

of CAD and are palliative in nature. lt is estimated byWHO

and other World Health Agencies that by the year 2010,

60%of al l the head patients in the world wil lbe Indians.

Psychological factors: The maior risk factorfor CADMedical scientists throughout the world have been

working day in and day out to find the real cause of CAD.

Recently, many well designed studies have shown thatpsychological behavior patterns play a very important role

in causation and progression of coronary blockages &formation of clots which in iurn lead to angina and heart

attacks.These behaviors are calegorized as Type A behavior

which inctude attitudes like 'hurry' sickness, feeiing

pressurized by time and work, strong likes and dislikes,perfectionist, idealistic, punctual, aggressive, competitive,polyphasic i.e. trying to accomplish various tasks at the

same time, orfeeling anxiety, depression, anger, cynicism,

hostility, job and family shess. Othersensitive behaviours

includefeeling of isolation, dependenceonsocial support

or emotional support, etc. These psychological behavioralpatterns lead to wrong dietary exercise orsleeping habits

and thus reduce control over hypertension, diabetes,

smoking, high cholesterol levels, obesity and lack ofphysical activity etc which are conventional dsk factors ot

CAD. This leads to further increase in the coronary

blockages at an eadyage.

b r€gression of CAD possible?Some of the well-designed studies (Dean ornish

etal, Manchanda etaletc.) have shown that management

ofstress through Yoga/ Meditation and change to healthy

diet & exercise habits can halt the progrcss ofthe above

mentioned blockages and thereby reduce thefrequency of

angina and heart attacks. Tlll today, medical scientists

consider CAD to be a progressive disease. This means

that if one is able to stop the progression ofthe disease, it

is reversal of the disease process.

We the medical team at J. W Global Hospital &

Research Centre, Prajapita Brahma Kumaris lshwaraya

Vishwa Vidyalay, MountAbu have been able to document

a highly signillcant opening of coronary blockages ingroups of patients who sincerely followed the ?Veallhy &

Happy Lfestyle ProgQm' in more than 300 repeat

angiographies. The angiographies werc analfzed by an

independent panel of angiographers. lt has been

observed that in certain cases, even the 100% calcified

blockages opened up significantly. These results havegiven an eye-opening messageto medical scientists.

AMultidiscipllnary Studyon CoronaryArt.ry Disoase:we have developed a unique user-friendly H€althy &

Happy Litestyle Program to fight back the epidemic of

CAD. Efficacy of this program has been evaluated in two

multidisciplinary prospective research studies i.e. the

Mount Abu Open Hea.l Trial and Abu Healthy Hoart

Trial - a randomized controlled study in more than 500

angiographically-documented CAD patients. These

studies included psychologists, spiritualists, physiologists,

endocrinologists, cardiologists, clinicians, dietitians and

fitness experts, who have been working hand in hand,

since February'1998.We have worked in association with Defence institute

of Physiology & Allied Sciences, Defence Institute of

Psychological Research, Defence Research &

Development Organization (DRDO), New Delhi and the

Morarji Desai National Institlte of Yoga, New Delhi. Thisproject has been sponsored by Central Council for

Research in Yoga & Naturopathy, N,'linistry of Health &

Family Welfare, Govt. of India. The angiographically-

documented moderate to severe CAD patienls were

refered from three tertiary cardiac care centers at Delhi,

Mumbai &Ahmedabad.

Sci6ntifi c presentation of CAD prorect results:The report of CAD poect was submitted to

l\4inistry of Health & Family Welfare, Govt. of India in

September 2004, to the Defence Research &

Development Organization (DRDO) in October 2004 and

to the Indian Council of Medical Research (lCl\4R) in

March 2005. Ministry of Health, Govt. of India is planning

to implement this unique, user-ffiendly program forprimary secondary and tertiary prevention of CAD. The

results of both lhe ldals were presented at Asia-Pacific

CongressofCardiology 2004 thatwas organized by World

Heart Federation at Singapore and Diamond APICON

2005 at [4umbai. These results werg accepted and wideiy

appreciated by top cardiologists and clinicians from all

overtheworld.

Briefae3ulta:> Highly signiticant improvements in symptoms like

Angina, breathlessness, palpitations, exercise, tolerance,

lefl ventricle ejection fraction (LVEF)> Healthy improvement in psychological parameters> Highly significant reduction in drugs required for

management of angina, hypertension and diabetes> Highly significant opening of coronary blockages.

Soul-ltllnd-Body Modlclne: A multidim€nslonal model

tor heallh managoment in 21st century. The two main

sali€nt features of healthy (heal + thy) & happy lifestyleplogramare:

A" S€f R€sponsibility through Solf Empowerment:Hoilthy= Hsal+ ThF Heal Yourself through self

emoowernent,Self empowerment @mes frcm proper & right

information, education & counselling about Soul,

Mind, Body & biologicaldocU circadian system.

B. Change ofconsciousness from body/rolg-

consclousneSS to 50ul-consciousneaa:The practice of primordial stiate of soul-consciousness

in each thought, word and action, at home/ofiice whilo

taking prescribed diot and exercise, is the essence of

healthy & happy lifestyle program which has four basic

components.

€ S t r e s s m a n a g e m e n t t h r o u g h R a j y o g a

meditation(Brahma Kumaris)

e Moderate aerobic exerciseq Lowfat, high fibervegetarian diet

€ Prooersleeo

Unique & user-trlendly approach of Healthy & Happy

Lifestyle (HLS) Program:A,l BoNalural:Stress M a n a g e m e nt th ro u g h Rai yog a Med i tatio n :

8e sou/-conscious ftther than rcle or body

conscious. Remembar, "l am a knowladgeful, pure,

peaceful, loveful, happy, blisstul & powertul 6oul. I am the

sd,'.l, point of light, dazzling in betvvaen the forehead,

mastet of this physical body". Be in the rcmembrance of

Sup|sm€ Soul Brahma Kumari's Rajyoga meditation is a

sci€nc€ and adof hamonizing spiritualenergy (energy of

soul), mental en€rgy (6nergy of mind) and physical energy(en€rgy oI physical body), through the connection with

ultimate source of spiritual eneqy i.e. Supreme Soul for

€njoylng ever heallhy, ev€r-wealthy and ever-happy life.Rajyoga meditation is purely a mental process which

lnvolves interaclion between mind and int€llect to reach

the stage of perfection. No Uxed physical postures are

required for practicing it. Suppod is provided by way of

daily group sessions and also through individual

counselling sessions by clinical psychologists and stress

management experts. Sessions on defining causes of

shess, importiance oftackling stress, time, work, isolation,

relationship, depression, fear, anger, insecurity, sleep,

disease & disaster management are taught by audio-

visual means & Dractical workshops.

A.l EalNetural:Low - F al H i g h - F i b re Veg eta r i a n D i et :Eat plenty of fresh fruits, vegetables, nuts, sprouts, lemon

and low-fat & high-fibre vegetarian diet at propertimes and

in proper quantity. Avoid fried foods, red meat, egg yolk,

refined sugars, maida, tea, coffee elc. Take your food in

silence and soul-conscious meditative state rather than

while talking, watching television or readang the

newspaperThe benefits of the prescribed diet and assistance in

preparation of broad-based menu, is demonstratedpractically and by audio-visual means.

B.l Be in lhe Lap of Nature:M od e rate Ae ro b i c ex e rc i se :Have a brisk morning walk with sunrise (the queen of all

exercises) and evening stroll beforc sunset. Exercisein an

oxygen-dch open environment (not indoors) in presence

ofsunlight- Pranayam, physical posturcs, shavasans etc.

are not advised in this exercise schedule. Individual brisk

walk is advised as per the baseline TIMT levels. The

scientific way of walking to get maximum benefit and to

minimize risks are taught in detai l . Individualcounsell ing

sessions are also arra nged.

O.l Enjoy Proper sleep:Sleep at 10.00 p.m. and getup at 4.00 a.m- Hormones

which creates harmony in our body secrete in balance if

we are awake and peaceful at 4.00am. The science of

sleep management istaught in detail.

Programs w€ off€r:This unique, user-friendly Healthy & Happy Lifeswle(HLS) Program is planned in two types to combat the

menaceof epidemic of CAD:For prevention of angina and heart attacks - 1 i) daycomprenensNe program.ii) Forangiographically-documentedCADpatients-7

days duration in-house pr€ram.

Healthy& Happy Lifestyle (HLS) Program for

Prev€ntion ot angina & HeartAttacks (7 days duration)An intense informatlon, education, training andcounsef f f ng program: For CAD patients'.> Who have recently undergone crronary angiography(within last one year) and do not wanl to undergo bypasssurgeryorangioplasty duo to various reasons e.9. not fit toundergo, do not have resourcesto undergo or do notwantlo undergo bypass surgery orangioplasty proc€dures.> Who have already undergone angioplasty or bypass

surgery (at least three months back and not more than3 years). Cardiac rehabilitation is aimed at thesepatients in order to prevent restenosis of coronaryadery and there by alleviating the need for repoatangioplasties and redo bypass sur9ery

Whocan participate?1. Coronary angiography proven coronary arterydiseases. Block in at least one of the coronary arteries

should be more lhan 50%. Coronarv Anoiooraohv shouldhave been carried out within last one year CT angioreports are also accepted. (Cartography repods are notacceoted)2. Age: 2'1 to 70 years.3. Patientwithoutsignificant left main stem disease.4, No myocardial infarction (heart attacky unstable

angina during the preceding 3 monlhs.5. Lefr ventricular ejection fraction > 25% and without leff

ventricularfailure (L.VF.).6 , P r e s e n t l y n o t s c h e d u l e d f o r b y p a s s

surgery/angioplasty.7. No other co-existing life threatening illness e.g.

advanced kid ney/liver failu re, advanced cancer, etc.

One can not.ioin thg program undertollowingcondilions:1. Any intervention procedure eg-Angioplasty or bypass

surgery within last three months.2. Patients suffered from acule coronary syndrome eg.

heart attack or unstable angina within last 3 months.3. Patients suffering from severe osteo-arthritis of knee

joints wh ich creates difticu lty in walking.4. Patients suffering from acute or chronic kidney

disease (Serum creatinine more than 1.2 mg/dl).Cartography reports not accepted. Congentional heart

diseases, rheumatoid heart l. disease, hole in heart,

valvulardiseases, and dilated cardiomyopathy etc. type ofdiseases are not addressed in the Healthy & HappyLifestyle program. Forthis, patients can take appointmenton phonetovisitto the OPD.

Not€:- You will be provided accommodation & food during

your stay. One attendant (preferably spouse) iscompulsory to accompany the participant.

- Your participation in this Healthy & Happy Lifestleprogram is totally voluntary

- No formal fee is required for participating in thisprograrm but voluntary conkibution (in favor ofGlobalHospital & Research Cenire, Mount Abu) isacceptable. Yourconkibution is income tax deductibleu/s.80-G/3sAC.

Process ot RegistrationiPatients arc requircd lo send their brief case-

summary prescribed treatmenl, latest serum cr€atinine,ECG, 2 D echo (Color Dopple4 report and recentangiographyreport(carried outwithin lastoneyear)alongwith five rupees stamped self addressed envelope.Reports sent by emailor fax will not be accepted.

Permission to attend the HLS program will be given

only affer your reports are reviewed by the reviewingcommittee. You willbe informed ofyour participation in duecourse of time. Please conlinue to take yourkeatment asper advice of your physician/ cardiologisl.

Prevention & Rehabilitation Program: (One day)

HLS Program For Prevention of Angina E H6artAttacks ProgJam:

Who al l canjoin?a) Personswith high psycholog ica I risk for

developing angina & heartattacks e.g.:1 .

2 .

Persons engaged in highly stressful jobs eg.Executives, Businessmen, lredical Professionalsetc.Persons prone for type 'A' behaviour, anxiety,anger, depression, isolalion, lack of emotionalsupport, lack of socia I su pport, cynicism, hostility,sensitive and emotional behaviour etc.

b) Persons who have high conventional dsk fordeveloping angina & heart attiacks e.g.:

1. Persons with familv hisloN ofheartdisease.

2. Psrsonswith high blood [email protected]. Persons with diabetes.4. Personswith high chole6terol.5. Smoke6.6. Ov€rweight porson.7. S€denbry p€6ons, who do not have the habit of

taking regular moming and evening walk.Tralnlng tho Tralnefs program: (3 day duration)Int€nsiv€ In-house Training for lredical Protessionals inHealthy & Happy Lifestyl€ (HLS) Program for Preventionof CAD and their lifestyle relat€d illnesses.THE WAY AHEAD...Having achieved and experienced a wealth of knowledgeabout CAD, where do w€ go from here?A number ol distinguished medical professionals andscientists have made ohenomenal discoveries ininte ening and remedying this killer disease, but nowwhat would be logical and appropriate is to uso theseexperionces and wisdom to start an active campaign in

PdmaryPrevenilonlItwould beextremely beneficialto educate children in theirschools about CAD and teach them how to be smart inprotecting theirbodies and minds.children should be given the skills and techniques ofmanaging their intellectual, physical, emotional andspiritual personalities as they grow and pursue higherstudies, careers and family lives. The importance oflivingby a strong value system should be inslilled at a youngage.Benefits of a low-fat and high-fibre diet should beconvoyed to children, along wilh 1) role of exerciseano propersreep.Young adults should be motivated to go in for regularcheck-ups so that proper scroening of hypertension,diabetes, high blood pressure otc can be carded out, andthus diseases will be diagnosed earlier on.

2) SecondaryProvontion:Adulb who have already developed CAD and are toundorgo by-pass surgery or angioplasty should be

A -lWnl:Ae.r'o fiail&

One dag, a pailiallq dwl loun-g2at oU frtuLcame ftone uilh a ndz pon ftia

tu&oL "'lhut Iomru1 id too otttpid to tcam, gd nim aut al &e ocAut" ftir molhez'&ad tne nrle attd auueted, " JtQ, Cartk* at nol otupid, J unlt k4cft nin mgael4,:'

Qnd tAat 1amna yut u.p te &e aAa g"24t fieon 6 Utton. iftnmat Uiaon ftad onl*

threz tntnrnt al lt'unal oeAtoling and fte ua,s pailtialA dea&

taught Rajyoga meditation, methods of keepingmental and emotional stability, proper diet, exerciseand sleep. In this way the challenge of CAD can befaced with courage and recovery would be fast andcomfortable.

In patients with border-line coronary artery disease,difiused disease, who are not fit for intervention andwho do not have resources forsurgery can follow thisprogram for a healthyand happy life.

3) Tertiary Pr€vention:Those who have akeady undergone angioplasty andby-pass surgery may be advised to enter the tertiaryprogram, so that they do not require repeatangioplastyorredo by-pass surgery in the future.

Ahealthy life can be achieved forallifthere is accu€te andtimely lntervention, intake of medicines and measures ofprevention. lt is valuable that lechniques of the CADregression progran be spread to every nook and cornerofIndia through the media, however personal counsellinghas proved to be vitalin transforming a patients health andthis cannol be compensaled in any way. Every personshou ld u nderstand the fundamentals of the d isease so thatthere is active and positive participation in healing mindand body. Science and Spirituality are two dominalingpowers in ourworld today; haamony and balance belweenthe two will show wonders time and again in creatinghealthy & happy society.

Dr. Satish Kr. GuptaSr Consultant Preveniive Cardiology &

Cardiac Rehabilitation,CAD Project Co-ordinator

J, Walumull Global Hospital& Research CentreShantivan 307510,Abu Road (Rajasthan), India

E-mail: [email protected]+91-2974 -228577,228116, M: +91 94141 54041

Ph: +91 - 2974 -229577,22810 1...106

THE DAWN OF HOPEPraveen Yogi, 35 yeals, Patan (Gujarat)

I am an Electroncs enqine€r bv orofession and in those days I had moved with my famrly toAhmedabad fotearnino mv livrnq. I fou-nd it diffcult lo adiusl mysslf with lhe life in a bq city. I lefr my tob and starled my ownbusine-ss. Due to-financisl problems I faced in ni business, I starled wo*ing lale at nighl lo make mo'e money. Iatenolhing exceptmy breeKastand tookcup affer cup of tea during reslofthe day. lhad become a viclimolleat.wony and lethargy.

lwas barelv 30 vears of aqe when lhad heart problem on 13" November,2001. On ang|oqtaphvone olmvarledes was fdund?0% blocFed. From then lwas labeled as a heart patient. My womes mulliplied Anyone Iadeieswaslound 70% blocked, From then I was laDeled as a nean pallen(. My womes munlpr|eo. Anyon€ Imetlalked about mv heartDroblem and possrble h€arl attacks - first, second, thrd and lhen the ENDI lhad thefear, everysecondofmylife, aboutsudden deah.lhad praalically lost all hope ofrecovery.

lcame back to Palan, mv native olace. lt wason the suqqestion ofan elderly man who is a Brahma Kumar. lsladed going loBrchma Kumari centre at P6tan. Ilelt peaceofmind th€re ahd thoughl lhal God had become kind to me again. lcame to knowfromthe c€nt€aboutthe c€mpsforlreatmentofheaddisease held atShanlvan,Abu Road. My teacherallhe cenlrelilled wilh myh€artwithcou€oe and motivaled me loattendoneof lhesecamps.

I found lhe atrnosohere at Shantivan exaclly the way my teacher had descnbed it to me, even more so. Dr Salish Kr. Guptagave us information in a very simpleway aboutieasons leadrng lo head lrouble. and lheir solulion. Alldo'rbls and wo.ies in my

ws€over lfelt lhad gota newleaseoflife.

Now Iam tadinE a very peacefuland happy life. Ifollow allthe lourrulestaught'n the CAD projecl camp - high liberandlowfaldet, momingand eteningwalkswilh properrcstand sleep, Rajyoga Meditalionand lahing my medicrnes regulany.

r \ r | ' \

IT'S WISE TO EDUCATE PATIENTSABOUT THE DISEASE -4. v t eshra.,:, Xalwa

ln November 1999.ldeveloDed chest oain whilechmbinq the hrllsofNainital, and lhis increased in Jan.raiy2000.lcollaosed onedavdu€ lo a mild attack. The cad|oloqisltook an ECG and advrsed me fora TIvlTlesl. which waspositiie. The angi6graphy done at Bombay Hospital slowed 6 blockages (99%. 90%, 909 o 70%,70ol0 509o) Heins|stsd lgo in loi bi-pasa su€erywhile Jaislok Hospitaladvrsed angioplasty lor lhree coronaryarler'es.

lwas unable to walk even 100 melres without expenencing pain and was taking 12-15 tablets daily {worth Rs150-2001. lt has b€6n mv exoerience that mosl doclorc nevbr educale lhe patlenl aboul the hearl problem, andyet they'charge Rs 60dfor_consulting, Rs 20.000 lor the ang,ogrcphy and Rs 2_3 lakhs for surgery nerlherallowing thepatienltoconsullolherdoctors norsLlggeslrng allernatlve herapes

Aheadoati6nl. who had benefiled fiom treatment in MountAbu shared his experience which motivated me to visit Dr Satish Guptaat abu dnd ioii lhe -EveFhealthy & Ever-happy' Prog.am for CAD rcgresson. We wete educaled lhorcughly and given experlouidance reoardinq our heallh Oioblem. lconsidor myseltvery lLrcky as llearned a lol aboul the physologrcal. psycholoqical andapiritual fact-ors coinected wlh ihe hsart I was inlroduced lo Raja Yoga and Meditalion which orovide lire-suppod and a strcng willt6 individuals who tread lhis path.

Now I c6n watk 10-12 km without any problem. lhaven t taken a single day s leave due to chesl pain o'any olher symploms for lhelast4years. I thrnk it is a mi€clel I am able lo play games like volleyball, cricket, table lennis. swimming elc

The studenls of mv school oreoared a demonstrative science proFct on lhe CAD tegression prcgram and have won pnzes alSchoot. Ward and ZonalLeiels. Med|cal prolessionals and screntists have showed inleresl and appreciation. Many of my fiendsand retatives have taken benetit hom lhis new lifestvle and rid themselves ol hearl problems and ilhesses like acidity. ulcers.constipation andso on.Afew newspapersand magaziies In English, Hindr, [4arathiand Kannada have published myexperience as

The CAD regression program should reach large numberofheart patienls padiculady_olyoungetage who are lhe bread-winners ortheir familiss. l humbly requeslonsand alllosupportand slrenglhsn lhrs nobrecause rorrne Denellor Inoransano alrnumanKln0.

In the end I express my heartJelt thanks to Dr Satish Gupla and his team of self-less workers for all they have done for me..

thattool had nointerest.lgot married in 1987.lhave two sons. Mywife isof

very cooperative and generous nature. she never lost hertemperwith meand always advised meto mend myways.But I never listened to her. I had become a lefior for mywifeandsons.

My two elder brothers died within a span of fouryears. The entire responsibility of running the family fellupon me. But, instead ofshouldering this burden, ltook toexcessive d nking and taking opium. I became totallydependent on ihem. I even started distilling illicit countryliquor in my own fields as a side business, for which I didsome time in jail. My linancial status was getting worseday by day. I started a bogus llnance company to makeeasymoney.

Once lfelt uneasinessand pain in the chestfollowedby vomiting and breathlessness- | thought that perhaps itwas due to gas on account ofthe food I had eaten orduetosome adulteration in the opium lwas taking. Ineverthought that these were symptoms of a hearl attack. Toease the chest pain ltook another half bottle of liquorthat Icould lay my hands upon, but with no effect. l\4y folkswanled to take me to lhe city for treatment but instead oflistening to them I became abusive and started quanelingwiththem. This happened in June2003. Somedayslater,lagain fell unbearable chest pain followed byvomiting andacute uneasiness. I was immediately rushed to a privatehospital in Karnal and kept in ihe lCt-J for the day. Fromthere I was referred to Jaipur Golden Hospital in Delhiwhere I underwent angiography and angioplasty costingme a neatslm ofRs 130,000-

But I did not leam any lesson from all this. I ag€instiarted smoking and drinking. lhied my best to gave upthese habits but it seemed impossible. .[4y health haddeteriorated, so much sothat lcould not even walk withoutpantingforbreath,At this point of time, I happened to meet Suraj Bhai whowas our neighbor in the village. This meeting marked a u-tum in my life. I was introduced to the Brahma Kumaricentre at Gharounda in lGmal district. There I did one-week course and came to know about the three-dimensional heart care approach for treating coronaryartery disease, a project for which was being conducted atShantivan, Abu Road. I attended the Proiect camp held inAugust, 2004. I had a shange experience dudng thecamp. Iteh as if my blockages were melting away throughsome power That was, in fact, Shiv Baba, acting as theSup€meSurgeon.

I am now a tolally new person. Gone are the wildways of the past that is best forgotten. My wite and kidsare very happy. I am greatty thankful to Brahma Kumariaislers and Dr Satish Gupta for bringing about thismiraculous chango in my Iife.

A TRYST WITH DESTINYKK K.!s/rr / 56 16 Delht

L4y traumalic journey begins inNovember, 1998 when I was hardly47 years old. I had a headattack on23'' November, '1998, lollowed byanother attack on 23'" I\,4arch, 1999.The angiography done in Escorts

Hospital, Delhi, in Apri l , 1999, revealed that I had 99%blockage in LAD mid stenosis and 70% in LCS distal. ltwas followed by angioplasty.

I had heart problem again in the month of June,1999. ltwasfound that I had 90% LCX proximal. Anotherangioplasty was done in Escorts Hospital. After sixmonths, in December 1999, it was found that I had TripleVessel Disease with 50% LAD mid LCX 90% proximal,70% mid and 2* Ob2 and 90% mid stenosis. RCA was100% blocked. I underwenl bypass surgery and wasdischarged from the hospital nexl monlh, in January, 2000.

I had anolher heart attack in August, 2000. Anangiography revealed right graft 100% blocked anddeposits inthe arteries increased. I was very miserable bythen. There was onset of deplession and I had no will tolive. lttook me one to two houls to take my meals. lwassimply not able to do any thing. Thedoctorsin the hospitaltold me that lwould have to live with itfor my remaining life.In the face of Dealh, I was advised to cultivate a posiiiveaftitude on lifel

It was in I\,4arch 2001 that latlended the first'Ever-healthyand Ever-happy" life style camp at Shantivan,AbuRoad. On the very first day I had this unusual spiritualexperience thai it was some trick of Destiny that hadbrought me to Shantivan. Since then I have attendedthese camps regularly. lfind myselfa completely changedperson. Medicines have reduced to the minimum. lplaybadminton and oiher games wilh friends. I enjoy mymorning and eveningwalk and am living my lifewilh zest.

Thanks to Shiv Baba and the Brahma Kumarisislers who have shown me the path to heallh andnormalcy.

A Suinde 5s Wsnetl

iftz+ taUL ant4rd & .uom"an't tpfroe aatfrouqfr. it had. q timil;

1futz ia nal a pkue in eedk oa Xearren,1ftote ic not a taaft to naoAind. git2n,

9&uB ie nat i-&Auinq o,r. o ut,Skeze A wl a wfri.apeud, gz,s a't tn,

1ftoe ir wI a &le, o't. dcatft, oz 6atfi,1ftot fua a katfrat\ ueiqfil sl uaa&

uilfr.oulauamanhil.

B.K. GYANKarnal Haryana

lam the son ofa farmer of districtKarnal, Haryana- | had all the evilhabits of smoking, drinking, stealing,gambling and quarelling in mycollege days. As lfai led in mystudies, I took to farming. But for

I NO LONGER AM AHEART PATIENT

- Rajni Mulchandani,Ahmedahad

I had been sufiering from highB.P for the last 15 year and used to

ke medicines regularly. Someyears ago, I felt chest Pain and afrerconsulting various physicians, itwas

The Power of super SurgeonPunna 14. Reddy, 36 years,

Karimnagar (AP)

I am a Sofrware Engineer byprofession. I stayed with my tamily inHyderabad. with her five daughtors(Lust, Anger, Greed, Attachmentand Ego) lvlaya played havoc with

my life to make it mise€ble and ter.ible. But with God'sgrace I was saved. I weighed only 40 kg with a height offive feet eleven. I had so many other physical problemslike chest pain, spinalcolumn pain, blood disorder, Sinus,acidity along with mental problems such as fear, worry,stress etc. The family of Nlaya expected that I wouldsurrenderto them by going into deep depression and thencommitsuicide. lcame to knowthatMaya can close allthepathsofrecovery in the outside world relating to body. Butshe could not curb my inner desire to knowwho lam andhow lcould contact God, the Suprcme Soul throughmeditation orRaiyoga.

Astonishingly, I came out from not only all thevices but also came oul of six moths of deep depressionand also gained bodily weight by 22 kg with in two & halfyears. lt all happened with the help of Raiyoga meditationand practicing soulconsciousness without contacting anydoctor lt was all automatic. I stopped smoking, eatingnon-vegetarian food, sleepingand getting up lale elc. NowI have healthy mind and body. learnestly practice Rajyoga(interacting with GOD)lo enrich my soulwith al the sevenoriginal attributes of soul (Peace, Love, Wisdom, Purity,Energy, Joy and Bliss)which lgetfrom the Supreme Soul,the source of all these qualities. In my search for Peaceand Love I reached Shantivan which is reallythe abode ofPeace. I am now giving free service to Dilwalas (CADpatients) and all other activities relating to them. I amgreatly thankful to GOD, Dadi jis and to all brothers andsisters ofthe B.K. family and, lastly butnotthe least, to DtSatish KumarGupta & B.KBalabehn.

0ptimiamOpatmian ia @ chaa'r&d P4nz 4l nindtlat e afita. q. teo4eale b tia* ea2n

thatai itfu in ftaL ual2talt ta iln naae-

. 4. br, .!., .

QDodu'o Qfuice,Ala*.'r, unde.x na tittumata@rt, tohe dLgpia*

pillA alA a taaaliac oa tfrz oanz niCltl.

diagnosed as unslable angina pain. The pain wasoersistent which disturbed my family and m€. On 22ndFebruary 2005, an angiography was car ed out whichreDorted thore was one 10070 blocked adery while othershad multiple blockages. We consulted three reputeddoctors at various hospitals inAhmedabad whoalladvisedsurgery therefore we setadate.

Suddenly, divine intervention came through afamilv fiiend. who informed us of the CAD regressioncam; hosted atthe Brahma Kumaris Headquarters. Withthe ;ssistance ot some BKs, I attended the camp in May2002, accompanied by my husband. We were impressedbythe methodology and Dr Gupta's style ofteaching. Hissioaan is to "heal thy self'. We had living examples ofoeo-ple who were completely cured by following thesvstem before us. Here, patients are told throughp'sychological testing why they are suffering and how toi'emove the roofcause ofsuffering. No other doctordoesthispractace.

We attended in allfo{rr progEmmes in the intervalof4-5 months. Every programme filled my heart with loveand an earnest desire to live. The personal visits of theqreat Dadis of Brahma Kumaris and their preachingsahanged my way of living. I started visiting the BrahmaKumaris centre in llemnagar, Ahmedabad. EveMhinggoes on normally now without angina or need forsurgery'l,,ty relatives, friends and neighbors doubt whether I wasevera heart patient!

Then came time for the second angaography inAuaust 2003. We chose a different hospital and thedodtors were surprised to see that the 100% blockedartery was now 100% open, and the other multipleblockageshad reduced to a great ex'tentl"lt's isa miracle. Icannot believe when I compare the first and repeatedangioqraphy repods."

Theso resultsare due to the blessings of God andthe holv Dadis of Brahma Kumaris. Moreover I dedicatemv suicess to Dr. Satish Gupta who took lot parns toddsign ihe programme, teach itin a very lucid manner, andattend tothe patienls uniformly.

I know the pain of heart patients and the agonytheir family members go through, which is curable nowTheheartof DrSatishGuptaisopenforal l Hecallsusnotheart patients but'Dilwale'. I can spread the light throughthe torch given by DrGupta and my services are available24 hourc anydayforany Dilwala.

lcontinued to follow the daily routinefrom 4.00 amto 10.00 at night and attended the follow-up programmeafrer six months. I attend every CAD Project camp andserve as a voluntoer. Dilwalas have formed the 'Healthy

Heart Education & Research Foundation' to spread themessage of CAD Proiect. I have motivated several CADpat|ents to attend the programme and we have alsostarted a Pune Chapter of the Foundation to help CADpatientsofthe city.

afiahyq ah.rii - tuFd ffiry o,!i.g..phy

tuFar c.l.*ry d'giogtuPht

TREATN,4ENT G VEN IN GOD'S REMEN4BRANCE- Ghanshyam C. Choksi, 63 yrs, Ahmedabad

I am a retired Civil Engineer During my career I had to work very hard. By naiure I was very punctual and sincere. lfsome lask was done incorrectly, I would get upset and angry.

In January 1998, I had to travelto Delhi from Ahmedabad by road and when I returned after six days my legs wereswollen. lvisited a physician who took my E.C.G' and found that my heart was nottunctioning properly.After an echo, Iwasadvised forangiography, whach revealed mulliple blocks in mycoronary arteries.lwas shocked bythis report as Ineitherhad chest pain norany symptoms ofbreathlessness etc. Due to poor ejection lraction of20% (pumping powerof the heart) neither by-pass nor angioplasiy was possible in my case making it a critical situation. N,4y wife andchildren became very depressed. Two months passed in tension and the doctor's medicines were not helping anymore. I left everything to God.

One day a friend insisted that lattend the'Healthy & Happy Living Programme for CAD Regress on'siarted atGlobalHospital, Rajasthan.lwas luckyto gel permission to attend lhe llrst programme from 15'" 21"'[,4ay 1998.

We were warmly received by Dr Satish Gupta and his team. Every patient was allotted an independeniwellequippedroom. The treatmentwas given sweetly in God's remembrance. They taught us how to live a life full of peace love, joyand happiness. After attending this camp I found a new direction. I conlinued to follow all components of theprog ra mme striclly.

After a follow-up visit, I had my Echo testdone before coming forthe third foilow-up visit in February 1999. ltwas reallywonderfulthat the pumping powerofmy heartwas raised to 35% from 20%! | have attended 5 camps wilhin hvo yearsand can graduallyfeelthe improvements. Life is colourfuland beauii fulagain.

I underwent a repeal angiography on 17th July 2000, and was astonished that the blockages had reduced 20% andthe pumping powerwas raised to 45%! lt's a great miracle thai God has saved my life. Dr. Satish Gupta is the angelwho hasfilled newjoy in my life. He put in greateffortswith God's mighty power

l a nson

I n J

FAITH IN MAINTAINING COIlSTANTGOOD HEALTH- K. H. Patel,

Fonet High Connissionet ol lndiato Uganda & Anbassadot Io Rwanda E Buundi,

El. DiEctot, Ministty ol External Atrai's,lcovt af tndia) 68 yts, Ahnedabad (Gul

lhad a massive heartattack in January,2000. lmmediately, I had to go throughangiographyand angioplasty, involvingthe olacement of two Stents. However. in next onemonih and three weeks lgot anolher heart attack.Followrng this, I went through second angiography. Theresult showed that the LAD, where angioplasty wasdone, had gotcompletely blocked. Two prominentHeartSurgeons opined that lshould go lhrough by-passsurgery. However, my Cardiology Consuliant thoughtlhat medical management should be sufflcient.

While accepting this view, I came in touch withDr. Satish Gupta who was conducting his CAD programat Abu, Rajasthan. I began to follow this programme,which has resulted in my EF improving from 45% to over60%. I have not felt any cardiac problem whatsoeverduring the last six-and-a-half years.I feel confidenl that as long as I praclice RajyogaMeditation and the basic princrples of CAD programmerelating to food , exercise and proper rest and sleep, Ishall nothave cardiac problem everagain.

EVERYONE SHOULD KNOW ABOUTTHIS PROGRAMME

-Shenaz A. Babi,57 yrs,Gujarct

latlended the CAD regression camp inSeptember2004, with 90o/o blockage ofthe r ight s ide CA, and 70% in r ightrenalartery lwas under constant stress andsuffering from diabetes, restlessness,domestic and professional problemsand had a sensitive naiure.

There are several good changes that I have undergonein my physical and emotiona health. I no longer getangina and have developed more stamina. lrypersonality has improved and ifestyle is simpler andmore peaceful. I have learned to overcome unnecessaryanxietyand take things ala normalpace.

I strongly feei the CAD Regression programme shouldbe arranged in small camps in all states of India, andbroadcaston television channels as well. lt's necessaryfor us to cultivate healthy habits for body and mind.Health is a gifr ofGod and we should not neglect it. Let'sinspire more people to attend such programmes andimprovetheir l ives.

The Four HeartAttacks Slillgoing strong- Satish S. Kawoor,55 yrs, Pune

I served in TATA Nrotors for 31 years.During this period I met with two majoraccidents: a severe electric shock onthechestin l9S'1 andaroadaccidentinwhich all the veins in my right ankle

Ayearfollowing my road accident I suffered from a heartattack in 1982, which was diagnosed to be myocardialinjury due to the electric shock on my chest. I had asecond heartattackwithin a month and was hospitalizedfor 4 months. I had my third attack in 1987 followed by aCVA attack in 1993 in which I lost my memory Theangiography report revealed a clot. lregained mymemory after treatment for 2-3 months and resumed myduties. But since thejob caused stress lfound it difficultto continue and opted forvoluniary retilemenl.

I opened a hotelat ShirdiSai Baba, 20 ki lometers frommy home in October2003. But running a profitable hotelis not an easy affair for a single person. The outcomewas the fourth heart attack. My angiography revealed Ihad six blockages ranging from 70to 90% and the doctorsuggested angioplastyfor 5 blockages. But consideringthe costs we opted for by-pass surgery and the day forooeration was fixed. I don't know what caused theoperating surgeon to change his mind but on seeing theCD he suggested I should flrst iry out yoga andayurvedic medicines and if need be, to come for theoperation after three months.

One of our doctor friends introduced me to the CADRegression Camp and l joined iton 16"August2004. l twas totally a new conceptfor me and by the fourth day Istarted feeling very lighl within. We had a picnic on thesixth day which was a virtual TMT test for us becauseevery Dilwala danced to garba and bhangra musicwithout feeling any physical discomfort. On the last dayeach one ofus had personal colnseling from Dr Gupta.

lcontinued to follow the daily routine from 4.00 am to10.00 at night and attended the follow-tlp proglammeafter six months. I attend every CAD Project camp andserve as a volunteer. Di|walas have formed the'HealthyHeart Education & Research Foundation'to spread themessage of CAD Project- | have motivated several CADpatients to attend the programme and we have alsostarted a Pune Chapter ofthe Foundation to help CADpatients of the city.

ALLAH'S ENCHANTING MEDICAL SYSTEM- Mazhar Mehsari, Munbai

On 11 ' ^ f u la rch '1999 , I sudden lydeveloped chest pain. I consulted myfamily doctor and gotT.M.T. done. Afterkeeping me in the ICU forlewdays, thedoctor recommended I go in for anangiography. At J.J. Hospital, lvlumbai,Dr Bhosale informed me of the CADregression camps organized by Brahma Kumaris, Abu,and said i f leverdecided toattend lshould lethim know.

lwent ahead with the angiogra phy wh ich revealed that Ihad 3 blockages: 80%, 90% and 99%. Though I wasn'tready for surgery, my family members and friendsinsisted lgo ahead. lhave strong belief inAllah and pray5 times a day; just before the surgery lfelt God wasinspiring me to contaci Dr Bhosale. He immediatelymade arrangements for me lo aome lo Shanlivan

Whatever I saw al the Brahma Kumaris Complex waswhat lslam calls'Jannat'or 'Paradise'. l t is such a pureenvironment. I\,4y mind blossomed on seeing thebehaviour and personality ofalllhose who live here. Thefirst miracle was renouncing the notion that ' l am apatient. ' lgave up non-vegetarian food on returninghome as the pufefood eaten in Shaniivan lefla pleasantmarkon my mind.

There is greal joy in practicing soulconsciousness anddetaching from the body and world 1o remember God.Whenever I share my experienceswith doctofs, none ofthem are oteoared to believe me. Heart disease isspreading rampantly in Bharat where the majority isunableto afford surgery. So at such iimes, lhis treatmentfrom God is a blessing. God is the Ocean and Iconstantly feelthe showers ofHis mercy on me.

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EASYTREATMENT & CREAT BENEFITSShivaji K. Nikalje,4s yrs. Pune

In 2003, whi le I was walking one day Is u d d e n l y f e l t d i z z y a s t h o u g heverything was going dark. I met thedoctor next daywho asked me to get anangiography done. The reportshowed Ihad three blockages: one was 100%blocked and the other two, 90%. l\,4ydoctor recommended I have by-pass surgeryimmediately. However I didnt have the two lacs to payforit .

lchanced tocome by a doctorwho informed meof the CAD regression camps held at Shantivan, AbuRoad. He told me to take a decision of having theoperation only after returning flom Shanlivan. Ivly wifeand lcameto Shantivan in Seotember2003.

We initially had the impression that ayurvedicmedicinewould be prescribed. Butfrom ihe firsl session,Dr Gupta shared very valuable information about howheart diseases develop, how a change in lifestyle isessential etc- | followed the proqramme diligently andstillmainiain it. The praclice of meditalion ioo helped megreatly in understanding myselfand connecting the soulwith the Divine Being.

lam absolutelyf inetodayand canwalk up to tenkilometres comfortably!

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Global Hospital & Research Centre (GHRG)

A pragmatic approach towards holistic healing, thatis, J Watumull Global Hospital & Research Centre. lt tookan induskialist, a surgeon and a spiritual leader to come upwith the novel idea of a multi-disciplinary secondary carehospital located in the verdant green hills of the Aravalirange,

In 1989, eminent head and neck cancer surg€onfrom MumbaiDrAshok Mehta visited NtountAbu and was

imoressed with the meticulous team work of the Brahma Kumaris in implementing their global UN-dedicated project,'Global Co-operation for a Better Worjd'. He then rcalised, he had found a group of like-minded people who wouldimplementhis vision ofa model hospitalfocusing on healthcare.

The project was adopted by Khuba and Gulab Watumull of Mumbai and Hawaii (U S A.) respectively, andnamed J.WatumullGlobal Hospital & Research Centre, in memory of theirlate father.Atthetime, district Sirohi's roughly70O,OOO strong population was seNed by 4 hospitals with a combined bed strength of 457 served the district's. JWatumull Global Hospital & Research Centrewas commissioned on October24, 1991.

Since then, word of the hospital and its philanthropic aims has gone around and flnancial support has beenforthcoming from theAmericas, Australia, Germany, Holland, Hong Kong, India, Japan, Kenya' Ivlauritius. Phillipines'SouthAfrica and United Kingdom. The hospitalhas expanded its scope ofoperation, both within the hospital premisesand in field wolk conducted in numerous villages around MountAbtl, under the leadership of BK Nirwair' appointedI\,4anaging Trustee of the govern ing board formed in 1 989. u4 ld.ghle€lu.eal0

GV Modi Health Care Centre

The G V l\,,lodi Rural Health Care centre & Eye HospitalatAbu Road was builtin '1994

with support from the N4odi family of Surat, a hospital patron - RobinRamsay of Australia, and Governmenl funding received underthe NalionalProgramme for conhol of Blindness.

The hospitalwas established as ageneralhealth cenhe, also housinga laboratory, x-ray unit, pharmacy, dentalclinic, and most important, an eye clinicthatwould function as a refer.alcumposloperative check-up clinic for the many eye patients 6eeking surgery for cataract, glaucoma and other blindnesscausing illnesses.Since then. the oohihalmic unil has been shiffed to the Global Hospital Institute ofOphthalmology. The centre presentlyhouses a cardiac clinic that serves as a consultation rcom for patients seeking admission to the hospital's coronary

artery disease regression project.

GLOBAL HOSPITAL INSTITUTE OF OPHTHALMOLOGY

The success of community ophthalmology services conducted in the fiold,and the appreciation for hospital services received from patients opeGted fordiseases causing blindness led to the establishment of the Global HospitalInstitute ofOphthalmology in 2003. The hospitalis stafied by five ophthalmicsurgeons supported by optometdsts and nursing staff.

It offers all anterior segment microsurgeies, cataract extraction by phaco-emulsification or by small inoisionwith posterior chamber IOL imptantation, glaucoma, trauma, adnexal and vitreo-retinal surgery contact lenses fittingand care, corneal services including eye banking and corneal transplantation' glaucoma care, lasor letinalphotocoagutation for diabetic retinopathy, low vision aids, Nd Yag laser services, neuro-ophthalmological car€,oculoplasty and orbit seNices, paediatri6ophthalmologyand shabismology and a uveitisclinics

The undedying aim is to develop the institute as a well_equipped, modern tertiary eye care cenhe lor p€Bons

livino in the dislricts iiserves- Jalore, Pali, Sirohi, UdaipurotRajasthan and areas ofneighbouring Gujarat

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has increased the capacity for indoor treatment, especially in paediatric and other specialized sub-branches ofophthalmology.

The Global Hospital & Research Centre Trust is extremely grateful to the Parmar Foundation, OrbisInternational Inc. and New World icare Pvt. Ltd. who helped establish this new unit.

P. C PARIIAR FOUNDATION GLOBALHOSPITAL EYE CARE CENTRE

l r l The excellent rcsponse of the community to theGlobal Hospital Institute of Ophlhalmology resulted in theconskuction of a new eye wing adjacent the existingcentre. This facility launched in 2007, named the P CParmar Foundation Global Hospital Eye Care Centre,houses specialist ophthalmic OPDS, as well as privatehospital rooms and an area to teach ophthalmology. This

RADHA MOHAN MEHROTRA GLOBAL HOSPITAL TRAUMA CENTRE

The Radha Mohan Mehrotra Global Hospital Trauma Centre, a trauma unit at Abu Road constructed withsuDoortofthe Radha [4ohan lvlehrotra Medical ReliefTrust was launched in 2007.

This centre offers emergency specialist medical care to trauma palients - road accident and medicalemergencies - aroundAbu Road. lt is equipped forenergency (and routine) surgery requirements in the disciplines ofgeneral surgery and orthopaedics. After conducling basic medical services, the cenhe hansfets patients toJ WatumullGlobalHospital& Research Centre atMountAbu orto othercitiesdepending on the seriousness ofthe case.

Laboratoryand imaging diagnosticdevices both as support services forsurgery and forthe routine diagnosis ofresidents in the vicinityofthecentre are alsoavailable.

A neurosurgeon is attached to the centre on a 'visiting basis' and a critical care ambu ance equipped withwireless control equipment to ensure prompt attention to cases rushed to the centre is also a vital part of our traumasetup.

BSES [G HOSPITA, I{UiIBAI

In theyear2002, the GlobalHospital& Research Centrc Trust entered into anovel public-private sector partnership with the BSES and the grihanmumbai

Municipal Corporation (B[rC). The BN,,IC allocated land for a hospita I at And heri inMumbai, the BSES covered the cost of conskucting the hospital building and itsequipment while lhe management of BSES MG Hospital as i t is cal led, is beingdone bythe Global Hospital& Research CenkeTrust.

This 100 bed multi-disciplinary hospital located at Andheri in Mumbai'ssu burbs has posted encou raging resulls ever since it began operations. Thehospital offers oulpatient clinics in the disciplines of cancer, cardiology, childguidance, chest medicine, dentistry diabetes, ENI endocrinology familymedicine, Gl endoscopy, gynaecology, homeopathy, medicine, nephrology,neurology, ophthalmology, orthopaedics, paediatf ics, pain management,physiothe.apy, psychiatry sports medicine, surgery and !rology.

Italso offers diagnostic, indoorand operative facilities. it has a wellequippedlabolatory, imaging department, blood bank and pharmacy. The hospital offers

health check-ups and specialty clinicswhere a large numberofcons!ltants proffer advice. Much emphasis is placed onorganizing medicalcampsfor underprivileged sections ofsociety and contlnuing med ical ed ucation programmes.

Jankl Foundatlonl-aunched in December 1997 at the Royal College of Physicians, London, The Janki

Trtr hNrl f(xjNl) I() =oundation for Global Health Care is a UK-registered charjty supporting research and

'"i(;iji* iiiiiiiiij.Erwareness in the field ofhealth and spintuality.fhe Foundation's original primary objective was to support the work of the GlobalHosDital and Research Centre (GHRC) in Mt Abu, India, where a holistic model of

heallhcarc enabled by a dedicated approach to values development has been pioneered- The hospital and itsassociated health outreach facilityworks in partnershipwith the World Health Organisation in the STOP TB campaignand is redlcing child mortality and improving maternal health in the region through nutritional supplements, healthcheckuosand immunization.The Foundation continues to provide extensive supportforthis work. Under the guidance of DadiJanki, its president, ithas also extended its remit to include values-based educalional initiatives within the healthcare sector worldwide. InSeptember2OO4 it launchedValues in Healthcare: a spiritual approach, a personaland team development programmefor healthcare practitioners. ByJune,2006, the programme had been introdlced in more than 30 countraesThe Foundation also publishes information leaflets for paiients and holds regularconferences, seminars and an annuallecture exploring the spiritual dimension of healthcare. Research findings and clinical experience increasingly revealthat spiritual faciors have a part to play in rccoveryfrom illness. The Foundation s premise is that betterunderstanding ofthese factors can beneflt both the patientand practitioner, by promoling the healing process, reducing strcss and stafffatigue and raising morale.The Foundation's activities include support for heallh practitioners in attending to thelr own well-being, throughreflective and othertechniques thatfacilitate re-connectionwith theirown highestvalues.DadiJanki, co-adminisirative head ofihe l\4tAbu-based Brahma Kumaris World Spirltual Universily, s chief patron ofthe GlobalHospital.

Medlcal WingTo develop awareness among the masses ofihe importanceofmaintaining a healthy life-styleTo reintroduce the ancient concept of holistic health care into the practice of modern medicine and afflrm the role ofmediialion in developing a healthyworld.To encourage a high standard ofelhics and exemplaryconductamong medicaland health professionals.To provide an environment in which distinguished medical scientists and specialists can diaLogue and exchangeexperiences,To conduct and publish research into the psycho-physiology of Raja Yoga fi/leditation and its application in theprevention of sickness and promotion of health.To encourage pu blic a nd professional responsibility in meeting the World H eallh O tgan isation's objectivesThere is no denying that lhe medical advances ofthe last decades ofthe 20th century are nothing short of miraculous.Wonders, such as major olgan transplants, heart bypasses, hip replacements, laser surgeres and soph sticateddiagnostic techniques, relieve the suffering and extend the life span of countless individuals who would olherwise bedoomed lo an untimelyand painfulend.There is also widespread recognition of the interrelationship between mind and body. Holistic medicine and healthpractices are sleadily gaining popularit. Diet, stress in the workplace and environmental factors-both physical andpsychologica! are being measured as to their impact on well-being and provisions are now made in the health carepolicies ofmajor companies foraliernativetherapies such as acupunclure and homoeopathyYetwhilethe mental, emolionaland socialaspects of a patient 's well-being are beginning to be addressed, there is st i l llittle understanding as to howa person'slhoughts, attitudes, and beliefs contribute to his orherwell_being.Dis-ease begins first at the levelofspirit. Ahuman being, who has a sense oftrue self-love and self-respect as wellas aclear underslanding of the value of his or her life, is resistant to diseases of all lypes. However, when these arediminished or damaged through loss or trauma, the spirit becomes susceptible to negative and wasle thoughts andvibraiions. The willtowards love and life is weakened and the physical system reflects this by being accidenfprone,vulnerable to disease-producing elements such as germs and viruses and with reduced psychological immunity tosocial oressures. inte rpersonal lension s and otherforms ofstress, Various forms ofsensual indulgence and addictivebehaviour resulifrom the soul's attemptto compensate orescape the inner impoverishmenl and discomfortSpiritually empowered medicine prescribes medilation and spirilual practices which enhance an individual's resistanceto the negative influences that drain spiritual energy. At the same time it promotes self-respect, purposefulness andothervalues which empowerthe willand strengthen lhe character. Spiritual empowerment demonstrates the lruth that'sound character contributes to a sound mind and body'. Best ofall, meditation is a medication that has no adverse side

Nurses. doctors and olher medical personnel can also benefitfrom spiritual empowerment. Often they are victims ofthesame addictive habits (smoking and drinking alcohol) as their paiients. Hospilals, medical schools and out-patientclinics are often stressful environments. The Global Hospital & Research Centre is an example of a spirituallyempowered medical environment where all staff regularly practice mediiation. Many patients describe its calm andcomforting ambiance-a marked contrast to many medical esiablishments ofthe same size and scope- as having playeda significant role in theirrecovery.

Brahma KumarisPrajapita Brahma Kumaris lswariya Vishwa

Vidyalaya (or Brahma Kumaris World SpiritualUniversity, BKWSU, as it is known in foreign countries)is an intemational spiritual organisalion. lt has beenworking atall levels ofsocietyfora positive change forthe last70 years. The organisation offers a wide rangeofeducalional programs through its more than 8000centers in morethan 100 countries.

The Brahma Kumaris institution acknowledges theintrinsic goodness of all people. A worldwide family ofindividuals from allwalks oflife. thev are committed tospiritual growthand personaltransformation, believingthem essential in creating a peaceful and jusl world.Acknowledging the challenges of rapid globalchange,we nurture the well-being ofthe entire human family by

promoting spiritual understand ing, leadership with integrity and elevated aciions towards a betterworld. The Universityworks alongside individuals and organisations in all areas of the community, such as healihcare, educaiion, youth,socialservices, thecriminaljusticesystem and in inter-religious dialogue.

Avisionary leader, thefounder, Brahma Baba, envisioned a time when peo roundswould cometogether lo rediscover and develop the spiritual dimensionoftheir lives. One of his most revolutionary inspirations wasto place women in the major leadership roles of theUniversily.

Apractical method of meditation istaughtthat helpsindividuals undeFtand their inner strengths and values.Raja Yoga lr4editation is a method of relaxing, refreshingand clearing the mind and heart. lt helps you look inside torcdiscover and reconnect with your original, spiritualessence.

The BKWSU has general consultative status withthe lJnited Nalions Economic and Social Council andconsultativestatuswith UNICEF.wwwbkwsu,oro, wwwbrahmakumaris.com

He.lthy Heart Educatlon & Research Foundation (HHERF)

The Beneficiaries of CAD programme have formed the HHERF, which was registered with CharityCommission, Ahmedabad (Gujarat) on January 8, 2004.

The main objective of the Foundalion is to spread awareness aboul the CAD Program as w dely aspossible in India, so that the maximum number of people can take its advantage. The Foundation rs administratedby a 11- member Board of Trustees, hailing from different part of India. Some of ihe office bearers of the Foundaiionare as oerow:

Dr.Satish Kumar Gupta - PtesidentShri B. L. Maheshwari - Vice President

B. K. Sharda . Managing TrusteeShri Shailesh Patel - Joint Secretary

Individual persons, Firms, Companies & Public Trusts, who subscribe lo the objectives of the Foundation,can become the Members. The Foundation is run on the basics of the Voluntary coniributions received. TheContributions to the Foundation are exempt from Income Tax U/S 80G @ 50% of donated anrount.

PresentAddress ofthe Foundation is as under:Healthy Heart Education & Research Foundation '110 ,Sampann complex, Navrangpura

Ahmedabad - 380 009 (Guj) Phr 079 - 26405892 95 Fax: 079- 26560136Email: h€[email protected] Web Site: www.healheart.org and www3dheartcarebkabu.orq

'--.5

For more details Contact :

CAD Project Office

Healthy Heart Office

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