A 46-year-old woman with uncontrolled diabetes for the past 8 years presents with chest pain to emergency. Found to have heart attack and taken up for angiogram which showed blockage in a main artery in the heart and was treated with stenting. This is a common story in India and also in my medical practice in Chennai.

Diabetes happens in younger population in India due to inappropriate diet, lack of exercise and central obesity (Tummy fat). Cardiovascular disease (CVD) is the leading cause of death and disability among individuals with diabetes mellitus, characterized by accelerated atherosclerosis(cholesterol plaque development in the blood vessels). In India, the convergence of a genetic predisposition and rapid lifestyle transitions has led to a disproportionate higher incidence of diabetes-related heart disease, often occurring at a younger age than in Western populations.

Key Findings in our People

• India is frequently termed the "diabetes capital of the world," with current estimates suggesting over 77 million to 101 million individuals are affected by the condition.
• Cardiovascular diseases account for nearly one-third of all deaths in India, with a national prevalence rate of approximately 7.5%.
• Indians exhibit a "thin-fat" phenotype, characterized by higher visceral adiposity and insulin resistance despite lower Body Mass Index (BMI), which exacerbates cardiovascular risk.
• Diabetic patients in India face a higher relative risk burden, including earlier onset of coronary artery disease (CAD – blockages in the blood vessels of the heart) and higher case fatality rates compared to other ethnic groups.
• The spectrum of complications includes coronary artery disease, heart failure, stroke, and peripheral artery disease, often complicated by "silent" ischemia due to autonomic neuropathy.

The cause of Diabetic heart problems

The primary driver of cardiovascular complications in diabetes is chronic high blood sugar levels, which induces oxidative stress in the blood vessel inner lining and the formation of Advanced Glycation End-products (AGEs). These processes lead to systemic inflammation and the stiffening of large arteries, accelerating atherosclerosis. Additionally, insulin resistance often coexists with a specific pattern of cholesterol problems —high triglycerides, high LDL and low High-Density Lipoprotein (HDL)—which further destabilizes arterial plaques leading to heart attacks.

The Indian Context and "Asian Indian Phenotype"

The significance of these complications in India is magnified by the "Asian Indian Phenotype." This genetic and metabolic profile involves higher levels of abdominal fat, even in individuals who appear non-obese by standard BMI measures. This metabolic environment promotes premature coronary artery disease, which often appears 5–10 years earlier in Indians than in Europeans.

Clinical Spectrum of Complications

1. Coronary Artery Disease (CAD): The most common complication, often involving multi-vessel disease and more diffuse disease in diabetic patients. This causes heart attack, chest pain, heart failure and breathlessness on exertion
2. Diabetic Cardiomyopathy: Structural and functional changes in the heart muscle that occur without blockages in the blood vessels or hypertension, often leading to heart failure.
3. Stroke: Diabetes significantly increases the risk of ischemic stroke due to blockages in the blood vessels to the brain and small vessel damage in the brain.

Practical Takeaway

• Early Screening: Indians with diabetes should undergo cardiovascular risk assessments, including ECG and lipid profiling, immediately upon diagnosis.
• Aggressive Management: Target blood pressure (typically < 130/80 mmHg) and lowering LDL cholesterol levels (LDL levels typically < 100 mg/dL) more strictly in diabetic patients are important to prevent major adverse cardiac events. In research, cholesterol lowering medication is found to lower heart attacks in diabetic patients in the long term.
• Lifestyle Modification: Focus on reducing refined carbohydrates, increasing intake of fruits, vegetables and wholesome  grains and pulses and increasing physical activity to combat visceral adiposity specific to the Indian population.
• Pharmacological Intervention: Utilization of modern glucose-lowering agents like SGLT2 inhibitors and GLP-1 receptor agonists, which have proven cardiovascular benefits beyond blood sugar control.