Stress is new-age tobacco for heart disease: Dr CN Manjunath

The man who turned around a government-run Sri Jayadeva Institute of Cardiovascular Sciences and Research (SJICSR) hospital to transform it into a super-speciality cardiac treatment facility, Dr CN Manjunath, SJICSR’s director, says heart disease as an epidemic had relatively more deaths than Covid through the pandemic, but the trauma and stigma was more in the latter. He blames stress as the most dominant cause for heart disease in an era where professional and personal lives are gripped by stress, and there is a need for everyone to slow down. In a free-wheeling interaction with the editors and staff of The New Sunday Express, the Padma Shri awardee also gave an assuring picture of Covid in India and Karnataka. Excerpts.

How is the Covid scenario now in Karnataka and India?
We are not anticipating another wave in India right now. We have seen a sporadic rise in the number of cases post the second wave. Despite a surge in cases seen briefly, it did not necessarily turn into a wave. January and February are generally seen to be conducive for viral infection, in the pre-pandemic era as well. Hence a small spurt in cases can be seen, but nothing worrisome. With the situation in countries like China and South Korea, fear continues to persist among people. However, India is not likely to see a worsened situation like that in China or the USA due to people’s strengthened immunity and better preparedness for managing Covid when compared to the first and second waves. Also, all the new variants seen are sub-lineages of Omicron, hence are not a cause of concern as the virus tends to lose its severity as it mutates further. It is still recommended that people continue to follow Covid Appropriate Behaviour and take booster doses. Comparing India with the USA and China, both countries continued to stay at a mid-level in terms of Covid. They did not see much reduction in cases due to the dilemma between the Republicans and Democrats over getting vaccinated in the USA and the zero-covid strategy followed by China which resulted in poor immunity among people. India’s current state, on the other hand, is different and strategies inculcated have proven to be more effective. In recent days, people have forgotten to get tested. If they are symptomatic, people should come forward for testing in the better interest of their family and the neighbourhood.

How susceptible is the younger generation to heart problems these days?
Young people are undoubtedly more vulnerable to developing issues related to the heart these days. A study taken up at Jayadeva itself showed that 6,000 young patients were treated for heart attacks in a span of four years at the hospital, the youngest being a 15 year old. The trend has changed and parents are seen getting their children to the hospital these days when it used to be the opposite earlier. People in the age group of 25-45 are definitely seeing more heart attacks. A 22 per cent rise is seen in terms of prevalence of heart attacks among the youth. Smoking is seen as the highest symptomatic cause for it with 51 per cent of patients being smokers among both young and old people. Other factors are high blood pressure and diabetes (15%), cholesterol (20%) and strong family history (15%). Beyond the conventional risk factors, 30% of cases have been seen with no history of smoking, high BP or cholesterol.

We have been seeing many instances of gym-goers collapsing while working out. What is the reason? What should gym enthusiasts do before joining a gym?
High-intensity exercise is not good for the heart. Unaccustomed high-intensity exercises put a lot of stress on the heart. Plaques, cholesterol ulcers inside the arteries, can rupture inside the arteries and can cause a heart attack. Suppose somebody can lift weights up to 30 kg and if he tries to lift 70 kg then it leads to problems. People should do some warming-up exercises for a few days and then scale up. Before taking a gym programme, it is advisable to have a preliminary cardiac check-up done. Also, people should not consume too many energy drinks. Just by walking 10,000 steps per day, the lifespan increases by eight to 10 years.

What is the role of stress in heart diseases?
Stress is the new-age tobacco which is a primary cause of heart ailments. Acute stress is an important risk factor, equivalent to smoking, in causing heart issues among people. Heart attacks in pre-menopausal women have become more prevalent. Earlier, hardly any cases were seen, but it has now risen to 8 per cent. The mental and physical health of people is seen to be affected, especially in the younger age group. People lack patience and aspire to achieve several goals at an early stage in life. Stress is nothing but a gap between expectation and performance. People tend to get stressed if they do not match. Other than stress, fatty liver consumption, narcotic drugs, air, soil and vehicular pollution are the emerging risk factors for heart ailments. India lost 20 lakh people last year due to air pollution. It is an emerging risk factor these days as particulate matter tends to block arteries and form clots resulting in heart attacks. Appropriate measures must be taken to decongest traffic to minimise vehicular pollution.  

Getting back to stress, what steps can be taken to combat it?
Stress management needs to be done individually at the student level, family level and workplace level as well. Workplace wellness has an immediate bearing on cardiovascular issues among employees. It should be ensured that people are provided with a healthy work environment. At an individual level, they should ensure to not carry work stress back home or vice-versa. People must ensure that they have a high happiness index. In India, people are often seen worrying either about their personal life, professional life, or both. Sixty per cent of deaths in India are due to lifestyle diseases with the most common being non-communicable diseases (NCDs), like heart attacks, high BP, diabetes, cancer, stroke, chronic obstructive lung diseases and screen addiction. Digitalisation and fast-moving technology have made people glue to the screens such that it has become a mental disorder.

How does Covid impact heart health? Should people infected with the virus go for heart check-ups?
Covid has contributed to the formation of clots in arteries, hence chances of a heart or a brain stroke are increasing. But the risk of all Covid-infected people getting a stroke is very less. Four per cent of people can get affected by it; hence, it will not largely add to being the cause of death over the next few years. People experiencing symptoms of burning sensations, chest pain, and shortness of breath should go for a yearly ECG (electrocardiogram) and treadmill ECG. People must also watch out for unconventional symptoms like upper stomach gastritis, throat and jaw pain or left shoulder or upper back pain which can also cause a sudden attack. People who experience any sort of chest pain or back pain which increases while walking or climbing stairs should also undergo a checkup. Since the burden of NCDs is high in India, people must annually go for these checkups to ensure early diagnosis of any ailment.

What are the solutions to provide better facilities and reduce deaths due to heart attacks in rural areas?
Since specialists are not readily available in small-scale hospitals, people end up travelling long distances seeking medical help. Often the doctors as well in these clinics do not facilitate the people as they do not wish to risk a person’s death. Doctors should be trained to facilitate patients either via telemedicine facilities or other technological advancements reducing a patient’s travel time from faraway places. It also reduces the risk of death in a patient. All doctors must also be educated in providing clot-dissolving medicines to a person suffering from a heart attack as it helps buy sufficient time to be able to facilitate them better. Since the rate of NCDs in rural and urban areas has become equal, it is important to narrow the gap in terms of providing better services in rural setups as well.

What are the technological advances in the treatment of heart-related diseases?
Today, even heart valves can be replaced using nonsurgical methods. Six to seven out of every 1,000 children born do have heart holes by birth. Nearly 50 per cent of heart holes can be closed by nonsurgical measures where the umbrella device is inserted into the heart without any scars. Just two or three days of stay is needed in the hospital.

How well-equipped are we to tackle the heart disease epidemic?
We have 2,200 cath labs in India. Going by the size of the population, and also looking at the magnitude or burden of cardiovascular disease, we need more than 7,000 cath labs. There is also a concern about specialists. We have close to one lakh MBBS seats in India and 60,000 post-graduation seats. In many private medical colleges, there are more students than patients. So obviously, they are under-trained. Their hands-on experience will also be less. This is what probably the National Medical Commission has to take note of so that medical degrees are not mere certificate degrees. Otherwise, a lot of half-baked doctors will come out, which is more harmful. I think as far as South India is concerned, there is no shortage of doctors. But there is maldistribution, with more doctors in cities and fewer in villages.

And why is that happening?
Despite giving quality care and timely treatment to patients, if the underlying disease is severe a patient will die. Doctors are blamed for this and assaulted. A conducive working atmosphere, for doctors, should be created in rural and semi-urban hospitals. A doctor should understand the financial background of the patient and offer the best treatment strategy within that financial bracket. For instance, a 15-day-old baby was brought to us from Mangaluru. The poor family had spent lakhs. We found the child had an untreatable heart disease. This is where all the problems start. A good transfer policy of patients from smaller hospitals in villages to bigger hospitals should be maintained.

What are your recommendations to the government in terms of reducing the cost of stents and treatment?
The cost of stents comes under the National Pharma Pricing Authority and they are standardised. In government institutions, all the costs are fixed. There is a misconception among the public relating to the Ayushman Bharat scheme. People think that the individual coverage is up to Rs 5 lakh. The amount is for the whole family and the individual patient’s coverage is just Rs 1.75 lakh. Many procedures are left out of the scheme. They have to be included. Suppose a patient requires a triple valve replacement to prevent sudden cardiac death, we use some implant that costs around Rs 4 lakh, excluding the procedure. That’s the reason many private hospitals are not taking a large number of patients. All new procedures and implants should be included in the scheme. We have written to the state and Central governments about this.

Heart diseases in India are considered epidemic. How would you compare that with the Covid pandemic over the last two-three years? Which is more serious?
If you take collective deaths, cardiac deaths may be relatively more than Covid deaths. But if we look at the suffering, the stigma and trauma around Covid, it paralysed the system affecting the livelihood of the masses. Whereas cardiac issues affect one individual or family.

Can you share incidents that motivated you to become a doctor?
When I was around eight years old, I had a high fever. My father, an agriculturist, carried me on his shoulders to our nearest city Channarayapatna for treatment. But there were no doctors. From there, he carried me to another hospital 5 km away, where I got treated. This incident moved me to become a doctor. I used to see people dying of typhoid and snake bites in my village. These instances made my dream to become a doctor even stronger. My mother was very particular that I should become a doctor. MD physicians were treating heart ailments, there were no cardiologists back then. In 1980-83, there was no big cardiac facility in our state. I made up my mind to become a cardiologist and establish a good cardiac hospital for the common man.

How were your initial days as a cardiologist? Did you face any challenges?
In the initial days, we were going to conferences where people from abroad used to deliver lectures about various procedures they did and sometimes ended up being disappointed that we were not able to do it here. However, around 1995, we started angiograms and angioplasties. As these were new procedures, there was a lot of resistance with many not ready to accept them. We had to explain and convince them. Today, Jayadeva is doing the highest number of cardiac cath lab procedures in India with 50,000 in 2022.

Tell us, how did you develop the government-run autonomous institute Jayadeva into one of the best cardiac hospitals in South East Asia today?
Government hospitals were seen as places for the poor as they were affordable. I wanted Jayadeva to be a role model and function like a five-star corporate hospital. We were passionate about our job and took a slew of measures. We never compromised on quality and care. We implemented the ‘treatment-first-payment-later’ principle. We decentralised the power. As a leader, I complimented the team for their good work and avoided punitive measures. When you let people around you grow, without your knowledge you and the institution will also grow. In case of blame, a leader should take more of it; and in case of fame, a leader should share less of it. From Bengaluru, we moved to other districts. While we have demand to open units in many districts, our request is to stick to revenue districts, where one hospital can cater to nearby 5-6 districts. The Indian Institute of Management-Bangalore did a case study on Jayadeva (SJICSR) and said this public hospital could be the best model for others to emulate. Despite limited grants from the government, we managed with internal revenue generation and support from various charitable organisations. Now we can proudly say there is a reverse flow of patients from private hospitals to Jayadeva.

What is your mantra to keep your heart healthy?
You have to keep the five ‘S’s’ — Salt, Stress, Spirit, Smoking and Sedentary lifestyle — as low as possible. You have to keep these five things as low as possible too: blood pressure, blood sugar, blood cholesterol, body weight and waist circumference, and over-ambition of achieving things quickly that otherwise take many years.

You are the son-in-law of former PM and JDS supremo HD Deve Gowda. What do you think about him? Does he take your suggestions?
He takes good care of his health. He is a disciplined patient and respects every doctor treating him. He reads a lot and is knowledgeable. When he took over as the PM of India, he had six cardiologists from AIIMS (All India Institute of Medical Sciences) to take care of him. I suggested that it is unnecessary as he did not have any cardiac issues. He immediately sent them back. He has taken my suggestions while formulating health policies.

How do you de-stress?
I inculcate a smile that is an antidepressant and carry a positive attitude. I avoid impulsive behaviour and try to hold back emotions for a while. We will be the first to get affected if we lose our cool. I try to keep conversations short. I talk to my patients every day and try to help the poor by raising funds for treatment. Their happiness and joy relieve my stress. Also, the best diet for the brain is having good friends.

The man who turned around a government-run Sri Jayadeva Institute of Cardiovascular Sciences and Research (SJICSR) hospital to transform it into a super-speciality cardiac treatment facility, Dr CN Manjunath, SJICSR’s director, says heart disease as an epidemic had relatively more deaths than Covid through the pandemic, but the trauma and stigma was more in the latter. He blames stress as the most dominant cause for heart disease in an era where professional and personal lives are gripped by stress, and there is a need for everyone to slow down. In a free-wheeling interaction with the editors and staff of The New Sunday Express, the Padma Shri awardee also gave an assuring picture of Covid in India and Karnataka. Excerpts. How is the Covid scenario now in Karnataka and India? We are not anticipating another wave in India right now. We have seen a sporadic rise in the number of cases post the second wave. Despite a surge in cases seen briefly, it did not necessarily turn into a wave. January and February are generally seen to be conducive for viral infection, in the pre-pandemic era as well. Hence a small spurt in cases can be seen, but nothing worrisome. With the situation in countries like China and South Korea, fear continues to persist among people. However, India is not likely to see a worsened situation like that in China or the USA due to people’s strengthened immunity and better preparedness for managing Covid when compared to the first and second waves. Also, all the new variants seen are sub-lineages of Omicron, hence are not a cause of concern as the virus tends to lose its severity as it mutates further. It is still recommended that people continue to follow Covid Appropriate Behaviour and take booster doses. Comparing India with the USA and China, both countries continued to stay at a mid-level in terms of Covid. They did not see much reduction in cases due to the dilemma between the Republicans and Democrats over getting vaccinated in the USA and the zero-covid strategy followed by China which resulted in poor immunity among people. India’s current state, on the other hand, is different and strategies inculcated have proven to be more effective. In recent days, people have forgotten to get tested. If they are symptomatic, people should come forward for testing in the better interest of their family and the neighbourhood. How susceptible is the younger generation to heart problems these days? Young people are undoubtedly more vulnerable to developing issues related to the heart these days. A study taken up at Jayadeva itself showed that 6,000 young patients were treated for heart attacks in a span of four years at the hospital, the youngest being a 15 year old. The trend has changed and parents are seen getting their children to the hospital these days when it used to be the opposite earlier. People in the age group of 25-45 are definitely seeing more heart attacks. A 22 per cent rise is seen in terms of prevalence of heart attacks among the youth. Smoking is seen as the highest symptomatic cause for it with 51 per cent of patients being smokers among both young and old people. Other factors are high blood pressure and diabetes (15%), cholesterol (20%) and strong family history (15%). Beyond the conventional risk factors, 30% of cases have been seen with no history of smoking, high BP or cholesterol. We have been seeing many instances of gym-goers collapsing while working out. What is the reason? What should gym enthusiasts do before joining a gym? High-intensity exercise is not good for the heart. Unaccustomed high-intensity exercises put a lot of stress on the heart. Plaques, cholesterol ulcers inside the arteries, can rupture inside the arteries and can cause a heart attack. Suppose somebody can lift weights up to 30 kg and if he tries to lift 70 kg then it leads to problems. People should do some warming-up exercises for a few days and then scale up. Before taking a gym programme, it is advisable to have a preliminary cardiac check-up done. Also, people should not consume too many energy drinks. Just by walking 10,000 steps per day, the lifespan increases by eight to 10 years. What is the role of stress in heart diseases? Stress is the new-age tobacco which is a primary cause of heart ailments. Acute stress is an important risk factor, equivalent to smoking, in causing heart issues among people. Heart attacks in pre-menopausal women have become more prevalent. Earlier, hardly any cases were seen, but it has now risen to 8 per cent. The mental and physical health of people is seen to be affected, especially in the younger age group. People lack patience and aspire to achieve several goals at an early stage in life. Stress is nothing but a gap between expectation and performance. People tend to get stressed if they do not match. Other than stress, fatty liver consumption, narcotic drugs, air, soil and vehicular pollution are the emerging risk factors for heart ailments. India lost 20 lakh people last year due to air pollution. It is an emerging risk factor these days as particulate matter tends to block arteries and form clots resulting in heart attacks. Appropriate measures must be taken to decongest traffic to minimise vehicular pollution.   Getting back to stress, what steps can be taken to combat it? Stress management needs to be done individually at the student level, family level and workplace level as well. Workplace wellness has an immediate bearing on cardiovascular issues among employees. It should be ensured that people are provided with a healthy work environment. At an individual level, they should ensure to not carry work stress back home or vice-versa. People must ensure that they have a high happiness index. In India, people are often seen worrying either about their personal life, professional life, or both. Sixty per cent of deaths in India are due to lifestyle diseases with the most common being non-communicable diseases (NCDs), like heart attacks, high BP, diabetes, cancer, stroke, chronic obstructive lung diseases and screen addiction. Digitalisation and fast-moving technology have made people glue to the screens such that it has become a mental disorder. How does Covid impact heart health? Should people infected with the virus go for heart check-ups? Covid has contributed to the formation of clots in arteries, hence chances of a heart or a brain stroke are increasing. But the risk of all Covid-infected people getting a stroke is very less. Four per cent of people can get affected by it; hence, it will not largely add to being the cause of death over the next few years. People experiencing symptoms of burning sensations, chest pain, and shortness of breath should go for a yearly ECG (electrocardiogram) and treadmill ECG. People must also watch out for unconventional symptoms like upper stomach gastritis, throat and jaw pain or left shoulder or upper back pain which can also cause a sudden attack. People who experience any sort of chest pain or back pain which increases while walking or climbing stairs should also undergo a checkup. Since the burden of NCDs is high in India, people must annually go for these checkups to ensure early diagnosis of any ailment. What are the solutions to provide better facilities and reduce deaths due to heart attacks in rural areas? Since specialists are not readily available in small-scale hospitals, people end up travelling long distances seeking medical help. Often the doctors as well in these clinics do not facilitate the people as they do not wish to risk a person’s death. Doctors should be trained to facilitate patients either via telemedicine facilities or other technological advancements reducing a patient’s travel time from faraway places. It also reduces the risk of death in a patient. All doctors must also be educated in providing clot-dissolving medicines to a person suffering from a heart attack as it helps buy sufficient time to be able to facilitate them better. Since the rate of NCDs in rural and urban areas has become equal, it is important to narrow the gap in terms of providing better services in rural setups as well. What are the technological advances in the treatment of heart-related diseases? Today, even heart valves can be replaced using nonsurgical methods. Six to seven out of every 1,000 children born do have heart holes by birth. Nearly 50 per cent of heart holes can be closed by nonsurgical measures where the umbrella device is inserted into the heart without any scars. Just two or three days of stay is needed in the hospital. How well-equipped are we to tackle the heart disease epidemic? We have 2,200 cath labs in India. Going by the size of the population, and also looking at the magnitude or burden of cardiovascular disease, we need more than 7,000 cath labs. There is also a concern about specialists. We have close to one lakh MBBS seats in India and 60,000 post-graduation seats. In many private medical colleges, there are more students than patients. So obviously, they are under-trained. Their hands-on experience will also be less. This is what probably the National Medical Commission has to take note of so that medical degrees are not mere certificate degrees. Otherwise, a lot of half-baked doctors will come out, which is more harmful. I think as far as South India is concerned, there is no shortage of doctors. But there is maldistribution, with more doctors in cities and fewer in villages. And why is that happening? Despite giving quality care and timely treatment to patients, if the underlying disease is severe a patient will die. Doctors are blamed for this and assaulted. A conducive working atmosphere, for doctors, should be created in rural and semi-urban hospitals. A doctor should understand the financial background of the patient and offer the best treatment strategy within that financial bracket. For instance, a 15-day-old baby was brought to us from Mangaluru. The poor family had spent lakhs. We found the child had an untreatable heart disease. This is where all the problems start. A good transfer policy of patients from smaller hospitals in villages to bigger hospitals should be maintained. What are your recommendations to the government in terms of reducing the cost of stents and treatment? The cost of stents comes under the National Pharma Pricing Authority and they are standardised. In government institutions, all the costs are fixed. There is a misconception among the public relating to the Ayushman Bharat scheme. People think that the individual coverage is up to Rs 5 lakh. The amount is for the whole family and the individual patient’s coverage is just Rs 1.75 lakh. Many procedures are left out of the scheme. They have to be included. Suppose a patient requires a triple valve replacement to prevent sudden cardiac death, we use some implant that costs around Rs 4 lakh, excluding the procedure. That’s the reason many private hospitals are not taking a large number of patients. All new procedures and implants should be included in the scheme. We have written to the state and Central governments about this. Heart diseases in India are considered epidemic. How would you compare that with the Covid pandemic over the last two-three years? Which is more serious? If you take collective deaths, cardiac deaths may be relatively more than Covid deaths. But if we look at the suffering, the stigma and trauma around Covid, it paralysed the system affecting the livelihood of the masses. Whereas cardiac issues affect one individual or family. Can you share incidents that motivated you to become a doctor? When I was around eight years old, I had a high fever. My father, an agriculturist, carried me on his shoulders to our nearest city Channarayapatna for treatment. But there were no doctors. From there, he carried me to another hospital 5 km away, where I got treated. This incident moved me to become a doctor. I used to see people dying of typhoid and snake bites in my village. These instances made my dream to become a doctor even stronger. My mother was very particular that I should become a doctor. MD physicians were treating heart ailments, there were no cardiologists back then. In 1980-83, there was no big cardiac facility in our state. I made up my mind to become a cardiologist and establish a good cardiac hospital for the common man. Sri Jayadeva Institute Director Dr CN Manjunath interacts with TNSE editors and journalists at The New Indian Express office in Bengaluru | nagaraja gadekal How were your initial days as a cardiologist? Did you face any challenges? In the initial days, we were going to conferences where people from abroad used to deliver lectures about various procedures they did and sometimes ended up being disappointed that we were not able to do it here. However, around 1995, we started angiograms and angioplasties. As these were new procedures, there was a lot of resistance with many not ready to accept them. We had to explain and convince them. Today, Jayadeva is doing the highest number of cardiac cath lab procedures in India with 50,000 in 2022. Tell us, how did you develop the government-run autonomous institute Jayadeva into one of the best cardiac hospitals in South East Asia today? Government hospitals were seen as places for the poor as they were affordable. I wanted Jayadeva to be a role model and function like a five-star corporate hospital. We were passionate about our job and took a slew of measures. We never compromised on quality and care. We implemented the ‘treatment-first-payment-later’ principle. We decentralised the power. As a leader, I complimented the team for their good work and avoided punitive measures. When you let people around you grow, without your knowledge you and the institution will also grow. In case of blame, a leader should take more of it; and in case of fame, a leader should share less of it. From Bengaluru, we moved to other districts. While we have demand to open units in many districts, our request is to stick to revenue districts, where one hospital can cater to nearby 5-6 districts. The Indian Institute of Management-Bangalore did a case study on Jayadeva (SJICSR) and said this public hospital could be the best model for others to emulate. Despite limited grants from the government, we managed with internal revenue generation and support from various charitable organisations. Now we can proudly say there is a reverse flow of patients from private hospitals to Jayadeva. What is your mantra to keep your heart healthy? You have to keep the five ‘S’s’ — Salt, Stress, Spirit, Smoking and Sedentary lifestyle — as low as possible. You have to keep these five things as low as possible too: blood pressure, blood sugar, blood cholesterol, body weight and waist circumference, and over-ambition of achieving things quickly that otherwise take many years. You are the son-in-law of former PM and JDS supremo HD Deve Gowda. What do you think about him? Does he take your suggestions? He takes good care of his health. He is a disciplined patient and respects every doctor treating him. He reads a lot and is knowledgeable. When he took over as the PM of India, he had six cardiologists from AIIMS (All India Institute of Medical Sciences) to take care of him. I suggested that it is unnecessary as he did not have any cardiac issues. He immediately sent them back. He has taken my suggestions while formulating health policies. How do you de-stress? I inculcate a smile that is an antidepressant and carry a positive attitude. I avoid impulsive behaviour and try to hold back emotions for a while. We will be the first to get affected if we lose our cool. I try to keep conversations short. I talk to my patients every day and try to help the poor by raising funds for treatment. Their happiness and joy relieve my stress. Also, the best diet for the brain is having good friends.