Dr. Enas A. Enas, a Chicago-based cardiologist, was honored with the Most Distinguished Physician Award by the American Association of Physicians of Indian Origin (AAPI), at its 37th annual convention and scientific assembly held in Atlanta over the July 4 weekend, for his decades-long research and activism to alleviate the significant incidence of heart disease among Indians, including Indian Americans.
This AAPI award, presented annually at its convention is given to a practicing U.S. physician of Indian origin, whose work has had a “significant impact on advances in medical science or innovations in medical care that greatly benefit humanity at large.”
AAPI said Enas was the recipient of the award—the highest honor the organization bestows each year at its convention, “for his pioneering and ground-breaking research spanning 30 years that has helped unravel the enigma of heightened risk of heart disease in Indians that had eluded explanation for decades.”
A native of Kerala, Enas graduated from the University of Kerala (Calicut Medical College) and then immigrated to the U.S. to pursue higher studies in cardiology. He is the first cardiologist in the U.S. to sound the alarm on the heightened risk of heart disease in Indians, and he did so with an article in the AAPI Journal in 1990, titled, ‘Immigrant Indian Men ̶ Sitting Ducks for Heart Attacks—A Cause for Alarm and Call for Action.’
Numerous studies since then, have confirmed that this heightened risk is not limited to Indians and extends to all 1.9 billion South Asians and that people from the subcontinent have the highest risk of developing and dying from cardiovascular disease, especially coronary artery disease (CAD). Their risk is said to be approximately double that of Americans, Europeans and other Asians, even after factoring the differences in established risk factors, which include smoking, diabetes, high blood pressure, high cholesterol, physical inactivity, and obesity.
Enas is the founding Director of CADI (Coronary Artery Disease in Indians) Research Foundation.
He’s a former Treasurer of AAPI and erstwhile chair of the policy-making Board of Trustees of AAPI in 1991. But instead of moving up the ladder of the executive committee and hierarchy to become AAPI president, he chose to conduct the CADI study with a $25,000 seed money from AAPI. The participants were AAPI physicians and their spouses attending the AAPI convention in Chicago in 1990.
In the initial stages, he was assisted by Dr. Isaac Thomas, a fellow Chicago cardiologist, and their study showed a four-fold higher rates of heart disease in Indians compared to white Americans.
In his ground-breaking research spanning three decades, he collaborated with many renowned researchers in the U.S., Canada, and India, including Dr. Salim Yusuf—a fellow Kerala native, whom Enas says has been “a guiding force in my research”-- and his seminal research findings and recommendations are now enshrined as scientific facts in the 2018 American Cholesterol Guidelines.
Excerpts from interview with Dr. Enas:
Q: How do you feel about being honored with this particular award?
A: I am pleased and humbled by the award and I consider the award as the recognition of the merits of my research spanning 30 years and the validation of my three or four seminal scientific discoveries.
Q: Exactly what are these discoveries?
A: The first discovery is that Indians have a higher risk of heart disease than whites, blacks, Hispanics and other Asians in the U.S. and around the world. When I wrote about this 30 years ago, no one believed it. Now even the New York Times and various cardiology journals and magazines have had extensive articles on this heightened risk of heart disease in South Asians and it has been accepted as a well-known phenomenon around the world. Subsequently the heightened risk of heart disease was found to apply to all South Asians, regardless of where they live. The second discovery is that established risk factors ̶ smoking, high blood pressure, high cholesterol and diabetes, though important, fail to explain the excess burden of heart disease in South Asians. In fact, South Asians have approximately double the risk of heart disease at any given combination of established risk factors. This fact was clearly documented by the LOLIPOPS (London Life Science Population Study), by far the largest study involving nearly 17,000 South Asians and 8,000 whites followed for 10 years.
Q: And, what are your other discoveries?
A: The third and the most important discovery is the identification of a genetic risk factor that increases the risk of heart attack at a young age--below 50 years of age. I am perhaps the first research cardiologist to look outside the box and report that high levels of a little known cholesterol called lipoprotein(a) [Lp(a)] in Indians. The importance and impact of lipoprotein in Indians is best understood when one realizes that South Asians have the second highest Lp(a) levels among the seven largest ethnic groups and the highest risk of heart attack from the elevated Lp(a) level ̶ more than double the risk observed in whites.
Q: How does Lipoprotein(a) compare with diabetes and other risk factors?
A: High Lp(a) level confers a twofold to threefold risk of heart attack ̶ a risk similar to that of established risk factors, including diabetes. In the Framingham Heart study, the risk of a first heart attack from Lp(a) 30 mg was comparable to cholesterol 240 mg per deciliter and double that of diabetes. According to NHLBI (National Heart Lung and Blood Institute), 25 percent of other South Asians have elevated Lp(a) levels--50 mg per deciliter or higher--compared to less than 10 percent having diabetes. Globally 1.43 billion have elevated Lp(a) compared 415 million having diabetes. Of the 1.9 billion South Asians 469 million have elevated Lp(a) compared to just over 100 million having diabetes.
Q: Is there anything special about heart disease and Lp(a) in Indians?
A: Indians, in general, develop first heart attack about 10 years earlier. Heart attack rates are threefold to fivefold higher in young Indians than in other populations. Lipoprotein(a) is increasingly recognized as the strongest known genetic risk factor for malignant heart disease and heart attack in young people. Malignant heart disease refers to a severe and extensive atherosclerotic process involving multiple coronary arteries. Young Indians in young with malignant heart disease have a low burden of established risk factors but high level of Lp(a). Higher the lipoprotein(a) lower is the age of first heart attack or stroke. People with very high Lp(a)--more than 50 to 100 mg per deciliter-- develop heart attacks in their twenties and thirties ̶ a pattern seen commonly in Indians. These features make Lp(a) a risk factor of great importance, similar to or surpassing diabetes.
Q: Does Lipoprotein(a) explain most heart attacks in Indians?
A: No. 50 percent to 65 percent of heart attack in Indians is attributed to abnormal lipids or LDL cholesterol and another 10 percent is attributed to Lp(a). The high risk of heart disease in Indians and other South Asians is due to a combination of nature and nurture. The nature is provided by elevated Lp(a) found in one in four South Asians. Unhealthy lifestyle provides the nurture. Nurture consists of tobacco use, physical inactivity, unhealthy diet, unhealthy weight and waistline. Indoor and outdoor air pollution is an additional factor in the entire South Asia.
Q: What does the American Guidelines state about lipoprotein(a) and South Asian ethnicity?
A: I have been recommending stain therapy in Indians to lower and maintain LDL cholesterol less than 70 mg per deciliter since 2005 when I first wrote the book “How to Beat the Heart Disease Epidemic among South Asians.” This was in recognition of the high level of Lp(a) and high risk of malignant heart disease in Indians. And, November 10, 2018 was an important milestone in my research carrier, when the 2018 cholesterol guidelines validated and embedded my research findings in updating that Cholesterol guideline. For the first time, the 2018 Cholesterol Guidelines lowered the threshold of initiating statin therapy from LDL 100 to 70 mg per deciliter. The guidelines also designated both South Asian ethnicity and elevated Lp(a) as heart disease risk-enhancing factors. The guideline further recommends initiation or intensification of statin therapy for all those with risk-enhancing factors and LDL 70 mg or higher. I applaud this recommendation. Accordingly, most Indians especially those with elevated would require statin therapy as most Indians have LDL 70 mg per deciliter or higher. Widespread adoption of these recommendation has the potentially to save millions of lives in the next decade especially among the nearly two billion South Asians.
Q: How do we reduce the risk of heart attack from lipoprotein?
A: Lipoprotein(a) can be measured in the blood any time after age five. High level identifies individuals at high risk of heart disease at a younger age. While Lp(a)-lowering therapy is being developed, statin therapy has been shown to reduce the risk of a heart attack significantly, without lowering Lp(a) level.
Q: Rewinding, what was the original impetus for you to launch this research that has obviously become your passion and essentially a labor of love in terms of alerting our South Asian community to the vulnerability to the disease, despite even when the risk factors are absent?
A: The initial impetus was my personal observations in the 1970’s of six patients who had severe hearts attack at a young age. Two of them were fellow interns from India in their twenties--one died 20 years later while awaiting a heart transplant. The next two were in their thirties, one died five years later and the other was permanently disabled. The other two were in their forties and they too were permanently disabled in the prime of their lives. And yes, a striking aspect of all these cases was the absence of established risk factors to account for the premature onset and severity of their heart disease. What I observed nearly 50 years ago, is now seen in Indians all over the world, especially in India, where an alarming number of Indians are dying from heart disease at a young age.
Q: What can physicians, and Indian American physicians in particular, and also the community do to be better informed of this malady among Indian and South Asians and to be better prepared in terms of prevention?
A: Unfortunately, despite a wealth of actionable guidelines--supported actionable scientific information accumulated in this decade through CADI research and others--the overwhelming majority of cardiologists and physicians and both Indian and non-Indian remain unaware or lukewarm of the magnitude of challenge facing young Indians. In order to remedy the situation, I have synthesized the major scientific breakthroughs of the past several decades into a color brochure ̶ 10 Facts about heart disease in Indians. It provides practical recommendations to reduce the burden of heart disease and stroke in Indians, and anyone who’s interested in this and any other information can contact me at email@example.com and I’ll be happy to provide this and all other details. In fact, you can then take this information with you to your physician and discuss the testing and treatment options.