Sri Sathya Sai Global Cardiovascular Conference & World Heart Day 2025

Dear esteemed colleagues, Om Sri Sairam. Namaste. Good morning and welcome to this historic medical conference, a groundbreaking collaboration between the World Heart Federation and Sri Sathya Sai institutions. Today, we gather under the theme Harmonizing Heart Health: Reducing Hurry, Worry, Curry. Our shared goal is to embrace a holistic vision, where the head, heart, and hands work in harmony to forge a healthier future for all of humanity.

Let us begin with a heartfelt expression of gratitude to Bhagwan Sri Sathya Sai Baba, whose selfless love, compassion, and message of service continue to inspire millions across the globe. A special acknowledgment goes to the World Heart Federation, the leading beacon of global cardiovascular advocacy, and of course, to the Sri Sathya Sai Healthcare Mission, which is rooted in top-quality, compassionate, free care—providing the best of the best to those facing the greatest hardship and need.

Most heartfelt gratitude also goes out to each of you here for your commitment to improving and saving lives, from clinicians to researchers to policymakers, and to students from India and across the globe.

Cardiovascular diseases account for 18 million deaths globally each year, many of which are preventable. Worldwide, urban lifestyles and socioeconomic challenges are steadily and rapidly increasing this disease burden, making prevention an urgent societal imperative.

Our conference theme, “Reducing Worry, Hurry, Curry,” comes directly from Sri Sathya Sai during the first International Cardiac Symposium held in Puttaparthi in 1993. As with so many of Baba’s insights, it often takes modern medicine decades of unbiased research to arrive at the same conclusions. “Worry, Hurry, and Curry” aptly encapsulate the modern drivers of heart disease.

Sri Sathya Sai said, “When the mind of man is unattached to the ups and downs of life and is able to maintain equanimity under all circumstances, even physical health can be assured.”

This conference will enrich your mind with cutting-edge research and practical tools, covering a wide range of topics to prevent and treat cardiovascular diseases. However, knowledge alone is not enough—our hearts must lead the way with empathy and connection. Every patient should be treated as our most cherished and respected family member, as the embodiment of what we hold most dear, and as Baba emphasized, no less than the embodiment of divinity itself.

At the core of this conference lies a shared belief: every human deserves access to health. Health is essential for success in every aspect of life, regardless of wealth, status, race, gender, or belief system.

Ultimately, knowledge and compassion find their fulfillment in our hands—the tools of action. The hands are where ideas become reality, where we roll up our sleeves to prevent disease and save lives. As Baba has proclaimed, “Hands that serve are holier than lips that pray.” This conference is a living expression of that ideal, uniting the World Heart Federation’s global leadership with the Sri Sathya Sai Health Mission’s model of free, selfless service.

Let us all unite and harness our minds, our hearts, and our hands during this conference and beyond, to prevent cardiac disease and build a better society, one heartbeat at a time.

Jai Sairam.

I offer my prayerful salutations at the divine lotus feet of our beloved master, Bhagwan Sri Sathya Sai Baba. Distinguished doctors, all the delegates, very loving Sairam and warm greetings to you on this wonderful day.

Right now in Prasanthi, we are having Navaratri celebrations and the entire Prasanthi Ashram is filled with Vedic chants and vibrant energy. When I heard the World Heart Federation was coming here on September 29th, which is World Heart Day, I checked with them and realized this somewhat clashed with our regular programs. However, Dr. Krishna Rao and Dr. Geeta convinced me that this is a great opportunity for all of us—that the World Heart Federation agreed to celebrate World Heart Day in India, and especially gave us the honor to host it in Prasanthi Nilayam. We are grateful to the World Heart Federation, especially Dr. Narula who led this, and Dr. Krishna Rao who was in touch with them. Dr. Geeta, you have organized a wonderful conference, and it is certainly a prestigious honor for all Sai institutions. Thank you very much for all your hard work, especially Dr. Krishna Rao and his family, who have been here for the last 10 to 15 days, doing all the work. Dr. Akshay joined them, and together they planned extensively, guided by Padma Shri Dr. Mohan. Let us put our hands together for this wonderful team.

Somehow, they always feel compelled to put the managing trustee on stage at every conference—it's like putting me under a bus! Whether it is an orthopedic, cardiac, or science conference, they ask me to say something. They said, “Don’t miss the beat,” but every time they make sure I do! Nevertheless, I need to fulfill this duty, and it truly is a wonderful thing. We run hospitals, but we don’t treat patients ourselves; we have hospitals here thanks to Bhagwan Sri Sathya Sai Baba, who started this medical mission long ago.

The first hospital he started in this remote village was in 1956. I always recall a beautiful episode when the director of the All India Institute of Medical Sciences came here for the inauguration of one of our blocks in the General Hospital. He asked me in the car, “When was the General Hospital inaugurated?” I said, “In 1956.” He was very excited and joyful. I asked him why, and he said, “When I speak at the inauguration address, you’ll hear.” I waited for his address, and he explained that in 1956, Swami Baba started a General Hospital in this remote place, while in the same year, Delhi inaugurated the All India Institute of Medical Sciences—a premium institution. Baba, however, recognized that medical care needed to reach rural areas, so he started in a small village called Puttaparthi.

Baba focused on rural healthcare, giving direction to the entire country on how the medical fraternity should progress—not only concentrating on cities, but recognizing that 70% of India’s population lives in rural areas and needs healthcare. So he started this mission back in 1956, and now, after nearly 70 years of selfless, completely free service, I don’t think anyone would ever come across anything similar. The Sai Mission has grown from a small General Hospital to a 125-bed facility serving the local community. Dr. Narasimhan is here; this hospital was the only one in the area for a long time. Now, we also have a super specialty hospital in Puttaparthi. These two hospitals largely serve the Sai district; if you have any cardiac problem or other issues, people automatically come here. Baba oversaw this and created these beautiful temples of healing, as he called them.

With compassion, kindness, and empathy, we treat people as Baba taught us, bringing together great experts and accomplished professionals in the medical field, either to work here or, as today, to participate in conferences. These events inspire attendees, showing them ways to serve people and create better treatment for patients.

Yesterday, I was taken around to every kiosk—Dr. Mohan took me for a diabetes checkup and a cardiac checkup. Only thing is, different machines gave different readings; my weight varied by four kilograms! I was happy to see the lower weight. Within a couple of hours, I lost four kilograms; only cardiac people can do this! That was yesterday’s experience.

I must tell you about our own kids and what they have done. Some of your doctors have done a fantastic job guiding them. If you visit the cardiac exhibition, you’ll find that most of our participants are school and university students (first and second year undergraduates), and the work they’ve done is fantastic—with great support from the cardiologists. I was especially impressed by the school children, how eloquently they spoke about medical jargon—whether they fully understood it or not, they spoke with such confidence. The Eshwarma school kids in particular made us proud; they come from very humble backgrounds—children of auto rickshaw drivers, vegetable vendors, flower vendors, milk vendors, construction workers, and so on. When they enter the Sai institution, they transform themselves so much. I encourage you to visit and see these boys, how eloquently they speak. It makes us happy that World Heart Day enabled this opportunity.

Yesterday was wonderful, seeing the kids explain with such passion. Some doctors remarked that even medical students wouldn’t do such work. We should put our hands together for these wonderful kids.

Most of the exhibition focused on preventive cardiology. Prevention is better than cure—a stitch in time saves nine. We have an outreach program called the Mobile Hospital—a full-fledged hospital on wheels—that regularly visits local communities. There are 350 doctors registered on a roster; they spend the first half of each month volunteering. They come from Hyderabad, Visakhapatnam, Bangalore, Chennai, and elsewhere, seeing this as service to God and society. We cover almost 400 villages, focusing on preventive medicine and teaching hygiene, exercise, and healthy eating habits.

Akshay referenced Swami’s teachings about “Hurry, Worry, Curry.” Swami always emphasized not to be in a hurry, as it causes mistakes. “Worry” increases stress, and “Kari” refers to what we eat. It’s easy to advise healthy eating, but how much do we practice it? For example, cardiac conferences warn about alcohol, but afterward there’s a cocktail dinner! It’s easy to say, harder to do.

Even cardiac surgeons are not immune to heart issues. Recently, I read about a young cardiac surgeon who collapsed in the operating theater and passed away at just 39 or 40. Last week, at our orthopedic conference, we lost an orthopedic surgeon to a sudden infarction. Doctors deal with these situations daily; for others, such events leave a deep impression. Prevention is essential. Our mobile hospital focuses on preventive care, and even our hospitals in Whitefield offer preventive programs like breast cancer mammography. All our institutions emphasize prevention.

The human brain is naturally inclined toward prevention—if you see a ditch, you avoid falling in. But when it comes to food and drink, we bypass this instinct. Yesterday at the exhibition, I saw how gadgets are increasing screen time and exposing people to violent content. Why should anyone see a murder live on CCTV when going to sleep? Such things affect our overall health.

Sai Hospitals and medical institutions are committed to providing care to the downtrodden, needy, and poor, as Bhagwan intended. In 1990, he declared his intention to build a hospital; many were skeptical, but within one year, on November 23rd, 1990, he announced a super specialty hospital in Puttaparthi, and by 1991, cardiac surgeries were being performed there by Dr. Venugopal. These are medical miracles performed for people who cannot afford corporate hospitals.

I am glad to share that we have a new surgeon in our cardiothoracic department, Dr. Anil Mulpur, recently introduced to me. He is an excellent surgeon who will perform robotic surgeries. Before Vijay Deshmi, he promised to start robotic surgeries at Sathya Sai Hospital, making ours the first free robotic surgery department in the world. Our urology department will also use these theaters.

After 2011, many people told me, “Mr. Ratnakar, you can’t run these hospitals for free; it’s too expensive. You may have to start charging.” But I said, “Bhagwan started this mission, and if necessary, we’ll reduce our departments, but we will not charge anyone.” Our output and numbers have only grown; all departments are doing fantastic work. I am glad these conferences bring people together. I request the organizers to arrange a tour for our guests to visit the hospitals—Dr. Mulpur, please organize this. We need everyone’s support.

It’s not easy to find doctors willing to work here; we are always appreciative and grateful. They make sacrifices by choosing to serve here rather than seeking lucrative opportunities elsewhere. Let us put our hands together for all of them—Dr. Neelam, Rita, and everyone who does so much good work. This conference is befitting for the World Heart Federation to be held in a place where all cardiac surgeries are performed completely free. There are no billing counters in our hospitals—no pressure to raise money or mortgage gold or ornaments, no need to take loans. That’s why recovery is fast; there’s no financial stress on families or patients.

The best way to avoid cardiac incidents is to follow the Sai path—this is the best prevention. I encourage all cardiologists and visitors to spend a day or two here; treat this as your home. You also need time to pause, as you are constantly immersed in your profession. Take time off, come here, and it will be a soothing balm for everyone. Sathya Sai has created this oasis—an abode of peace—where you can relax and heal.

In fact, those who serve in our institutions often live well into their 90s or even reach 100, because their minds are free and relaxed. Even people diagnosed with cancer for 30 or 35 years live full lives here. Disease does not progress after coming here, for some miraculous reason, because the mind is at ease; the mind creates more complications otherwise.

You are all here, and I wish you the very best for this session and the next two days. Tomorrow, Dr. Narula is expected; today afternoon, we have wonderful sessions ahead. I wish all of you the very best. Once again, thank you for coming and giving us the honor of hosting the World Heart Federation. Thank you very much. Sairam.

Om Sri Sairam. Offering my most prayerful salutations at the divine lotus feet of our Lord and Master, Bhagwan Sri Sathya Sai Baba—without whom none of us would be here. He is the cause of this institution, the trust of Prasanthi Nilayam, and indeed, of this conference. We are very grateful to the World Heart Federation for choosing India, and Prasanthi Nilayam, for this conference and the World Heart Day celebrations.

To those of you visiting Prasanthi Nilayam for the first time—as a doctor and as a trustee—I say: Welcome to Prasanthi Nilayam. Please keep visiting, because for those of us who come regularly, we feel our batteries recharge every time we come here. It is not fiction; it’s something we experience every day. In this abode of peace—Prasanthi Nilayam literally translates to “Abode of Peace”—we offer our humble pranams at the divine lotus feet and pray for blessings on this conference.

My heartfelt thanks to the organizers, Dr. Krishna Rao, Akshay, all the hospital directors, the Vice Chancellor, who is so involved in the World Heart Day activities starting tomorrow, and of course, the Managing Trustee for all his support. Thanks also to the trustees, faculty, and delegates who have come from all over India and the world.

Today, I will talk about diabetes in Indians and share some lessons we have learned over the last few years.

Last year, I delivered the Kelly West Lecture at the American Diabetes Association. They asked me to speak on this topic at the ADA, and my lecture was published in the February issue of Diabetes Care. The U.S. was very interested in the fact that South Asian diabetes seems to be different, and wanted to know what lessons we have learned that might apply not only to India and South Asia, but to many parts of the world.

If you look at the prevalence of diabetes in India, in 1972, when I was 18 and joined my father in medical school, a survey by the Indian Council of Medical Research found that the prevalence of diabetes was 2% in urban areas and 1% in rural areas, among people aged 20 and above. Gradually, the prevalence increased.

The green dotted line on the graph marks 1991, a significant year when Dr. Manmohan Singh, then Finance Minister, opened up India’s economy. The socioeconomic status of people rose, which had many benefits, but also brought a sharp increase in diabetes and obesity rates.

The next study showed prevalence in double figures—11.6%. Since then, the prevalence has continued to rise. The last citywide study we did in Delhi and Chennai was in 2015, when it had already reached 25%. That means one in four people aged 20 or above in these cities has diabetes. If you look at those aged 50 and above, the prevalence is 50%. In other words, in Chennai or Delhi, half of the people over 50 have diabetes, regardless of socioeconomic status, and another 25% have prediabetes. So, three out of four have either diabetes or prediabetes. The rates are lower in smaller cities and villages, but even in villages, it has risen to 16% based on the INDAP studies.

In rural Kerala, diabetes prevalence is higher than in urban Kerala. What was once thought to be a “rich man’s disease” is no longer so. My father used to say, “We have the genes for diabetes, but when you go abroad, the environment brings it out.” Years ago, we wanted to test this hypothesis. At that time, prevalence among Indians in the U.S. or U.K. was much higher than in India. Now, with increased rates in India, we wanted to see if the hypothesis still held.

We collaborated with the University of California and Northern Chicago’s Masala Study in the U.S., using the same criteria as our Chennai data. Now, the prevalence in Chennai is as high as among migrant Indians in the U.S., so it’s no longer just a migrant phenomenon.

In 40 years, the situation has changed completely; India now has higher rates. When my daughter joined me, she asked, “Papa, why are you studying just Chennai and Delhi and then generalizing to India?” She wanted to study the whole country. With support from the ICMR, we conducted the largest epidemiological study on diabetes ever done, covering every state, union territory, and even islands like the Andaman & Nicobar. The study was published in Lancet in June 2023. It found 101 million people with diabetes in India and 136 million with prediabetes. Together, that’s 237 million people—a number larger than the population of most countries.

Providing comprehensive care to so many people is a huge challenge. More concerning than the numbers are the complications—if one-fifth develop heart problems or kidney disease, the need for treatment would be staggering. For example, 25% of people have early kidney disease—25 million people. If one-fifth progress to renal failure, that’s 5 million needing dialysis, but only 10,000–15,000 transplants are performed in India annually. That’s where Swami’s teaching—hari, wari, kari—comes in as the main causes of disease, which this conference has rightly emphasized.

The Asian Indian phenotype means we get type 2 diabetes much younger—20 years earlier than in the West. Heart disease also appears at a younger age. In 1985, when I worked at Hammersmith Hospital in London, there were no heart attacks below age 40 among white men, but 70% among South Asians and 30% among Afro-Caribbean people.

We have studied genetics extensively and published in Nature Medicine, showing South Asians do have genetic risk factors, but genetics alone cannot explain the epidemic. Environmental factors play a major role. In an interview, Swami asked me, “Did all your genes change since the 1970s? Why has diabetes increased?” He encouraged me to analyze my own data, and we found that carbohydrate consumption, especially rice, was a key driver.

We published our first study in the British Journal of Nutrition, showing a strong correlation between carbohydrate intake and diabetes in Chennai, even after adjusting for obesity, BMI, family history, socioeconomic status, and physical activity.

To further validate, we participated in the PURE study, following 130,000 people across five continents for 15 years. South Asia had the highest white rice intake, and a strong correlation was found between rice intake and new-onset diabetes. The hazard ratio was 1.61, meaning a 61% higher risk.

Our upcoming Nature Medicine paper will present state-by-state correlations between rice, wheat, oil consumption, and diabetes, including which dietary changes bring the most benefit. Good news: physical activity can reduce risk, even if rice intake is high. Among physically inactive people, risk is 50%, but with exercise, it drops to 16% and is no longer statistically significant.

Another paper by my daughter used mathematical modeling to determine how much carbohydrate should be reduced. If you replace just 10% of your carbohydrate intake with plant protein, you can reduce and even prevent diabetes. Animal protein gives some benefit, but plant protein is much more effective. This supports Swami’s advice that a vegetarian diet is best. Replacing carbohydrate with fat, however, showed no benefit—so we must reduce fat intake and increase protein, especially plant protein. Most people eat rice three times a day but don’t consume enough pulses, vegetables, and actual proteins.

Newer risk factors are also being studied. Dr. Prabhakaran and others have shown that pollution, particularly PM 2.5 particles, is an independent risk factor for hypertension, diabetes, cholesterol, and heart disease.

To conclude, India faces a diabetes epidemic closely tied to cardiovascular disease, but much of it is preventable. Simple steps like reducing carbohydrate, filling our plates with vegetables and fruit, and following Swami’s advice can help prevent both diabetes and heart disease. Once again, welcome to Prasanthi Nilayam. Thank you very much.

Over the past 18 to 24 months, significant developments have occurred in the field of medicine, particularly regarding cardiovascular disease. I will provide a concise overview of our current knowledge, its relevance to future medical practice, and the urgent need to contain the growing pandemic of cardiovascular disease, especially in India.

Ladies and gentlemen, the financial burden of cardiovascular disease in India over the preceding decade has been enormous. When converted to rupees, the expenditure amounts to 20 lakh crores. These costs were incurred to treat individuals with cardiovascular disease—conditions that could have been prevented through aggressive management of cardiovascular risk factors. Unlike most countries where the cardiovascular disease burden is decreasing, South Asia, and India in particular, is experiencing an increase. We are moving in the opposite direction compared to the rest of the world. While there are multiple reasons for this trend—which I will not elaborate on here—we must recognize that the “time bomb” of cardiovascular disease continues to progress, despite the availability of many therapeutic approaches.

Hypertension is the most significant cause of atherosclerosis. While hyperlipidemia, diabetes, and tobacco use are also important, high blood pressure remains the leading contributor. Many of you may be familiar with coarctation of the aorta. In this condition, atherosclerosis develops above the coarctation, but not below it. This simple biological phenomenon illustrates that blood pressure is elevated above the coarctation and normal below it, resulting in atherosclerosis only in the area of high pressure. This clearly confirms that high blood pressure is a key driver of atherosclerosis.

Although Dr. Krishna Rao requested that I focus on developments from the last two years, I will briefly revisit the past 100 years regarding optimal blood pressure targets. Nearly a century ago, it was proposed that a blood pressure of 120/80 mmHg was associated with longer life expectancy, while higher levels were linked to reduced longevity. Remarkably, current guidelines in 2025 once again recommend a target blood pressure close to 120/80 mmHg. What insurance companies advocated 100 years ago remains true today.

Until three years ago, hypertension was defined as a blood pressure of around 130/80 mmHg. Now, new recommendations suggest aiming for 120/80 mmHg if possible. Patients and their relatives often ask whether they can use salt substitutes when advised to reduce salt intake. While we once casually permitted salt substitutes to retain flavor, overwhelming evidence now shows that they can lower blood pressure, reduce cardiovascular disease, decrease mortality, and reduce stroke risk. Pure salt is 99% sodium chloride, while salt substitutes contain 60–70% potassium chloride, with the remainder being sodium chloride. These substitutes preserve taste and, according to new studies, not only lower blood pressure but also reduce mortality.

A recent study involving 21,000 patients compared normal salt to salt substitutes. Those using salt substitutes experienced significantly lower blood pressure, reduced risk of cardiovascular events, and decreased mortality. Thus, when advising patients to use salt substitutes, we now have scientific evidence supporting their benefits for blood pressure and target organ protection.

Let me now discuss the rapid development of new molecules for hypertension treatment over the past decade—progress that exceeds the advancements made in the previous 70 to 80 years. These new drugs target the underlying pathophysiology of hypertension.

One such molecule, the endothelin antagonist, has been approved in the United States. Endothelin is the most potent vasoconstrictor in humans, 10,000 times stronger than noradrenaline. Blocking both endothelin A and B receptors leads to a substantial reduction in blood pressure. A recent U.S. study showed remarkable blood pressure reductions in patients treated with endothelin antagonists, marking a significant advance in hypertension therapy.

Other new molecules target the renin-angiotensin system. While ACE inhibitors and ARBs are well-known, newer drugs aim to block the actual formation of angiotensin. By inhibiting angiotensin generation, the entire cascade is suppressed. One such drug is an MRA inhibitor called zelbisiran, which blocks angiotensin production in the liver. A single injection of zelbisiran can lower blood pressure for six to nine months or longer. Studies show zelbisiran reduces angiotensin and significantly lowers blood pressure. Importantly, if excessive hypotension occurs, its effects can be reversed with a drug called reversar. Thus, long-lasting antihypertensive effects can be controlled as needed.

In addition to blocking angiotensin, efforts are underway to inhibit aldosterone synthesis—not just the receptor. Aldosterone synthase inhibitors are being developed to address the root mechanisms of hypertension. These drugs have demonstrated efficacy in lowering blood pressure.

Overall, we are moving from “irrational” therapy to rational approaches that target the specific mechanisms responsible for hypertension. The development of these molecules is progressing rapidly, and many will become available during our lifetimes.

For those in long-term clinical practice, a common debate has centered around whether hydrochlorothiazide or chlorthalidone is the better diuretic. Past studies showed chlorthalidone lowered blood pressure slightly more than hydrochlorothiazide but lacked outcome data. Last year, an outcome study revealed that both drugs equally lower blood pressure and affect potassium. However, patients on chlorthalidone experienced better outcomes, including a lower incidence of heart failure. Therefore, while both drugs are effective for hypertension, chlorthalidone is slightly superior for preventing cardiovascular disease and heart failure, settling this longstanding debate.

Recently, new U.S. guidelines for hypertension were released on August 14. It remains uncertain whether these guidelines are applicable in India, as Indian guidelines are expected by December. The U.S. guidelines now define two stages of hypertension and encourage lowering blood pressure to less than 120/80 mmHg—previously 130/80 mmHg—a major shift from earlier recommendations. Achieving this goal depends on accurate blood pressure measurement.

Additionally, the term “hypertensive urgency” has been removed from the guidelines; it is now referred to as “severe hypertension.” The guidelines also confirm a strong link between blood pressure and cognitive dysfunction. Uncontrolled hypertension is the number one cause of cognitive decline, whether classified as Alzheimer’s disease or vascular dementia.

How did experts determine the benefit of a blood pressure target of 120 mmHg? One pivotal trial showed that patients who achieved blood pressure levels below 120 mmHg had the greatest benefit.

In closing, I want to comment briefly on the growing role of artificial intelligence in diagnosing and treating hypertension. Research in this area is expanding rapidly, with numerous publications and new models under development. The application of artificial intelligence may lead to more rational and appropriate hypertension management. However, as Bill Gates has noted, it must be managed carefully to ensure the benefits outweigh the risks. While AI will not replace physicians, those who utilize AI may surpass those who do not. There are still unresolved issues regarding whether AI models can replicate human judgment, data access, and data custodianship—whether the computer, AI vendor, insurance company, or patient should be responsible for the data. Legal questions remain, but the application of AI in hypertension is being widely studied.

Mr. Chairman, ladies and gentlemen, in the time allocated, I have provided a rapid overview of developments from the past two years. I discussed the evidence for salt substitutes, the use of endothelin antagonists, long-acting drugs that block the renin-angiotensin system, aldosterone synthase inhibitors, and the resolved debate between hydrochlorothiazide and chlorthalidone. Finally, I touched on artificial intelligence in hypertension. Thank you for your attention, and thanks to Swami for giving me this privilege. Thank you very much.

Question:

A lot of patients come to us with confusion, delirium, and a history of falls. Should we continue diuretics in these cases, or should we stop them? Also, as a preventive measure, what about other molecules, such as aldosterone antagonists?

Answer:

According to current guidelines, both types of diuretics are equally effective. However, comparative studies have shown the superiority of certain options. If the patient's blood pressure is stable and they are doing well, I don't think there is any need to change the existing therapy at all.

Follow-up Question:

So, should we completely avoid diuretics in elderly patients, or can we continue them? What about starting new patients on these medications?

Answer:

When starting a new patient or a new drug, you can consider either option. However, I would not change existing therapies if they are effectively controlling the patient's blood pressure.

Thank you:

Thank you very much for your excellent talk. My question is regarding salt substitutes. In patients who are on ACE inhibitors, ARBs, or finerenone, is there any study that looks at the combination of these molecules with salt substitutes? Specifically, with salt substitutes that have a high amount of potassium and a low amount of sodium, is there any increased risk of hyperkalemia in these patients?

Answer:

You are asking about the risk of hyperkalemia in patients taking salt substitutes along with finerenone, ACE inhibitors, or ARBs. In patients with normal renal function, it is impossible to cause hyperkalemia unless the patient has conditions like rhabdomyolysis or is undergoing cancer treatment that causes cell necrosis. With normal kidney function, you cannot cause hyperkalemia. However, in patients with stage 3 or higher chronic kidney disease, you do need to be careful with salt substitutes, as they can cause hyperkalemia in this group. With normal renal function, it should not be a concern.

Moderator:

Due to time constraints, we can have further questions answered by Dr. Venkataram online. We will proceed to the next session. Thank you.

Rheumatic heart disease perplexes all of us in the audience every day. Every day in our hospital, we perform two to three valve surgeries, whether single or double valves, and there are many more patients waiting for these surgeries. Forty years ago, we found that the incidence of rheumatic heart disease in tertiary hospitals was 40%. Now, in 2025, that percentage remains unchanged at 40%.

Is rheumatic heart disease a big problem? If we pause and ask ourselves—and refer to the World Health Organization (WHO), even if we may not attach much importance to WHO or the United Nations these days—we find some ballpark figures: there are 55 million people worldwide living with rheumatic heart disease, and approximately 1,000 people die from it every single day. Usually, these are not elderly patients as seen in developed countries. Instead, these are often breadwinners who are succumbing to this disease, which we are still unable to prevent.

Traditionally, we discussed three levels of prevention: primary, secondary, and tertiary. In recent years, we have added primordial and quaternary prevention as well. As a surgeon, my perspective on these comes from preventive cardiology, since we are faced with treating thousands of patients daily across the country, and many more are still awaiting treatment for valvular heart disease.

Primary prevention involves health education and specific protection, while primordial prevention focuses on addressing risk factors—even before disease develops. Whether this is possible in our country remains a big question. Basically, we are saying: improve living conditions, ventilation, prevent overcrowding, and improve nutrition. But my big question is, if a family has five children—sharing the same ventilation, the same overcrowding, the same nutrition—why does only one develop valvular heart disease while the others do not? While this is a valid concept, translating it into action in our country is challenging.

If primary prevention for rheumatic heart disease worked, it could wipe out the disease, and perhaps, in my lifetime, there would be no more valvular heart disease cases—though this is likely just a dream. There has been talk of developing vaccines for rheumatic heart disease. However, as of September 2025, there is still no effective vaccine. The first reason is the phenomenal strain diversity of Streptococcus pyogenes. Influenza also has strain diversity, yet we have a vaccine for it. For Streptococcus pyogenes, there are 250 strains, and no vaccine covers all of them.

The second issue is safety concerns. In the idiopathogenesis of rheumatic heart disease, antibodies formed against streptococcal antigens can mimic valvular antigens. If we introduce a vaccine that increases antibody production, could it inadvertently increase disease risk rather than decrease it? Third, the main target for vaccines has been the M protein, but there are also attempts to target other molecules like carbohydrates in the Streptococcus pyogenes organism. Still, the most important problem is lack of investment. There is little research funding for rheumatic heart disease because there is no financial incentive.

Swami used to say, when we listen to the heart sounds—S1 and S2, "lub dub, lub dub"—in Telugu, "labo diba." But, for some so-called corporate doctors, the second heart sound is all they care about: "dub dub dub," since "dubbu" in Telugu means money. Thus, investment in research is minimal. Yet, there is some hope. In New Zealand and Australia, there are tribes where rheumatic heart disease is still common. There are informative videos, such as "Take Heart: Quest for the Holy Grail of Rheumatic Heart Disease Vaccines." However, I personally have little hope at present, though I will let you know if that changes.

The World Heart Federation, which is organizing this event in Prasanthi Nilayam, is also involved in vaccine research for rheumatic heart disease. Briefly, there are efforts to develop vaccines such as the 30-valent M protein vaccine, vaccines targeting other molecules, and the serum opacity factor vaccine. None have shown significant promise so far. Researchers have also explored secreted proteins of Streptococcus pyogenes and carbohydrates as vaccine targets, again with little success. The only area that might hold promise is "reverse vaccinology."

During the COVID-19 pandemic, healthcare developed vaccines in record time. We've heard of in vitro and in vivo research, but now, there is also "in silico" research—using computational modeling. The entire genome of Streptococcus pyogenes is mapped, and computational biologists analyze various antigens that could be targets for vaccines. Once these are identified, the vaccine development cycle—screening, cloning, expression, and eventually human trials—can begin. As of now, human trials have not yet started.

Secondary prevention focuses on early diagnosis and treatment, both of which remain very challenging in rheumatic heart disease. Health promotion and specific protection haven't worked, and vaccines are still unavailable. In a large country like ours, early diagnosis of rheumatic valvulitis remains a distant dream. The fact that the incidence remains at 40% after 40 years means that we have not made significant progress addressing the root causes. Benzathine penicillin still works as a good prophylactic, but there are frequent shortages. I regularly receive calls from Assam, Orissa, and other areas about penicillin shortages, and I've found that this is a global issue, not just in India. Manufacturers are not producing penicillin because it is cheap, costly to manufacture, and unprofitable. Instead, companies focus on expensive drugs, such as monoclonal antibodies for cancer, which are highly profitable. Thus, penicillin production and research have stagnated.

When it comes to treatment, one thing we can be proud of is the Indian-made TTK Chitra valve. I openly state that the myth that a single-leaflet valve is inferior to a bileaflet valve is just that—a myth. We have implanted tens of thousands of TTK Chitra valves, and it is an excellent, reliable valve. We should applaud the efforts of Ms. Waliathan and former President Bharat Ratna APJ Abdul Kalam, who helped develop it. It is now being exported and is well-suited for the Indian population. Some even say that the thromboembolic complications of the TTK Chitra valve are less than those of bileaflet valves, which are sold at 20 times the price in India—though not in America or the UK.

Monitoring INR remains a major challenge. We sometimes see patients with stuck valves or intracranial bleeds, and we feel sorry because there is no standardization or universal availability of monitoring. The valve is made using Haynes alloy, which prevents "galling" due to microscopic material transfer. In vitro studies suggest these valves could function for 200 years—more than sufficient for any patient.

The Center for Cellular and Molecular Biology began researching why, among five siblings, only one develops valvular heart disease. This points to genetic variation among individuals within the same family, and further research may shed more light on this topic.

In pregnancy, we were traditionally taught to switch to heparin during the first and third trimesters. However, recent European guidelines suggest this is unnecessary. The take-home message for clinical practice is: do not change the vitamin K antagonist regimen throughout pregnancy. Simply perform the necessary tests at 24 weeks, and do not complicate the management. There is no need to implant biological valves just because a woman is of reproductive age; that approach is outdated.

Tertiary prevention in rheumatic heart disease involves disability limitation and rehabilitation. This afternoon, you will hear more about the role of organizations like Sai Save, which are working in primordial, primary, secondary, and tertiary prevention. This is a remarkable experiment, as we reach every district and "Samiti," allowing us to follow up with our patients. Telemedicine helps us monitor INR, though standardization gaps remain. However, much of this work depends on philanthropists, as government agencies in remote areas are often unable to provide support. There is neither sustainability nor accountability, so we rely on NGOs and philanthropists to move things forward.

Finally, quaternary prevention involves avoiding overmedicalization, drug-drug and drug-food interactions, iatrogenesis, and promoting ethically sound interventions such as TAVR. Some American colleagues may argue that TAVR can be used for anyone with aortic valve disease, but in India, we need to carefully define its indications.

On the research front, I am pleased to announce that the Sri Sathya Sai Institute of Higher Learning—where education is completely free from primary to PhD level—has formalized a memorandum of understanding (MOU) with the Sri Sathya Sai Institute of Higher Medical Sciences at both campuses to support research. We also have an MOU with the University of Chicago for artificial hearts, transplants, and LVADs, as well as with the Institute of Science in Tokyo and, most recently, with Rutgers University in New Jersey. These are all recent developments, and I hope they will enable us to conduct meaningful research to improve the quality of life for the common man.

Sairam. And in the interest of the organizers' coronary calcium scores, I will not take any questions.

I am indeed honored and privileged to be here with all of you during these centennial celebrations of Sri Sathya Sai Baba, as well as another landmark event—the World Heart Federation's 25th anniversary. Two landmark events in the holy precincts of Prashanthi Nilayam. We are all indeed very fortunate and blessed to be here.

The topic for my presentation today is “Stress and Heart Disease: Fact or Fiction?” Is it based on objective evidence, or is it simply anecdotal and reported in the lay press? The reason I chose this topic is that, as a member of the CME committee, I have no financial disclosures, but I do have one disclosure to make: As you all know, Krishna Rao is one of the organizers, but all credit goes to Swami—Sri Sathya Sai Baba—who is the true source and inspiration for everything happening here today. It is not me or anyone else; it is Swami.

Another reason for choosing this topic is that in one of his discourses, Sai Baba said, "Hurry, worry, and curry are the root causes of heart diseases." This idea is not new. In fact, it dates back to the mid-18th century when William Heberden, who coined the term “angina,” stated that angina is caused by disturbance of the mind. Around the same time, rising death rates from heart disease were attributed to great mental strain and excitement, as published in a Times Magazine article. Later, Hans Selye, author of the “General Adaptation Syndrome,” concluded that a life under stress results in premature aging due to wear and tear.

If you search online, you will find an astounding 1.5 million articles linking stress and heart disease. Stress has become an integral part of life—who doesn't have stress? There are many reasons for this. We continuously add stress factors to our lives. It can be our mindset—a desire for perfection, achievement, wealth, or position. It can be life events, daily hassles, or serious issues such as the diagnosis of a serious illness in a family member or losing someone you love.

On top of all this, technological factors contribute as well. Many of us are addicted to cell phones and social media, which adds further stress. Dr. Ratnagar spoke this morning about the impact of social media and lifestyle factors such as inactivity, smoking, diabetes, alcoholism, drug use, and the lack of coping skills. We know that the “stress paradox” means some people take stress lightly, while others take it very seriously. The same stressor can impact different individuals in different ways.

To illustrate, take the northeastern United States. Early in the morning, as you rush to work at the hospital, you may find your car buried in snow and struggle to dig it out. This is a stress factor. As a cardiologist, I see patients in the emergency department with myocardial infarction or sudden cardiac death related to shoveling snow. This is not uncommon and continues for six months each year. In the western United States, they face wildfires and earthquakes. For example, during the 1994 Los Angeles earthquake, there was a fivefold increase in sudden cardiac death triggered by stress, not by physical harm from the earthquake itself.

When it comes to the pathophysiology of stress and heart disease, there are two components: emotional and physical stress, usually due to negative emotions, though sometimes positive ones. This is why emotional balance is so important. Emotional or physical stress—such as surgery, post-operative stress-induced cardiomyopathy, medications, intoxication, or drug withdrawal—can trigger events, especially in predisposed individuals such as females, post-menopausal women, or those with psychiatric illnesses, diabetes, or COPD.

These triggers stimulate the hypothalamus and limbic system, leading to activation of the adrenal axis and a surge of catecholamines and neuropeptides. This can cause direct damage to the left ventricle or indirect damage through endothelial injury, coronary vasospasms, and spontaneous coronary dissection.

Chronic stress is also known to be associated with diabetes, hypertension, and other social factors, as Dr. V Mohan and Dr. Venkatam have mentioned. These can foster unhealthy behaviors such as overeating, smoking, and physical inactivity, all of which increase plaque burden and platelet reactivity—a recipe for heart attack or sudden cardiac death. Notably, females are much more prone to stress-induced heart disease; as shown by data, as many as 90% of such cases are female. Again, the “stress paradox” explains why stress affects individuals differently.

I would like to share some classic case examples. There are three well-established entities: Takotsubo syndrome (“broken heart syndrome”), coronary spasm, and spontaneous coronary dissection—all proven to be caused by stress.

The first case: a 55-year-old female with no traditional risk factors presented with chest pain and new-onset heart failure after a minor altercation with a neighbor over her unleashed dog. She was found to have a classic STEMI, and echocardiogram revealed a ballooned apex of the left ventricle. The good news is that her heart function normalized after a few weeks—a classic case of broken heart syndrome.

The second case: a 69-year-old Hispanic female, recently immigrated to the United States with her large family, suffered multiple episodes of chest pain, anxiety, and social/language barriers. After several hospital visits and tests, she was diagnosed with coronary artery spasm, confirmed by her EKG and response to nitroglycerin. She required complex treatment, including a phospholipid kinase inhibitor, and after psychiatric counseling, she did well for 15 years before passing away from dementia—not a cardiac event.

The third case: a 45-year-old female with risk factors for coronary artery disease and poor compliance with medical therapy. She experienced multiple episodes of chest pain, hypertensive emergencies, and eventually suffered a STEMI and spontaneous coronary artery dissection, requiring stenting. Social factors played a significant role in her adverse outcomes, and despite aggressive treatment, she sadly passed away.

Next, as Dr. Ratnagar mentioned, we have seen cardiac surgeons and interventional cardiologists dropping dead in the OR. Here's an example: an interventional cardiologist spending 12 hours a day in the cath lab, with mild hyperlipidemia and well-controlled GERD, but no primary care provider. He ignored symptoms, assuming it was GERD, but his EKG revealed subtle ST elevation and distal LAD occlusion. The angiogram showed it was not classic atherosclerosis, but either spasm or spontaneous coronary event. His heart function normalized a few weeks later.

Another case involves a 58-year-old female with anxiety and panic attacks who presented with chest pain after a family member was diagnosed with a serious illness. Her EKG showed lateral ST segment elevation, and angiography revealed lesions up to the main artery. Further investigation showed intimal tears and intraluminal hematoma—classic spontaneous coronary artery dissection. Remarkably, her follow-up showed complete healing. In fact, she is here with us today. Kylie, could you please come to the podium and share what changed in your life?

First, I would like to thank Dr. Rao and his cardiac team. Without their skill and dedication, I would not be here today. He told me, "Don't let that happen again; you won't survive." As a result, I had to make some changes in my life. I eliminated as much stress as possible, started walking, reading, and meditating on the goodness of God. I lost weight, became more involved with my church, joined a Bible study, and grew closer to God, which gave me a peace that passes all understanding. My life has changed from worry and stress to acceptance and surrender. My focus now is to share God's love and peace with those around me, to be kind, appreciate nature and creation, and walk humbly and serve others. Sairam.

Thank you, Kylie, for coming all the way to India to be with us today. We truly appreciate you.

Here are five key take-away messages from my talk:

• Stress-induced heart disease is real, not fiction.

• Acute stress can lead to diseases such as Takotsubo syndrome (broken heart syndrome), spontaneous coronary artery dissection, and coronary spasm.

• The “stress paradox” means that the same stress can produce different responses in different individuals.

• Low levels of stress may be cardioprotective; some stress exposure prepares us for future challenges.

• The prognosis is excellent with appropriate management strategies, including exercise, meditation, yoga, and spending time in nature—these are the best antidotes for stress-induced cardiac disease.

Even elite athletes practice meditation and yoga during breaks to enhance their performance. Nothing beats a walk in nature. Autumn in the northeastern United States is beautiful, and here, walking along the Chitravathi banks in the early morning and listening to nature can be as tranquilizing as anything. Thank you very much for your attention.

I would like to thank the World Heart Federation, Sai Health Mission, and the entire team of Sai devotees and organizers for inviting me to share some of my experiences on preventive cardiology, specifically regarding the role of CT scans and calcium scoring.

The groundwork for this discussion has been perfectly established, starting from diabetes, moving to hypertension, then to risk factors, and finally stress. All the elements contributing to heart attacks are present. Now, our focus should be on how to prevent heart attacks.

In the next few minutes, I assure you I will not overwhelm you with slides, nor will I stress myself trying to finish them quickly. Let’s try to understand why we are focusing on preventive cardiology. Why should we prevent heart attacks? Heart attacks occur because of the rupture of atherosclerotic plaques, which leads to infarction—meaning the death of heart muscle.

When the heart muscle dies, two things can happen. If it happens acutely, the patient may not reach the hospital and could die within minutes. If the patient survives and reaches the hospital, depending on the extent of damage, they may suffer significant muscle loss, leading to a severely impaired quality of life. They may struggle with daily activities, develop breathlessness, face complications, require a pacemaker, medications, or possibly need stenting or bypass surgery.

Our goal in preventive cardiology is to avoid catastrophic outcomes like sudden death, which can be devastating for families, or heart failure, which can leave individuals unable to perform regular activities and facing ongoing hospital visits and medications. We want to prevent these scenarios.

So, how do we prevent heart attacks before they occur? First, we need to screen individuals for diabetes, hypertension, stressful lifestyles, family history, and abnormal lipid levels. Identifying these risk factors is crucial. Evidence-based medicine tells us that individuals without these risk factors are less likely to develop heart attacks, so they can generally be considered low risk. However, there are exceptions, which I’ll address later.

Next, we use treadmill or stress tests to determine if a person is likely to develop heart abnormalities under stress, which could indicate a risk for heart attack. These tests, along with traditional risk factors, have been the cornerstone of assessment. However, in the last decade, we’ve learned that both risk factors and treadmill tests lack high accuracy in predicting heart attacks. The treadmill test, for example, has a 25% false negative rate—meaning 25 out of 100 people who test normal may still have a heart attack in the near future.

This is where radiology, specifically calcium scoring and CT angiography, comes in. When we perform a CT calcium score or CT angiogram, we can detect plaque buildup in the coronary arteries at an early stage, helping us prevent heart attacks by identifying lipid or calcium deposits in blood vessels.

Who should undergo these tests? Beyond traditional risk factors, strong family history is especially important. Individuals with a family history of heart disease, coronary disease, or sudden cardiac death—particularly if the family member developed heart problems before age 50—are at higher risk for premature coronary artery disease.

Premature heart disease refers to family members under 50 who have experienced a heart attack, stent, or bypass surgery. Individuals with such family history, combined with stressful lifestyles, hypertension, diabetes, smoking, or hyperlipidemia, are at greater risk. Family history is a critical root cause.

My topic today is “catch them young.” We must focus on preventing heart disease in young individuals. India is now the world’s largest population and, unfortunately, the capital for coronary artery disease. We are also becoming the capital for young stroke and young coronary artery disease. Prevention is key.

To prevent these conditions, we need to identify individuals under 40 who have a family history of coronary disease or premature coronary disease. We also need to check if they are smokers, diabetic, have high cholesterol, high LDL, or low HDL. These individuals should be considered for CT coronary calcium scoring or, if needed, CT angiography, which can help prevent major heart attacks.

In India, young individuals often develop coronary disease at an early age, and the severity is often high from the outset. Their morbidity and mortality rates are also high, leading to significantly impaired lives if they suffer a heart attack young. We must act to prevent this.

Prevention cannot be accomplished just by talking at conferences or listening to lectures. I urge the Sai Health Mission and World Heart Federation to start programs to identify young individuals at risk and provide necessary interventions, including CT calcium scoring and CT angiography if needed. This will help prevent major heart attacks and deaths, and reduce morbidity and mortality.

We must go beyond conferences and reach out to the public. I challenge the organizers to take up this initiative, at least in parts of India, in collaboration with other foundations. By identifying risk factors in individuals under 40 and utilizing radiology—especially CT calcium scoring and CT angiography—we can make significant progress in preventing strokes and heart attacks among young people.

CT calcium scoring is a direct marker for coronary atherosclerosis. Calcium in the coronary arteries results solely from cholesterol deposits, which eventually calcify and cause blockages. By measuring calcium directly in the arteries, we can assess the presence of coronary atherosclerosis.

For example, a normal calcium score is zero; 100 indicates mild risk, and 400 indicates severe risk. If a 30-year-old has a calcium score of 10, it could rise to 400 or 500 by age 50 or 60, indicating substantial future risk. Early detection allows for early intervention.

By prioritizing high-risk individuals and assessing their coronary heart risk, we can prevent heart attacks, reduce morbidity and mortality, and ultimately save lives across India.

Thank you for allowing me to share my heritage and thoughts. If you have any questions, I’ll be happy to address them.

My humble pranams at the lotus feet of our father, Bhagavan Sri Satya Sai Baba. Thank you for the opportunity to share some of my thoughts and experiences with this audience. I would also like to extend my gratitude to Dr. Guru Murthy, Director of the Sri Satya Sai Super Specialty Hospital; Dr. Anil Mulpur, Chair of the Department; and Dr. Neelam Desai, Co-Director of the Cardiovascular Program and Department of Cardiovascular Surgery.

Today, I am going to share with you on the topic of minimally invasive coronary revascularization. Coronary artery disease remains one of the leading causes of morbidity and mortality worldwide and presents with a myriad of symptoms, ranging from typical chest pain and angina to acute coronary syndrome and cardiogenic shock. This disease, as you know, can be preventable when addressed early through lifestyle changes and preventive therapy. However, for those patients with left main disease or multivessel coronary artery disease, or who present with associated comorbid conditions such as diabetes, renal failure, and others, additional modalities are available.

Percutaneous intervention as a means of revascularization is very popular and plays an important role, but for patients with multivessel disease and left main disease, or those who present with acute coronary syndrome and require further intervention, coronary bypass grafting remains the gold standard of care, especially because of its long-lasting effect—up to 30 years after surgery once the intervention is performed.

There are several terms that are used interchangeably, which can sometimes cause confusion. When discussing minimally invasive cardiac surgery, terms such as minimally invasive direct coronary artery bypass (MIDCAB), minimally invasive cardiac surgery (MICS), and coronary artery bypass grafting (CABG) are often used, but not all necessarily refer to coronary revascularization. These approaches can also apply to other ways of accessing the cardiovascular system, such as for valvular disease.

Traditional cardiopulmonary bypass has long supported coronary artery surgery and has been the gold standard in cardiovascular disease management. The historical background of cardiac surgery began with the introduction of the heart-lung machine by Dr. John Gibbon in 1947, which greatly expanded the field. Initially, the focus was on congenital heart disease, but with research at the Cleveland Clinic by Dr. Rene Favaloro, an Argentinian physician, coronary artery surgery as we know it today was introduced, opening a new era in cardiovascular surgery management. Advancements in cardioplegia and myocardial protection in the mid-1970s and mid-1980s also had a tremendous impact.

The initial heart-lung machine was bulky and cumbersome but had a tremendous impact during the early stages of the field, including groundbreaking interventions in early cases such as ASD repair. This introduction preceded the development of technical aspects of cardiopulmonary cardiac surgery and coronary artery bypass grafting. We have come a long way since those early days, and the current cardiopulmonary bypass machine is much more sophisticated.

During bypass, blood is drained from the venous side of the circulation, passes through a reservoir, and comes into contact with a filter—a membrane oxygenator—where the exchange of oxygen and carbon dioxide occurs. The oxygenated blood then returns to the arterial circulation. Despite these advances, cardiopulmonary bypass has disadvantages. To place someone on the heart-lung machine, you must cannulate the heart, including the great vessels, which is quite invasive. It also requires large amounts of heparin to maintain an activated clotting time (ACT) between 400 and 500 and is associated with a severe inflammatory response syndrome due to the blood’s contact with artificial surfaces such as tubing and membrane oxygenators.

The inflammatory response is triggered by contact with synthetic surfaces and changes in blood flow, which becomes more laminar instead of pulsatile. Changes in temperature, such as hypothermia, surgical trauma, and ischemia-reperfusion can also occur, including splenic-level changes leading to translocation of bacteria, endotoxemia, hypotension, and vasoplegia. When examining the circuit operationally, we can understand why these changes take place. These can be classified into two major groups: humoral and cellular changes. As shown in this diagram, there is a release of interleukin, activation of complement, the intrinsic and extrinsic pathways, fibrinolysis, and activation of endothelial cells and adhesion molecules, all contributing to organ dysfunction. In some elderly patients or those with comorbidities, this can lead to multi-organ failure. Patients can recover from the initial insult, develop some degree of dysfunction, or progress to multi-organ failure and death.

When we look at off-pump coronary artery bypass, the advantages are clear: it does not require cannulation, is less invasive, does not trigger the inflammatory response, and overall has proven benefits such as reduced renal failure, stroke, and arrhythmia. Patients also have fewer respiratory issues, such as pneumonia, and can be extubated early, sometimes directly on the operating table, allowing for faster recovery. The disadvantage is that the technique requires significant training, with a steep learning curve, and is operator-dependent. It is contraindicated in unstable patients, such as those presenting with acute coronary syndrome or cardiogenic shock.

Because off-pump coronary bypass has become popular, higher-risk patients are now referred for consultation, increasing the pool of patients for surgeons with busy practices. There is also an economic impact, as hospitals and healthcare organizations pay close attention to cost-effectiveness: off-pump procedures can save between $45,000 and $60,000 depending on the type of surgery, and spare the bypass circuit and supplies—important in resource-limited settings.

But what truly defines a minimally invasive procedure in cardiac surgery? Is it the incision size, the avoidance of the cardiopulmonary bypass machine, the use of a robotic platform, or performing cardiopulmonary bypass with normothermia on a beating heart? All these approaches are part of the armamentarium for vascularization or valvular disease. As a cardiac surgeon, I believe that avoiding the heart-lung machine is one of the most important aspects benefitting the patient and truly making the procedure minimally invasive.

The current trend is to perform surgeries through sternum-sparing incisions. There is a significant difference between a median sternotomy and a small incision used for procedures such as MIDCAB. Surgeons may think that sternotomies are not painful, but patients attest otherwise. For patients with high comorbidities such as diabetes and COPD, sternotomies can present significant challenges if complications arise, such as wound dehiscence or infection. Many of these patients may be colonized by bacteria like pseudomonas or staph. Comparing a MIDCAB with a small incision to a traditional approach, the difference is not only aesthetic but also affects breathing mechanics and physiological recovery. Patients recover more quickly and are typically extubated on the table or within 2–3 hours after surgery.

This minimally invasive approach can also be extended to other interventions, such as mitral and aortic valve procedures. Graft harvesting techniques—including endoscopic vein harvesting and radial artery harvesting—should also be performed endoscopically. Traditional harvesting of the saphenous vein in patients with comorbidities increases the risk of wound infection, dehiscence, and slow recovery. As depicted in this cartoon, there is a big difference between a small keyhole incision on the leg and a full incision from groin to ankle, illustrating the benefits of minimally invasive, endoscopic vein harvesting.

What makes someone proficient in off-pump procedures? Initially in the mid-1990s to early 2000s, it was thought that performing 50 cases in addition to on-pump experience was sufficient, but in reality, mastery requires dedication—no different from a musician mastering an instrument, which may require at least 10,000 hours. For cardiac surgeons starting off-pump surgery, the initial mortality rate is around 3–3.5%, but with experience, this rate drops to nearly 1% or less. Dedication matters when comparing off-pump and on-pump cases, and crossover data shows that off-pump coronary bypasses have fewer complications.

There are basically two platforms I use for MIDCAB: one uses the Medtronic system, where a small incision is made in the left fourth intercostal space, and the other is off-pump CABG for multivessel disease through a sternotomy using Guidant devices, which include a stabilizer, suction cup, coronary shunts, Mr. Blowers, and disposable retractable blades. This is a frame from one of the cases performed at the Super Specialty Hospital a couple of days ago.

The sequence of steps in MIDCAB begins with an incision in the left fourth intercostal space, tailored to the patient's anatomy. A tissue retractor is placed, especially in obese patients. The pericardium is opened, the coronary artery is identified, and a snare is placed proximally to control blood flow and induce ischemia, allowing the patient to acclimate to the procedure. The coronary vessel is opened and a shunt is introduced. Once the anastomosis is completed, the proximal anastomosis is performed. The off-pump technique allows for a clampless method, reducing the risk of aortic dissection or embolic stroke. After performing the proximal aortic punch, the heartstring device is introduced, which facilitates anastomosis without clamping the aorta.

How do we assess the bypass graft after completion? Several methods exist. An arteriogram is possible but cumbersome, requiring a hybrid room and contrast, which is not ideal for patients with renal impairment or diabetes. I prefer transit flow velocity measurement using a flow meter from Transonic, which provides an objective assessment of graft patency, mean perfusion pressures, and the perfusion index, helping us determine if the graft is patent and if there are issues such as intimal flaps or anastomotic stenosis.

With improvements in off-pump technology, we have been able to increase the complexity of procedures. For example, a recent case involved a 40-year-old male with ischemia and multivessel coronary artery disease. The LAD was exposed for a sequential bypass using the LIMA, and the PDA was exposed for a vein graft, with a radial artery graft to the obtuse marginal branch. After completing the venous and arterial anastomoses, the proximal anastomosis was performed using the clampless technique. This is a quick demonstration of how the clampless technique is performed, deploying the heartstring device and completing the anastomosis.

In the interest of time, I will conclude here. If you have any questions, please feel free to ask afterwards. Thank you.

Om Sri Sairam.

Offering our most humble pranams to the primordial Lord Ganesha and our most beloved Bhagwan Sri Sathya Sai Baba, we begin our panel discussion. As we gather here to celebrate the centenary of the advent of Bhagwan Sri Sathya Sai Baba, in collaboration with the Silver Jubilee celebration of World Heart Day, it is most appropriate for us to look into the heart of Bhagwan’s healthcare mission.

For everyone present, and for those who may not know Bhagwan Sri Sathya Sai Baba, we would like to give you a brief glimpse of his life and activities. Bhagwan was an embodiment of love who undertook various humanitarian projects in his 85 years, benefiting humanity at large. He firmly believed in propagating five basic human values, which he said made a person truly human: Satya (Truth), Dharma (Righteousness), Shanti (Peace), Prema (Love), and Ahimsa (Non-violence). He advocated the unity of all religions, often saying, “There is only one religion, the religion of love; one language, the language of the heart; and one caste, the caste of humanity.” If I were to summarize Bhagwan's message and life in two sentences, it would be: “Love all, serve all,” and “Help ever, hurt never.” His life was his message. He believed that service to mankind is service to God and demonstrated this through numerous projects. Bhagwan was a strong proponent of providing free education and healthcare to all.

Now, turning to the healthcare mission of Bhagwan: it began at the grassroots level with a two-bedded general hospital. Although you heard about this from the managing trustee this morning, I’d like to elaborate, as this is the only tribute we can pay to Bhagwan on his centenary celebrations. In 1956, Bhagwan laid the foundation stone for a two-bedded general hospital in Puttaparthi, which was followed, two decades later, by another general hospital at Whitefield. Moved by the plight of poor patients who could not afford costly cardiac surgery, Bhagwan started the Sri Sathya Sai Institute of Higher Medical Sciences, Prashanthigram, in 1991. Within another decade, he established another super-specialty hospital at Whitefield. Recognizing that some people could not reach these hospitals, Bhagwan initiated the Sri Sathya Sai Mobile Hospital in 2005, taking medical care directly to villagers and the underserved. Through these initiatives, Bhagwan’s healthcare mission grew to cover primary, secondary, and tertiary care.

Moderator: Now, I’d like to ask my fellow panelists to share their perspectives. Rajan, could you tell us about the beginnings of the Puttaparthi Super Specialty Hospital and how the journey has been since its inception?

Rajan: Sairam. Thank you, Madam. It was indeed a glorious journey. In the early days, there were many doubters who questioned the sustainability of our hospital. However, our loving Bhagwan chose something more valuable than money—pure and selfless love. It is this love that has nurtured and guided our institute, allowing it to grow beyond imagination. Even today, despite cutting-edge technology and advancements, healthcare remains inaccessible to the vast majority. A single episode of illness can wipe out a family's entire lifetime savings. In this context, the idea of creating a super-specialty hospital providing services free of cost seemed almost impossible. Yet, our Bhagwan transformed this impossibility into reality with infinite compassion, establishing a super-specialty hospital that provides state-of-the-art healthcare entirely free of cost.

Let me take you back to November 23, 1990, when, during Swami’s 65th birthday, Bhagwan made a momentous declaration: within a year, a world-class hospital worth 100 crore rupees would be established in Puttaparthi, offering advanced healthcare free of cost. One word from Bhagwan resonated across continents and was realized as the Sri Sathya Sai Institute of Higher Medical Sciences. In just six months, the dry and barren lands of Puttaparthi were transformed into a massive edifice of care and compassion. Many men and women worked tirelessly to fulfill God’s word. On the morning of November 22, 1991, the Institute was ready for inauguration. It must have been an exhilarating sight for then Prime Minister P.V. Narasimha Rao to see the hospital from his helicopter—the building resembled two huge arms offering love and solace to all who entered. Remarkably, on the very first day, four major cardiac surgeries were successfully performed. Since then, our hospital has blossomed into a 300-bed super-specialty institution with state-of-the-art operating theaters, intensive care units, and cardiac cath labs, offering a range of specialties from cardiac surgery and cardiology to many more added over the years. Today, the hospital has performed over 315,000 surgeries and procedures, served more than 4.4 million outpatients, and stands as a living testimony that the highest order of healthcare can be provided with love and compassion, entirely free of cost.

Moderator: Very true, Rajan. I recall that just two years after its inception, our hospital was ranked in Architectural Digest magazine among the top 50 hospitals in the world from developing countries. The architects, Paul Jones and Ken Nooks, said they chose our hospital for two reasons: Bhagwan’s philosophy that healthcare and education must be free for all, and because the institute was a perfect blend of form and function. Next, I’d like to ask Chitranjan: What challenges do you see in running the hospital, especially since it’s located in a village far from the city?

Chitranjan: Yes, ma’am. One of the major challenges we face in running the Super Specialty Hospital at Puttaparthi is its very location. Being in a remote village, it is difficult to attract and retain skilled manpower, ensure the continuous availability of all resources, and manage technical challenges like breakdowns or failures of highly sophisticated equipment, which often require specialized engineering and spare parts from abroad. Despite these challenges, our Sri Sathya Sai Hospital at Puttaparthi continues to thrive, thanks to Swami’s grace. In fact, we started another hospital at Whitefield a decade later, which was also founded on the same principles. Initially, this hospital catered to both cardiac and neuro patients, but since 2016, more specialties have been added. To date, there have been almost 2.8 million outpatient visits and more than 200,000 surgeries performed since 2000.

Moderator: Very commendable. Can you briefly describe the work output of both hospitals and the diagnostic facilities available?

Chitranjan: Certainly. In cardiac surgery, we handle the entire spectrum of cardiac diseases, except for heart transplants, and routinely perform more than 1,000 procedures at Prasanthigram and over 1,400 at Whitefield each year. In terms of consultations and diagnostics, more than 40,000 patients are seen annually at Prasanthigram and over 50,000 at Whitefield. Our cardiac catheterization labs perform more than 2,700 intervention procedures at Prasanthigram and 2,800 at Whitefield each year. Both hospitals are equipped with state-of-the-art technology, including high-end 128-slice CT scanners that offer high image quality and reduced radiation exposure, as well as MRI machines. At Puttaparthi, the MRI has been upgraded from 1.5 Tesla to 3 Tesla, allowing us to provide the best possible care for our patients.

Moderator: Thank you. Gautam, could you tell us about the facilities in our hospitals apart from surgical treatment?

Gautam: Yes, ma’am. The work done in our hospitals goes far beyond regular treatment. We place equal emphasis on preventive health, offering patient and family counseling, nutritional guidance, and community outreach through awareness kits, health talks in villages, and school educational programs. We believe that preventing disease is more important than curing it. Education is another important pillar: we run DNB programs, fellowship courses in various specialties, nursing programs, allied health sciences courses, and organize numerous workshops, conferences, and research activities throughout the year. This enables the next generation of healthcare professionals to serve with both competence and compassion.

Moderator: Can you substantiate what you’re saying with some facts and figures?

Gautam: Certainly. For example, a study conducted in 2017 estimated the value of investigations done in the radiology department—CT scans, MRI, ultrasound, X-rays—at more than $921 million (over 7,800 crore rupees at the time) for just one department. This demonstrates the enormous economic impact of our health services, especially considering that all these services are provided free of cost. In fact, the only department missing is the billing department!

Moderator: Very true. So, how are these hospitals different from others?

Gautam: What sets our hospitals apart is the healing atmosphere on a green, serene campus, compassionate care from staff and volunteers, wholesome food prepared and served with love, and a spiritual environment that uplifts patients and families alike. Every patient is treated with dignity, regardless of their background, and the focus is on holistic healing—addressing not just physical recovery, but also emotional and spiritual well-being. In short, the Sri Sathya Sai Baba Hospital is not just a hospital; it is a temple of healing, where science and spirituality come together to serve humanity selflessly.

Moderator: You have beautifully summed up what Bhagwan started—the Sri Sathya Sai model is universal, free, comprehensive, loving, and preventive. Bhagwan emphasized there should be no distinction between caste, color, creed, gender, or financial status, because disease affects everyone equally. He advocated a three-dimensional approach: treating the body, mind, and spirit. Bhagwan said patients should be treated with love and compassion, which heals faster than medicine alone. He also highlighted the importance of prevention, saying we should strive for fewer surgeries by focusing on disease prevention.

Bhagwan conducted the first international symposium on cardiovascular diseases in the 1990s, and in his divine discourses, he covered every aspect of healthcare, including the role of food, traditional systems like Ayurveda, and more. There are pearls of wisdom we should take home from this conference:

• Healthcare should be administered with love and compassion. The human agents of this delivery system should be perfectly humane in thought, word, and deed.

• A doctor should reflect love, sacrifice, and compassion while treating patients. Soft words and compassion heal more effectively than medicine alone.

• Treatment for the poor should not be poor treatment. Service should be offered with humility and love, as if to God, not as charity.

• A comprehensive approach is required—treating body, mind, and spirit, as the two cannot be separated.

• Ultimately, while doctors may operate, it is God who heals.

Patients come to our hospital with smiles and leave with smiles. Many even tell us, “No problem, doc, I enjoyed my illness.” Of course, no one truly enjoys being ill, but this reflects the loving environment created by Bhagwan’s vision. Never before has there been such a loving and complete avatar, who showered compassion on the masses throughout his life. Thank you.

Pranams at Swami's lotus feet. Sai Ram, everyone. I am so happy to be here and to present on World Heart Day. The talk I was assigned is on heart transplantation, and I have added transformation—lessons learned from our beloved Swami. This presentation is half scientific, half spiritual, and all about our beloved Bhagavan.

In terms of disclosures, I have no financial disclosures. However, I have been working on transplants and mechanical support since 1989. So, for over 35 years, I have done many transplants. I became a Swami devotee in 1990. Swami would always affect me and called me his coconut tree surgeon because I was so tall. He would keep tapping my head, saying it was like a coconut. I think he was just trying to tell me I have a hard head and that it took him a long time to actually transform me. He would also tease me by saying, “You transplant hearts, but only God can transform hearts,” and he certainly transformed me. The main thing he taught me is that we all have a mission. I find that what I do—even when I am tired and have operated for three or four days in a row—is not a job but a privilege he has given me.

Today, we’ve talked a lot about hyperlipidemia, hypertension, and prevention. If all that fails, the final treatment is transplantation. Here is a normal chest X-ray and a normal echocardiogram of a healthy heart. Many things can go wrong—myocardial infarction, viral infections, genetic problems, chemotherapy, or valve problems. All these can lead to heart failure, with major symptoms like shortness of breath, fatigue, and decreased activity. You can see the difference in the echocardiogram between a normal heart and one in failure. We try all possible medications, but ultimately, if nothing works, the only therapy left is a transplant.

For people who start off with heart failure, you can see that most experience a cycle of deterioration and improvement as we adjust their medications—an up-and-down journey until eventual pump failure. Heart transplantation is designed to intervene at a point when the patient is deteriorating, before complete pump failure, to improve their quality of life and survival.

Transplantation started in 1912 with Alexis Carrel, who won the Nobel Prize in Medicine for demonstrating that you could connect two blood vessels. Dr. Shumway and Dr. Lower developed the transplantation technique at Stanford University. Dr. Christiaan Barnard, due to changes in brain death legislation, performed the first transplant in South Africa. Initially, only surgeons participated in the surgery, and in 1971, there was a major article declaring an era of medical failure. It was at that time that Dr. Shumway and his team at Stanford coordinated care among surgery, pathology, and cardiology. They began to understand rejection, developed new drugs and suppressive agents, and now heart transplantation is the gold standard for treating advanced heart failure. We now expect patients not just to survive a year, but to live decades with a good quality of life. That is an absolute expectation.

Regarding the transplant procedure: It’s a major operation. Sometimes the heart is barely moving, dark due to desaturated venous blood. On bypass, when the heart doesn’t have to work, it may pick up some contractions. We clamp the aorta, open the chest, remove the ICD and the electrodes, clamp the pulmonary artery, and remove the inferior vena cava and left atrium. The failing heart is then removed from the chest. Notice how large, foggy, and thin-walled it is. Eventually, you’re left with the aorta, pulmonary artery, IVC, SVC, and pulmonary veins.

The new heart arrives in an ice cooler, kept at about 4 to 8 degrees Celsius. The heart is carefully labeled so we don’t put the wrong organ in the patient. We prepare it for transplant, and then sew it in, starting with the left atrial anastomosis, followed by the inferior and superior vena cavae. This is the transplant.

In terms of results, from 1992 to 2017, the 20-year survival rate after heart transplantation was about 40%. Some may think that’s not great, but if you look at survival after coronary artery bypass surgery for patients with coronary disease, the 20-year survival is just 22%. So, transplantation, especially in the modern era, is even better than most valve or bypass surgeries in the 60- to 70-year-old patient population. That’s why transplantation is considered the gold standard.

What about quality of life? There’s the Hancock Building in Chicago, a hundred stories tall. Every year, there’s a charity event to climb it, from the ground floor to the top. Right next to me in the event are three transplant patients—one had heart, liver, and kidney transplants; another (in blue) had a heart transplant; and the third had a heart transplant just four months prior. Here they are at the 100th floor. So, the quality of life after transplantation can be excellent.

The number of transplants is growing, especially in the United States and India, where they’re now doing 300 to 400 transplants per year. This growth is helping to deliver advanced care to more people in India.

Transplantation is a medical miracle, but transformation is truly divine. I want to share examples of how Swami has transformed me. First, Swami’s omnipotence: I was at Temple University, leading the largest program in the U.S. In 1998, Swami told me, “I have made a job for you in Chicago. You’re going to Chicago.” I had no desire to leave Philadelphia, but Swami insisted. Eventually, I went to the University of Chicago. For years, things were fine, but not as great as at Temple. I kept asking Swami why he sent me to Chicago, and he would say, “Temple was no good. Swami likes quality, not quantity.”

In 2022, I stepped down as director of the transplant program after 24 years in Chicago. Looking back, data from the United States transplant agency showed that the University of Chicago had the lowest observed-to-expected mortality ratio in the U.S.—the best in the country and possibly the world. When Swami said “quality over quantity,” this is what he meant. Only he could have foreseen this outcome, 24 years in advance.

Other lessons from Swami: In my early years, I performed many transplants. Sometimes older patients did well; sometimes younger patients died. People would say, “He was so young.” In an interview, Swami told me that my job was to work as hard as I could and do my best, but ultimately, death is his gift. We don’t know why someone dies—perhaps it spares them suffering. It is not in my hands; it is all in his hands. That truth transformed my approach to medicine: do our best, but the results are his.

Swami also said we are all his instruments. I have two examples. Once, in Chicago, a young donor heart was offered to us, but other programs had turned it down due to low ejection fraction and blood pressure. I worked all night to stabilize the heart, and the next morning, the coordinator told me another program would get it instead. I was frustrated, but at a meeting weeks later, a cardiologist described a “miracle”—a dying patient with no options received a heart that unexpectedly became available and did well. That was the heart I had worked on. Swami’s message of connectedness and being his instrument became clear: I made that heart viable, not for my patient, but for another. We are all part of his reality, playing our roles as instruments in his mission.

Another case involved a Jehovah’s Witness patient who waited six weeks for a heart. Just before surgery, she developed a fever and couldn’t be transplanted. The donor heart was offered to another patient in the ICU who had 100% PRA—meaning almost all donor hearts would be incompatible. Miraculously, this heart was compatible. The original patient’s fever resolved after three days, and she also received a transplant. Everything is connected and happens according to Swami’s will.

Our program is unique: 25% of our patients come from other transplant programs, and we handle very complex cases. We think differently because I have Sai confidence. Swami promised he would protect his patients from me—if a patient was not meant to be transplanted, it wouldn’t happen. This confidence allowed us to perform the world’s first successful heart-liver-kidney transplant in 1999, and we have since completed many such cases, including for Jehovah’s Witnesses who refuse blood. We have done more bloodless transplants than anyone else. Swami instilled this confidence in us: he will take care of everyone; we are just his instruments.

On our fourth floor at the University of Chicago, we have tried to make it a part of Swami’s mission. Everyone wears “Love All, Serve All” shirts, and we have gradually developed that culture within the hospital.

In conclusion, heart transplantation has evolved dramatically over the last 50 years and continues to do so. With increasing donors and improved immunology management, outcomes are better than ever. But ultimately, Sai Baba has transformed my heart—a much greater miracle than any transplant I have performed. Transformation truly involves the destruction of the ego and the road to spirituality. For Swami’s guidance and blessings, I am forever grateful. Thank you very much.

As you can see, optimizing heart health is about reducing hurry, worry, and curry. In 2005, I had an interview with Swami, which was recorded on video. He spoke only about food, heart disease, and the importance of moderation. He said South Indians should eat chapatis and North Indians should eat rice, so no one would overindulge in what they love. His message was: hurry, worry, curry—avoid these to prevent heart disease. Thank you all. Sai Ram.

Respected brothers and sisters,

Sairam

Today, I will be speaking about the overall activities undertaken by the CCSSA Healthcare initiative, as part of this organization in India.

Our inspiration has been our beloved Bhagwan, who established the General Hospital in the 1950s, followed by two super-specialty hospitals, another General Hospital, a mobile hospital, and medical camps that serve people in over 150 countries.

Bhagwan once addressed doctors and said, “Doctors should serve the poor with a spirit of sacrifice. There is no greater service than this. God is the sole refuge of the destitute and forlorn. As man is the embodiment of God, it is his primary duty to help the destitute and forlorn.”

The objectives of our healthcare initiative are twofold: First, to provide holistic healthcare that reaches the most underserved and poor people; and second, to educate the public on how to maintain good health and prevent illness, using audio-visual presentations about preventive healthcare, including health and hygiene.

The guiding principles include state-of-the-art healthcare, comprehensive care, free healthcare, preventive measures, compassionate care, and timely delivery.

Bhagwan has always emphasized the importance of preventive healthcare awareness. All our activities and medical camps across India are conducted with a strong focus on public health education, regardless of the camp’s specific services.

The module prepared by Dr. V. Mohan and myself is being followed nationwide and has been translated into various languages.

Our services include general medical camps, eye camps, pediatric camps, exclusive camps for pregnant women, cancer screening camps, dental camps, and other specialized camps such as ENT, orthopedics, and skills clinics. Our static free clinics, known as “Sai Seva Clinics,” operate throughout metropolitan areas in India.

Institutional care enables us to utilize existing hospitals and clinics for needy patients. Patients do not have to spend any money; the entire cost is covered by the institution providing the treatment.

Single doctor clinics refer to doctors affiliated with CCSSA India who offer free treatment to patients in their own clinics.

CCSSA India has also been at the forefront of volunteer blood donation. Our blood donation drives include year-long camps, special drives during the summer when blood banks experience shortages, and need-based donations for hospitalized and thalassemia patients.

The young adults of CCSSA India initiated a blood donation camp in 2021 as part of Bhagwan’s birthday celebrations. Our digital platform allows donors to register for emergency blood donations, and patients or their attendants can quickly submit requests. A dedicated team of volunteers ensures timely fulfillment by contacting nearby matching donors. In just one year, this portal registered over 405,000 donors.

Mobile medical care is also provided through SSI mobile hospitals. Healthcare is integrated with other initiatives such as individual care, employment care, educational care, spiritual care, agricultural care, and social care.

Veterinary camps are an integral part of our outreach to rural communities, and we have a wide network of veterinary doctors. We also organize homeopathy camps and weather camps.

These camps are conducted not only for the benefit of devotees and patients, but also for our own growth. Bhagwan is not concerned with the number of patients treated, but rather with the unity among doctors and the delivery of care with love and compassion.

CCSSA India’s rehabilitation program offers follow-up care for heart patients operated on at the Satsia Hospital, both at Prashanti Gram and Whitefield.

The Sai Global Council organizes medical camps twice a year: during Gurupurnima in July and Bhagwan’s birthday in November. Doctors, paramedics, and allied medical personnel from various states in India and overseas participate in these camps.

One example is the medical camp at the Andaman and Nicobar Islands, where Divine Love reached remote villages on March 1 and 2, 2024. Highlights included offering livelihood support equipment and health checkup camps for villagers.

Medical camps in Leh Ladakh are conducted with support from the Ladakh Unit Administration, Central Reserve Police Force, and Indian Army in the Himalayan mountains. These have taken place since 2021.

Telemedicine services are also offered through the Sai Telemedicine Service and are integrated into our medical initiatives and clinics.

Dr. Seva at SRB, popularly known as the Cardiac Training Outpatient Program, is held at Satsia Medical Sales Prashantigram. This initiative began in 1999 and runs throughout the year, with doctors from all states volunteering. The minimum period of service is ten days, and all accommodation and food are provided free of charge by the organization. A roster is maintained to ensure coverage throughout the year.

Dr. Seva at the Sai General Hospital in Prashanti Nilayam began in 2012, with similar arrangements for doctors’ accommodation and meals.

We also focus on skill development in healthcare. Our bedside assistant course for geriatric care offers five months of intensive training, covering care for both pediatric and geriatric patients, followed by a one-month practical internship, including telemedicine concepts. In February 2024, 18 students from Himachal Pradesh graduated from this program and have found employment in the private health sector in the state. This initiative addresses the growing need for bedside care, especially when children move abroad and elderly parents require support.

On October 4, 2024, CCSSA Andhra Pradesh, with the permission of the All India President, signed an MOU with the AP State Skill Development Corporation to launch the bedside assistant course.

The Sai Divyangjan Seva Project is a heartfelt initiative by the organization, supported and guided by the Sai Central Trust. This noble project, launched as part of Bhagwan’s centenary celebrations, aims to bring comfort and empowerment to differently abled individuals by providing artificial limbs and arms to 100,000 people across India.

Our medical services also work in tandem with disaster management as needed.

Finally, I would like to share a summary of our medical activities in India from April 1, 2024 to March 31, 2025. The number of general medical camps conducted was 19,130, with 7,872 mobile medical camps and 1,504 eye camps. The general medical camps benefitted 5,087,303 people, mobile medical care reached 791,479 individuals, and eye camps assisted 741,840 people. These are cumulative figures.

If we conservatively estimate the cost of delivering these seven activities free of charge, the total would be approximately Rs. 214,198,295. This is not money spent by the CCSSA Central Trust or organization alone, but is contributed by each one of us—the common man—out of love for Bhagwan.

Yet, this service cannot be measured in currency alone. What is truly priceless is the hope restored, dignity preserved, and compassion rekindled in every patient and every life touched.

This is healthcare with a heart—a true model of love in action.

Salutations to the Almighty.

My loving master, loving greetings to all the assembled doctors here.

Dear doctors, I will be making my presentation today under three distinct and specific headings.

• First, defining and outlining the difficult and perhaps dangerous situation confronting the human race today in the form of non-communicable diseases (NCDs), especially cardiac diseases.

• Second, analyzing the reasons for this grave situation.

• Finally, providing a practical, workable, time-tested solution innovated by our Bhagwan, Sri Satisai Baba, our divine master.

Dear doctors, you will all agree that there have been tremendous and spectacular advances and improvements in the field of cardiothoracic surgery. I have listed a few, but I am sure you will agree that there are many more. In fact, I would say the sky is not the limit for such improvements and advancements.

But paradoxically, and unfortunately, if you look at the cardiac community's disease load—a very important term in public health—it tells us the utility value of all the interventions made in this specialty. Sadly, the disease load has been increasing rapidly and distressingly, accounting for 32% of all deaths worldwide. In a country like India, 50% of all acute events, especially acute myocardial infarction or heart attacks, occur in individuals below 40 years of age. This is a very sad state of affairs.

If we analyze the reasons for this surge and dangerous situation, I have identified five reasons:

1. Socioeconomic poverty and unaffordability—this is the domain of politicians, bureaucrats, and economists, so I will not elaborate much on that.

2. The dramatic increase in instances of diabetes and hypertension—other speakers are addressing this issue.

3. Defective healthcare system and the near total absence of focus on prevention—these are particularly important.

Even within this, the first is a defective healthcare system, and second is the near total absence of focus on prevention. The second is an offshoot of the first problem.

With the advent of industrialization in every country, a phenomenon called the rural-urban divide occurred. People working in factories and industries settled in cities and towns, which became epicenters of progress and development. Those who stuck to agriculture remained in villages, cut off from the mainstream. This aspect was not considered when healthcare planners devised services for many countries. In India, the system is especially defective. The three-tier pattern of healthcare services devised by the Bore Committee did not take into account that 70% of our population still lives in villages. Thus, 70% of the population is served only by primary healthcare centers, which are rudimentary, while 30%—the urban population—has access to all three levels of care. This is not just a gross inequity; it is a gross injustice perpetrated and perpetuated by successive governments on poor Indian villagers.

Rural healthcare delivery, based on 25 years of field experience, is caught in a tricky triangle: challenges faced by the government, doctors' reluctance to serve in rural areas, and constraints experienced by villagers. Government challenges include poor budgetary allocation and inability to transfer technology, especially diagnostic equipment. Modern medicine is all about diagnostics, but the government claims there is no mechanism to install, service, or maintain them. Inputs from field experts are rarely considered, and the health department is manned by bureaucrats, leading to improper planning.

Doctors are unwilling to serve in rural areas, citing professional and personal reasons. Professionally, a doctor at a government primary health center may not have even a glucometer or any worthwhile diagnostic tools, leading to dissatisfaction. Personally, the absence of schools for their children makes rural service unattractive.

The third issue is the constraints villagers face in accessing facilities in towns and cities. Many are engaged in daily wage labor, senior citizens lack assistance, transportation costs are prohibitive, and women juggle work at home and in the fields. This creates a very difficult situation that seems unsolvable.

The consequences are clear: 70% of people live in villages, but 80% of facilities are in towns and cities. Public health parameters like infant mortality rate and life expectancy in rural areas are unfavorable compared to urban areas. Another important point is the lack of integration among primary, secondary, and tertiary care—they function in isolation. For example, a villager with chest pain may visit a primary healthcare center, but without proper diagnostics, is told to go to a town. There is no guidance or support for this journey, resulting in loss and suffering.

The second major reason is the absence of focus on preventive services. Most countries, including developed ones, spend only 3 to 5% of their medical budget on prevention, despite knowing that every dollar spent on preventive education can save ten dollars in curative services. Yet, there is a lack of interest among doctors in prevention. Modern discoveries have radically transformed concepts about nutrition, sleep, exercise, and more, but many doctors are unaware of these advancements. For example, inappropriate carbohydrate intake, circadian rhythm, autophagy, gut microbiome, and the best time for exercise are often overlooked.

I experimented with these concepts myself and lost 18 kilograms in one year, normalizing my metabolic parameters. There is an urgent need to update doctors on these five important topics.

When the healthcare service itself is defective, there is no portal to transmit preventive education or curative services. Preventive services cannot be sporadic or superficial; they must be serious, regular, and sustained, and primarily delivered by doctors for credibility and receptivity, supported by counselors and paramedics.

The solution for the twin problem of defective health service and lack of focus on prevention was ultimately addressed by our Bhagwan, who delivered what I call the master's master stroke. Having provided primary and tertiary healthcare services, Swami made a three-pronged approach. He declared that medical service requires not just doctors, diagnostics, and drugs, but a fourth dimension: delivery, especially in countries where people are cut off from the mainstream. Outreach is essential.

Swami emphasized that outreach creates goodwill and respect, making doctors the best candidates for preventive services. He gave us a beautiful model combining curative and preventive services with a base of spirituality. The mobile hospital model delivers primary and some secondary care, ensures a guided patient journey for tertiary care, and creates an end-to-end solution. Recently, major surgeries have been performed through collaboration among doctors from different hospitals.

The mobile hospital service is a free, rural outreach, comprehensive, and high-quality service benefiting 400 to 450 villages, with computerized data management. It benefits a population of about 500,000 to 600,000 people across 12 regions. Started in March 2006, it operates from the 1st to the 12th of every month at fixed nodal villages, regardless of holidays, building faith and credibility among villagers.

Every service began with an ideology that guides the methodology. Our operative strategy includes classifying community ailments as common, chronic, intricate, asymptomatic, preventive, and emergencies. This classification helps develop effective strategies for each specialty and understand the community disease spectrum.

The service is regular, operating in 12 nodal villages. Bhagwan insisted on high standards; on any given day, doctors from 12 specialties work together, unlike in cities where meeting multiple specialists is rare. For example, a patient with uncontrolled diabetes is immediately referred to a dental surgeon for periodontal disease assessment, ensuring coordinated care.

The mobile hospital provides on-site diagnostics with digitized X-ray, lab, ultrasound, ECG, EEG, and aspiration cytology. Off-site diagnostics like CT and MRI scans are guided by the system. A rich pharmacy ensures patients receive a month's supply of medicines for uninterrupted treatment and high compliance, especially for chronic diseases requiring regular monitoring and counseling.

Backup support is available for cases needing higher-level treatment or surgery. Case identification, diagnosis, and surgical profiling are done on the field, and integration among three hospitals ensures seamless care. Collaboration among voluntary doctors from various specialties enhances the quality of care.

Preventive education is conducted intensively and extensively at individual, family, group, and community levels. Doctors use flip charts and demonstrative materials during patient interactions, prioritize health education, and engage villagers in informal discussions. Strong curative services generate goodwill, making people receptive to preventive advice.

Health education is also provided at the group level in hospitals and at the community level in the evenings, using practical demonstrations. This approach generates goodwill and addresses issues like malnutrition, emphasizing the need for life-transforming habits instead of harmful lifestyle choices.

In summary, cardiac diseases are rising due to increased diabetes and hypertension and, more importantly, the absence of an effective healthcare delivery system and focus on prevention, especially in countries like India. Doctors must rise to the challenge and fulfill their mandate to provide health education.

The holistic healthcare model is based on spirituality, which Swami clarified does not pertain to any religion, race, leader, or cult, but to broad ideals and practices common to all religions, such as prayer and meditation. Holistic health requires a combination of metabolic and mental health, with mental well-being being each individual's responsibility.

This model, innovated by our Bhagwan, provides an effective solution to crises like COVID-19. Outreach care must penetrate communities deeply to address the vast number of patients with these diseases.

The larger purpose of medical service is to bring light and spirituality into people's lives. There is an urgent need for an ideal healthcare delivery system, and the mobile hospital model has attracted governmental attention, with agencies seeking to replicate it. Suggestions include involving postgraduate doctors during their training, as government hospitals are often managed by them, and the numbers match well for the needs of states like Andhra Pradesh.

In conclusion, there is an urgent need for outreach service systems, for doctors to update their knowledge on key topics, and for governments to increase budgetary provisions for preventive services. Emphasizing the role of prevention is crucial, as it is the theme of this conference. Thank you all for your patient attention, and thank Bhagwan for giving me this opportunity. Jai Sairam.

My humble salutations are offered at the lotus feet of our beloved Lord Bhagwan, Sai Baba, and also to each of you, as he resides in your heart and inspires you to engage in this great service. Truly, serving humanity is serving God. I am deeply grateful to our beloved Lord for granting me this opportunity, and I extend my heartfelt thanks to the organizers, especially Dr. Akshay Italia and Dr. Rao, for allowing me to take part in this wonderful celebration of Swami’s 100th birthday, an event that is being honored across the globe.

This occasion is a once-in-a-lifetime achievement—most of us may never witness another centenary celebration like this. We are extremely fortunate. I would also like to pay my respect to our Sai Global Council trustee, Dr. Mohan, who is present with us, as well as to our esteemed guests and distinguished speakers.

After hearing such inspiring talks, I am certain many of you will be motivated to change your lifestyle, especially after visiting the exhibition here and yesterday’s medical camp. These experiences remind us to care for our hearts so we may continue serving Sai and share his message worldwide. I feel blessed that one of my greatest achievements in my medical career has been learning how to bring medical care to the remotest corners of the world, a journey that began forty years ago during Swami’s 60th birthday celebration in 1985.

Swami guided us with immense love, showing us how to serve others. Every morning, sixty villages were chosen, and Swami would commence the day by breaking a coconut and sending us out with loving encouragement. He would not rest until every last volunteer had returned, personally ensuring everyone’s safety. Swami taught us the importance of teamwork and caring deeply for those we serve.

Over the years, Swami has directed us to conduct international medical camps in numerous countries, always emphasizing prevention and compassion. As Dr. Neelam shared this morning, love is the most important ingredient in healing. If we listen with an open mind and treat others with genuine care and compassion, the healing process begins right there. This is often what is missing in many hospitals. The module demonstrated by Dr. Darsim is exactly what we use in our international medical camps, ever guided by Swami’s critical yet loving feedback.

Transformation comes through action, not preaching. Let me share an incident from Sierra Leone, a country ravaged by war and depicted in the film "Blood Diamond." At Swami’s behest, we held a medical camp there, despite active mines and immense danger. At first, locals were hesitant, fearing a trap. But Swami’s name and love drew them in. They came not only for medical help but to experience the love Swami inspires, even though they had never seen him in person. One patient said, “We have not seen Swami, but we are seeing the eyes that have seen the Swami.”

One evening, a truck arrived at our camp, unloading many casualties with severe injuries. With limited resources, we could do little but pray. A simple volunteer began applying vibuti to each patient and even to the generator to keep the lights running. Miraculously, the generator lasted through the night until the last patient was treated. Swami's presence was felt, demonstrating his omnipresence and loving guidance.

We faced countless challenges, from transporting patients over 100 kilometers to Freetown without proper roads, to managing critical injuries with minimal supplies. Yet, through faith and teamwork, none of the patients died en route, and the local hospital director was amazed at their survival. The next day, the President of Sierra Leone visited our camp, saying: “Rebels came to this country and did the killing, Sai angels came to this country and did the healing, and brought hope and smiles to my countrymen.”

These medical camps are not just about curing ailments; they are about restoring hope and smiles to those suffering. Our duty is to bring this joy to the faces of the afflicted, which in turn brings joy to our beloved Lord and is the greatest birthday gift we can offer him.

If time allows, I’d like to share another story about the power of love from Geneva, where Chief Justice Bhagwati organized a Sai event in the Hall of Human Justice. United Nations dignitaries were present, and after presenting Swami’s work in war-torn countries, I was asked how we received so much love from locals, while peacekeeping forces and WHO staff sometimes faced hostility. Swami answered through a simple gesture—a man entered with a gun to deliver a note. I explained, “You go with a gun and are received with a gun. Our Lord says, you go with love and you are received with love.” That is the power of love.

Swami’s blessings have allowed me to work with Mother Teresa, learning the true meaning of service. As Swami says, “Manava Seva is Madhava Seva”—serving humanity is serving God. We must offer our service with the devotion of offering a lotus at Swami’s feet, delivering it with immense love.

Finally, let us not forget our colleagues who are no longer with us, those who made the ultimate sacrifice. Sacrifice is the hallmark of the medical community, as evidenced during the COVID pandemic when we lost many dear friends. Let us pray that Swami grants them peace and a place at his lotus feet, and gives us strength to continue this work.

At this holiest place and at this sacred time, let us remember and pray for those who are not with us, and renew our commitment to serving others with love, compassion, and gratitude. Thank you once again for allowing me to share these reflections. Thank you very much.

Good afternoon, everyone. First, I’d like to thank the organizers for welcoming us, and I’m grateful to my fellow panelists, some of whom have reviewed the slides in advance. If there are any disagreements today, they come from a place of good intent.

Many of you know Dr. Dash well; he needs no introduction. I am from the Mayo Clinic, trained in Rochester, and now based in Arizona. Dr. Rahman has long supported the Whitefield campus—perhaps for a couple of decades—and Dr. Garg, who has worked in Putaparti, regularly visits Whitefield even after moving to the U.S.

Let me begin with the topic of coronary artery disease and how life can abruptly end due to ventricular fibrillation. If intervention occurs within the first 45 seconds, recovery rates are around 99%. At two minutes, this drops to 80%, and after four minutes—even if recovery is possible—the brain starts exhibiting hypoxic damage. At eight minutes, irreversible brain injury occurs. All of this originates from acute events, especially when prevention fails, which unfortunately happens at a younger age in the Indian population.

In India, many cases of acute anterior myocardial infarction occur at a young age. If symptoms present within 60 minutes, there may be negligible long-term effects, but waiting 90 to 120 minutes can lead to minimal, yet significant consequences. After four hours, lifelong complications become substantial.

As the heart heals after an event, scar tissue can create areas of slow conduction, which may result in ventricular tachycardia later on. Acute monomorphic ventricular tachycardias are typically due to healed scars, not new infarctions. For example, in Kerala, it’s observed that even young people develop coronary artery dysfunction because the arteries are extremely small.

There have been cases where routine treadmill tests triggered serious arrhythmias requiring immediate intervention—a reminder that such issues occur at very young ages in India. Diabetes and hypertension are common contributors to this risk. Sometimes, medications that prolong the QT interval are prescribed unknowingly, increasing the risk for life-threatening arrhythmias.

Accessory pathways also play a role, and we regularly see cases of pre-excited atrial fibrillation. In such emergencies, beta blockers are contraindicated; only procainamide or ibutilide should be used. Ablation is a highly effective treatment for these patients.

In Andhra Pradesh, studies revealed that chest discomfort preceding collapse is frequent, and uncontrolled hypertension is widespread—often due to high salt intake. Women may die suddenly without prior evaluation, possibly because their symptoms are ignored or they don’t complain to avoid burdening their families. Access to care in cities is better, but rural areas face challenges.

A sample of 451 individuals showed that by age 40, around 60% already had coronary artery disease, often asymptomatic. Early detection—using coronary CT angiograms, for instance—can make a significant difference, as seen in European studies. I’m not suggesting that everyone needs a CT angiogram, but early symptoms or exercise intolerance should not be ignored. Indians tend to have higher coronary disease rates, so prompt testing is vital.

Most sudden death prevention efforts focus on patients already diagnosed with heart disease, but the majority of sudden deaths occur in individuals without prior cardiac history. This underscores the importance of having automated external defibrillators (AEDs) in every village. Every medication prescribed, such as beta blockers, angiotensin receptor blockers, and statins, can reduce the risk of sudden cardiac death. Defibrillators and ICDs are valuable, but medication can also be effective in prevention.

I’d now like to invite my panelists to share their perspectives on prevention in the Indian context.

Dr. Rahman emphasized risk factors—diabetes, hypertension, family history—and the importance of education. In India, premature coronary artery disease and sudden cardiac death are alarmingly common below the age of 40. Educating the public on early symptom recognition—chest pain, shortness of breath, palpitations, syncope—is crucial, as is individual risk factor modification.

Dr. Garg added that sudden cardiac death is a major challenge, citing the sudden loss of a 39-year-old surgeon as an example. Diagnosis and management of early coronary disease are critical. At the community level, everyone should know cardiopulmonary resuscitation (CPR), and AEDs should be available wherever people gather. He suggested that CPR training be mandatory in schools for students over 15 or 16 years old.

It’s important to address lifestyle derangements through education, especially in lower socioeconomic groups where rice is the main source of energy. Many people are unaware that smoking can cause heart attacks—they only associate it with lung cancer. Education on risk factors and lifelong management of conditions like hypertension is essential for both the public and physicians.

For non-ischemic cardiomyopathy, ICDs provide less benefit in patients with excellent functional status, especially in resource-constrained environments. MRI can help assess fibrosis burden, which influences treatment decisions.

Turning to atrial fibrillation, this condition is a pandemic in Europe and increasingly relevant in India. Advancements like cryoablation and pulse field ablation have made procedures quicker and safer, especially for isolating pulmonary veins. In the Indian context, if ablation is unavailable, medication is key—amiodarone is preferred for heart failure patients (limited to 100 mg to reduce risk), while beta blockers and calcium channel blockers can be used in other cases. Vigilance is necessary when monitoring for complications, such as pulmonary fibrosis with higher doses.

Atrial fibrillation is a major cause of stroke, particularly in the elderly, and can be asymptomatic. Regular EKGs after age 60 or 70 are advisable if symptoms arise, and wearable devices may help detect arrhythmias. Anticoagulation should be strongly considered for older patients found to have atrial fibrillation.

Not all chest pains are due to coronary disease. For example, concave ST elevations outside vascular territories may indicate pericarditis, not myocardial infarction. Conditions like Brugada syndrome can also mimic heart attacks and cause sudden cardiac death, but are not related to coronary artery disease.

Recent innovations like leadless pacemakers offer new treatment options. In closing, coronary artery disease remains the most common issue, with high patient volumes in clinics and hospitals. Early detection is vital—even young people with chest pain may benefit from coronary CT angiograms or stress testing, though access remains a challenge in rural areas.

Lifelong management and adherence to guidelines are essential. European protocols use acronyms to address comorbidities—obesity, hypertension, diabetes—all of which are risk factors for atrial fibrillation. Treating sleep apnea, for example, can restore normal sinus rhythm in some patients.

With that, I’d like to thank my panelists and all of you for your attention. Let’s remain committed to education, early detection, and providing life-saving resources to every community. Thank you.

Good afternoon, everyone. As the panel comes together, I’d like to begin. Although Dr. Sunil Agarwal couldn’t join us today due to a family event, the rest of our panel is here, and we’ll proceed with a combination of lecture and discussion.

Let me first thank the organizing committee for the opportunity to participate. It’s an honor, and I especially want to thank Swami for his blessings and Dr. Keshav Naik for coordinating the U.S. contingent. We have our slides ready, so let’s get started.

When I was asked to speak as an interventionist, I realized preventive cardiology is at the heart of our work, even though it’s often viewed as downstream. Our clinic does focus on prevention, and since this conference centers on prevention, my topic today is inflammation—an area I’m passionate about due to my research and practice in complex cardiovascular disease, coronary spasm, and microvascular angina.

Inflammation is a timely topic, especially in relation to coronary artery disease. While preparing, I came across new research presented at the ESC by Dr. Paul Ridker, who’s spent his career studying inflammation. He introduced the term “Smurfless”—referring to patients without standard modifiable risk factors like diabetes, hypertension, hyperlipidemia, or smoking, yet who still develop disease due to underlying inflammation.

Many patients lack these classic risk factors but still face heart disease. Ridker’s thesis is that other mediators of inflammation play a role, and I’ll share data supporting this. Even popular media, like a recent Guardian article, highlight five easy, evidence-based ways to fight chronic inflammation—practices accessible to everyone, regardless of income or access to healthcare.

Reflecting on our medical training, we learned that the earliest stage of atherosclerosis is endothelial injury and lipid entry, followed by inflammation as monocytes, macrophages, and T lymphocytes infiltrate the vessel wall. Inflammation has long been recognized as important, but only recently have we understood its impact on outcomes—independent of cholesterol or clinical risk scores. Elevated high-sensitivity CRP (HSCRP) correlates with worse prognosis, as Dr. Narasiman mentioned earlier regarding lifestyle changes normalizing CRP.

Dr. Ridker’s recent publication analyzed data from the Women’s Health Study at Harvard, following “Smurfless” women for thirty years. He found a clear dose-response: higher HSCRP predicted worse outcomes, with a threshold around three—reinforcing that inflammation is a meaningful clinical target.

The Jupiter trial further supports this. Ten thousand patients, with no indication for lipid-lowering therapy, were randomized based on CRP levels. Even among those without standard risk factors, treating elevated CRP led to a 38% reduction in events—a compelling case for addressing inflammation.

Inflammation is systemic, with adipose (fat) tissue as a major site, explaining the dangers of central obesity. The liver then releases the CRP we measure. So, how do we detect inflammation? Several biomarkers exist, but CRP is preferred due to its stability and well-standardized assay, especially high-sensitivity CRP for subclinical inflammation. In vivo, advanced imaging like OCT, CT, PET, and AI-enhanced CT now lets us visualize vessel wall inflammation.

As technology advances, non-invasive tools will enhance our understanding—not just of plaque burden, but of plaque inflammation, potentially transforming clinical practice.

Turning to treatment, traditional Indian medicine has long promoted phytonutrients like turmeric, though large trials are limited. More robust evidence comes from pharmacological agents. The Cantos trial, for example, used canakinumab—a monoclonal antibody targeting interleukin-1 beta—in stable coronary disease patients. Over five years, it reduced major adverse events by about 15%. However, concerns over cost and increased risk of serious infections prevented widespread adoption. Still, it proved the concept.

Cardiologists continued investigating, and now nine trials show benefit for colchicine, a well-known anti-inflammatory drug. Meta-analysis shows a roughly 12% relative reduction in events. While colchicine can cause mild GI side effects, it’s effective at low doses. The FDA now approves colchicine for secondary prevention in coronary disease, with a Class II recommendation pending more data. Ongoing large trials will clarify its role further, along with novel biologics like interleukin-6 antibodies.

So how do we help patients right now? Returning to the Guardian article, five practical anti-inflammatory strategies stand out: spending time in nature, engaging with art and music, regular exercise, spirituality, and supporting others—community service. These “social prescriptions” are gaining traction, especially in the West, as antidotes to the loneliness epidemic.

Pharmacologically, colchicine, statins, and GLP-1 agents like semaglutide (now Class II recommended for coronary disease in the U.S.) are important tools. Their benefits likely extend beyond weight loss to reducing inflammation. Measuring HSCRP, especially in younger patients with premature coronary disease, is prudent; if elevated despite standard therapy, consider direct anti-inflammatory interventions.

New agents and approaches are on the horizon. In summary, inflammation is causally linked to atherosclerosis, not just a bystander. We have reliable biomarkers and advanced imaging—both invasive and non-invasive. An HSCRP threshold of three should prompt consideration of intervention. Lifestyle changes, including spirituality and service, matter, and pharmacological options are expanding.

Thank you all for your attention. I invite questions from the panel and audience as we continue this important discussion.

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Now, Dr. Keshav will share a couple of stories and insights. As a former student from Putaparthi, I’m grateful for this opportunity. Swami always cherished our visits, and I encourage everyone to continue this tradition. He manifests daily, and his presence is felt by all who serve.

I’d like to share a personal experience. As a medical student in Philadelphia, I suffered a serious bicycle accident. Amid the chaos, I felt Swami’s divine compassion—I recovered fully, and my grandfather later recounted this to Swami, who confirmed his spiritual intervention. Swami’s love is ever-present and guides us in caring for patients.

On the occasion of Swami’s hundredth birthday, I reflect on longevity. Some patients live past a hundred; I performed a transcatheter aortic valve replacement (TAVR) on a 103-year-old pastor who survived and continued working until age 106. Sometimes, with high-risk procedures, surrendering to Swami’s guidance is essential.

TAVR, now a mature therapy, began with balloon valvuloplasty and evolved to stented aortic valves. The first TAVR was performed on a patient in cardiogenic shock and has since become routine, with over 100,000 procedures annually. Collaboration between cardiologists and surgeons is key to selecting the best approach for each patient.

India now offers the MyVal valve, a cost-effective alternative to American valves, with landmark trials showing non-inferiority in safety and efficacy. Advances in procedural planning, vascular access, and valve design have improved outcomes and reduced complications like stroke and pacemaker requirement.

Artificial intelligence is also transforming TAVR, with predictive models for complications and personalized valve selection.

Swami teaches us to treat not just the disease, but its cause. Chronic inflammation, oxidative stress, and lipoprotein A contribute to aortic stenosis progression. Early intervention—before heart failure and mortality—now guides our practice, moving beyond watchful waiting.

In conclusion, TAVR is an established therapy with expanding indications. Early, proactive treatment is our goal. I pray to Swami for guidance as we endeavor to start a TAVR program at Whitefield and Putaparthi. Thank you all very much.

It has been so blissful to be at this hall at this time, and it's truly a serene moment—a unique conference where science, service, and spirituality meet. I don't think there is anywhere else in the world with a conference quite like this one.

I was asked to talk about a difficult topic, but seeing Dr. Jagat Narula here—he is the world-renowned expert on this very subject—I'm going to attempt to discuss a topic he has dedicated his life to, with extensive research and publications. So, if there are any questions at the end, I will refer them to him.

Jagat Narula is my classmate, my friend, my dear brother, and also our chief guest for the conference and the keynote speaker tomorrow. So let me get started.

The number one problem is: how do we detect a heart attack before it happens, especially in South Asians, and how do we identify the disease before it strikes? This is the million-dollar question, and after five decades of research and countless expert opinions, I have to present the findings in just ten minutes.

Let me give you a case that may sound familiar to many of you. A 45-year-old man was jogging in a park near my home in Pittsburgh. He was very fit and healthy but one morning, he suddenly collapsed from cardiac arrest. Thanks to immediate CPR and resuscitation, he was rushed to the hospital, treated in the cardiac catheterization lab, and a stent was placed. He recovered and went home.

A few days later, he came to see me, very emotional, with tears in his eyes. He asked three questions: Why did this happen to me? How can I prevent this from happening to my children? And what can I do to prevent it from happening again?

He was a typical South Asian Indian living in America—a story we see often. His blood pressure and BMI were borderline, and he had low HDL, which is common for South Asians. According to American Heart Association guidelines, he was considered low risk and did not qualify for statins. Even his calcium score was zero. However, calcium scoring can miss a lot of soft plaques.

He was missed multiple times—his stress test was also unremarkable. So, what went wrong? The problem was relying only on conventional risk scoring systems, which can be flawed. The new approach is to look for the disease and treat it—a paradigm shift.

Many South Asians fall into a low-risk category and don’t get statins. Primary care physicians may not order a calcium score, following guidelines, but for South Asians, especially those with a family history or diabetes, further risk stratification is needed—starting with a calcium score, but also recognizing that calcium scoring is not enough.

Calcium scoring is a major development and helpful for intermediate-risk patients, but there’s still a detection gap. Over the years, risk scores have evolved, but the best way to detect coronary atherosclerosis—especially when it’s subclinical—is to see it and treat it. Just as we use mammograms for breast cancer and CT scans for lung cancer, why not use a heart CT scan as a first-line screening tool?

No matter what causes the disease—metabolic, genetic, or other factors—if there’s a plaque, that is the surest sign. So, the lesson is: see the disease, treat the disease.

You may have heard of different types of plaques: soft plaque and fibro-fatty plaque. The “tip-of-the-iceberg” model reminds us that calcium scoring only shows the visible part, but 80% of the disease is soft plaque below the surface, which can’t be seen by calcium scoring alone.

Studies show that two-thirds of people with acute coronary syndrome have non-obstructive, non-calcified plaque. Even a zero calcium score can miss soft plaque—so while calcium scoring is a good screening tool, it’s not enough for people with high risk features.

For those with a family history, diabetes, or already high risk, coronary CT angiography (CTA) may be the best approach. While large trials are pending, and it’s not a universal guideline, CTA can be justified for personal, precision therapy.

Coronary CTA combines risk factors and calcium score for the best predictive value. For some high-risk patients, even if they are asymptomatic, CTA could be the first test.

Over the last 50 years, we’ve learned that the real culprit in acute coronary syndrome is not just stenosis, but plaque rupture—especially thin-cap fibroatheroma. CTA adds value by showing not just the quantity of plaque, but also its morphology, biology, and inflammation.

CTA is a one-stop shop, identifying high-risk features and allowing for disease tracking and follow-up. For a personalized approach, CTA is preferable.

Other individual plaque-imaging techniques exist, but they are invasive, time-consuming, and not cost-effective for the general population. Non-invasive CTA is the best first choice for high-risk groups.

The focus now is on the “vulnerable patient”—those with inflammation and multiple plaques. The definition of high-risk plaque has expanded to include not just plaque rupture, but also plaque erosion and eruption of calcified nodules.

Coronary CTA can help identify high-risk features as well as invasive tests for practical purposes. So, calcium scores are good for stratifying and reclassifying patients, but for precision and personal care—especially with high risk or family history—CTA should be used and followed.

CTA advancements now allow us to assess physiology, biology, and inflammation, acting like a CCTV for your heart. You can track it and use it as motivation for lifestyle changes.

The paradigm is shifting: if you have a plaque, you already need secondary prevention—don’t wait for an event. There’s a “golden period” of 10–15 years where intervention can make the biggest difference before a rupture occurs.

Once you find high-risk plaque on CTA, what can you do? The first is lifestyle changes, but most importantly, high-potency statins to lower LDL cholesterol. The lower, the better. For example, my LDL is 32, and I take Lipitor 80mg.

Though you can’t remove plaque completely, you can stabilize or modify it, turning unstable plaque into stable plaque and reducing the risk of rupture. All trials show: the lower the LDL, the better.

If statins cause problems, other medications like PCSK9 inhibitors and ezetimibe may be used. All effective cholesterol-lowering therapies help with plaque regression and inflammation.

Lifestyle changes are critical, but the biggest impact comes from aggressively lowering LDL. In many clinics, not enough attention is paid to achieving sufficiently low LDL targets.

Statins alone reduce risk by about 40%, but there’s still 60% residual risk, so additional strategies are needed—such as anti-inflammatory diets (like plant-based or vegan diets), anti-platelet therapy, and newer medications such as GLP-1 and SGLT2 inhibitors.

Everyone should get an Lp(a) test at least once, especially in the South Asian population. Lower LDL, address Lp(a), and if statins are not tolerated, use alternatives.

Other therapies, such as highly purified EPA (as shown in the EVAPORATE trial), can also reduce inflammation and lead to plaque regression.

Ultimately, interventions like stents for vulnerable, unstable plaques are being studied, but are not yet standard care.

So, to prevent heart attacks: detect the plaque, especially soft plaque, and treat it—through lifestyle changes, medication, and, in some cases, intervention.

Thank you. If there are any questions, Dr. Narula, the world-renowned expert, is here, or I am happy to answer questions about coronary calcium scoring or CTA as a primary prevention modality.

Now, to address a question: The triggering of plaque is due to shear force and hemodynamic changes at thin-cap areas, combined with biological factors like macrophages, which rupture the plaque.

Another question was about statin use: Statins stabilize plaque, sometimes increasing calcium score, but each 1% reduction in plaque volume translates to a 20% reduction in adverse cardiac events, and each one mmol/L drop in cholesterol can lead to a 25% reduction in events. So, lowering LDL is the best investment for heart health.

A question about anti-inflammatory diets: The most potent is a plant-based diet—I'm vegan, and that’s a good starting point. Turmeric and other natural foods can also help reduce inflammation, benefiting both heart and brain health.

Thank you.

Dr. Kameshwari from the US is going to address the heart of preventive cardiology. Dr. Ashwin from Sweden will focus on LV strain imaging in various cardiac situations. And Renae Bronakoski, also from the USA, will speak on the role of artificial intelligence in echocardiography. First, I would like to invite Dr. Kameshwari to speak.

Namaste, everyone. It's a pleasure to be among so many esteemed colleagues. I truly appreciate this opportunity to speak with you all, and I see many familiar faces in the audience. My topic will be slightly different from the previous speakers; I will focus on POCUS (Point-of-Care Ultrasound) and discuss POCUS-guided care, as it can be used for prevention at every level of patient care.

I have no disclosures related to these slides. Here are a few learning objectives: What is POCUS? How do we use it for cardiovascular applications? And as part of that, what is lung ultrasound, and are there any exciting developments on the horizon?

Point-of-care ultrasound, or a POCUS exam, is performed at the patient's bedside. It can be used in acute clinical situations and provides rapid, qualitative assessment. This allows for quick triage and evaluation. The advantages are that it is extremely fast and delivers immediate results—the information is directly in your hands. POCUS is non-invasive and dynamic, allowing for serial monitoring. For example, with heart failure patients, you can reassess the IVC during treatment to monitor volume status.

However, one major disadvantage is that POCUS is highly user-dependent. Novice users may struggle to acquire adequate images, but this is likely to change as AI advances. AI is being developed to help novice users position the probe correctly and obtain high-quality images. Currently, POCUS does not provide complete quantitative assessment, but developments are in progress. At the recent American Society of Echo Scientific Sessions, new technology was showcased that may soon enable more quantitative assessments than previously possible.

For cardiologists, volume status can be well defined with POCUS. You can assess conditions such as cardiac tamponade, LV and RV failure (which are common in patients admitted with pulmonary embolism), and RV strain to determine the need for advanced therapies or possible interventions.

In our clinic, we encourage cardiology fellows to supplement traditional stethoscope exams with POCUS devices. These devices enable immediate assessment of LV and RV function, valve status, and more, enhancing both anatomical and physiological understanding during physical exams.

POCUS is also useful procedurally, allowing clinicians to answer basic clinical questions quickly, such as assessing volume status or the number of B-lines in lung ultrasound, and evaluating the IVC. In consultative cardiology, we still rely heavily on traditional echocardiography.

There are several POCUS probes available on the market. I have used GE, B Scan Air, Philips Lumify, and Butterfly, and found all of them to be excellent—easy to hold and scan with.

POCUS applications extend beyond cardiac imaging to lung, musculoskeletal, and urinary assessments, such as detecting kidney stones or evaluating bladder volumes, as well as musculoskeletal tears.

Let’s consider a case: A 73-year-old woman presented with a STEMI and underwent successful proximal to mid-LAD PCI with a DES. A few weeks later, a transthoracic echo showed normal LV size and function with no regional wall motion abnormalities. However, she returned to the emergency room with severe chest pain after an interruption in her care due to a COVID admission at an outside hospital. ECG showed no abnormalities, but bedside POCUS revealed an apical wall motion abnormality. The cardiac cath lab was activated, and due to high suspicion for in-stent thrombosis, mechanical thrombectomy and repeat stenting were performed—care was delivered within one hour of her arrival.

Some unique features of these probes include silicon chips instead of piezoelectric ones, making them more durable. Image quality is good, especially if you know how to optimize imaging. Harmonic imaging provides excellent endocardial border definition. With wireless and Bluetooth technology, you can connect the device to your phone, view images in real-time, store them in the cloud, and access them later. The initial and maintenance costs are low, although these devices may be more expensive or less available in some countries due to regulatory restrictions.

With cardiac POCUS, you can assess LV and RV size, stroke volume, cardiac output, pulmonary artery systolic pressure, pericardial fluid, pulmonary edema, and IVC collapsibility.

In lung ultrasound, different probe positions provide various views. For example, the “batwing sign” shows two rib shadows with lung tissue and A-lines, which are reverberation artifacts indicating correct probe placement. Lung sliding is visualized as movement of the pleura, resembling a line of moving ants—another positive sign. B-lines, which are hyperechoic vertical artifacts, indicate pulmonary edema. B-lines are more sensitive and specific than elevated pro-BNP or physical exam and outperform chest X-ray, which has a sensitivity of only 50–60%.

Another case: A 73-year-old woman presented with chest pain, shortness of breath, and leg edema. Her history included hypertension, hyperlipidemia, diabetes, and stroke. She was admitted for hypertensive emergency and found to have three-vessel coronary disease. While awaiting surgery, she developed acute heart failure with significant LVH and left atrial enlargement. Imaging revealed a type A aortic dissection extending into the descending aorta (type B). She underwent successful emergent surgery, including hemiarch reconstruction and CABG. Postoperative echo showed normal LV function, mildly reduced RV function, and no pericardial effusion. However, on days 6–9, she deteriorated, requiring reintubation and mediastinal washout. POCUS revealed RV and RA compression and a plethoric IVC, consistent with tamponade physiology. After washout, her recovery progressed, though she required long-term care.

The key point about POCUS is that it should be goal-directed. Basic views are easy to learn, usually requiring only a few training sessions. Understanding normal versus abnormal findings is crucial. Segmental scanning is acceptable; not every segment needs to be visualized in every view. POCUS is a valuable tool for patient care. We recently published a study in JAMA showing that POCUS use in hospitalized heart failure patients led to significant cost savings. It remains a cornerstone of bedside diagnostic assessment, offering excellent diagnostic and prognostic value. We should take responsibility for teaching future clinicians how to use it effectively. Thank you for allowing me to share these insights.

Echocardiography plays a key role not only in cardiac assessment but also in detecting significant lung pathology. Now, we move to the second talk by Dr. Ashwin, who will discuss LV imaging.

Thank you for inviting me to speak. I will give a brief talk on strain imaging, a relatively new application that contributes to preventive cardiology. I have no disclosures. I want to start by highlighting the global impact of heart failure: it affects over 64 million people worldwide, and one in five people will develop heart failure in their lifetime. It is the leading cause of hospitalization, and more than half of these patients are rehospitalized within six months, resulting in significant social and economic impact. Heart failure is often a silent disorder, beginning with risk factors like hypertension and diabetes and progressing gradually to more severe symptoms such as shortness of breath and fatigue.

When reviewing a heart failure patient’s report, you'll usually see the ejection fraction (EF), a volumetric measure of cardiac pump performance. EF is the cornerstone of heart failure imaging—simple to perform and widely used—but it has significant limitations. It is a late marker of dysfunction and has limited value in detecting subclinical disease. In preventive cardiology, early detection leads to early treatment. Imagine detecting heart failure before EF drops—strain imaging is like spotting cracks in the ice before it breaks, potentially saving many lives.

To illustrate, consider a patient undergoing cardiac evaluation before cancer therapy. The initial EF and strain are normal. Six months into therapy, EF remains normal, but strain (global longitudinal strain, GLS) drops significantly, indicating early cardiotoxicity—well before EF changes, which may not appear until 12 months later. Thus, changes in strain precede those in EF.

Strain measures deformation: if a 10-millimeter spring is stretched to 12 millimeters, that’s 20% strain. In the heart, muscle fibers deform in various ways: longitudinal shortening, radial thickening, and circumferential twisting. Clinically, we typically measure longitudinal strain, as it’s the most robust. The subendocardial longitudinal fibers, closest to the blood pool, are most sensitive to early damage—GLS captures this.

Strain imaging uses echocardiography (usually speckle tracking) or MRI. Speckle tracking is akin to facial recognition software—it tracks specific patterns (speckles) over time. Strain imaging has multiple clinical applications. For example, in cardiac oncology, it detects early myocardial damage. In patients with LV hypertrophy, strain can help distinguish among different etiologies. GLS also provides prognostic information in heart failure, regardless of EF, and is valuable in patients with preserved EF.

In ischemic heart disease, strain can detect regional dysfunction even when symptoms or EKG findings are atypical, and echocardiography is inconclusive. For instance, strain may reveal regional wall motion abnormalities suggestive of significant coronary artery disease, later confirmed on angiography.

In valvular heart disease, especially aortic stenosis, strain can provide diagnostic and prognostic information—even in asymptomatic patients. Strain is not limited to the left ventricle; left atrial strain is a sensitive marker of early diastolic dysfunction and has been incorporated into recent diastolic guidelines.

In summary, GLS is a sensitive marker that detects subclinical dysfunction, enables timely diagnosis, risk stratification, and outcome prediction across diverse cardiac conditions. Early detection with strain imaging can translate into earlier intervention and better outcomes in preventive cardiology. Thank you. Now, I’ll hand over to Renae Bronakoski, who will discuss the future of echocardiography with AI-powered techniques.

Thank you, Dr. Ashwin. Due to time constraints, we will proceed to our next speaker, Dr. Renae Bronakoski, who will discuss AI-powered echocardiography.

Hello, I’m at the University of Rochester in New York, and I’m here to talk about artificial intelligence in echocardiography. What is AI? We often talk about it, but essentially, AI is a computer program that can perform human tasks and mimic our thought processes. In echocardiography, common AI uses include strain analysis (speckle tracking), automatic LVEF calculations, 3D and 4D imaging, and automated 2D measurements.

Current limitations of AI include limited knowledge and experience, lack of proper equipment (software and hardware), variability among manufacturers and users, and sometimes poor image quality or acoustic windows in certain patient populations.

How can AI benefit sonographers and providers? In critical care, there is limited time to diagnose patients. Using POCUS ultrasound with AI can help quickly identify immediate dangers, reduce human error, and produce consistent automated images. At the medical camp yesterday, I used a Vscan probe with AI capability, which can connect to a phone or tablet via Bluetooth and has both cardiac and vascular probes. The AI component tells you if you’ve captured a good image and will automatically record it, guiding users to optimize image acquisition. This is especially helpful for new sonographers, providers, or fellows who are still developing their scanning skills.

That concludes my presentation. Thank you.

Are there any questions or comments from the audience?

All three presentations were excellent and clear. I have two questions. Regarding LA and LV strain, you mentioned diagnostic and prognostic implications. Are there any therapeutic implications? For example, does LA strain improve with medication or intervention?

To answer your question, left ventricular strain has strong therapeutic implications, especially in cardio-oncology, where it helps detect cardiotoxicity before EF declines. In patients treated with beta-blockers, ACE inhibitors, or ARBs, improvement in GLS can be observed, particularly in those treated with HER2 inhibitors. Improvement is also seen in both HFrEF and HFpEF patients on guideline-directed medical therapy—both LV GLS and LA reservoir strain can improve. A decrease in LA reservoir strain below -18% is concerning and is something we monitor closely.

Another question: When electrophysiologists perform radiofrequency ablation for atrial fibrillation, but the arrhythmia is persistent or refractory, is there a relationship with reduced LA strain?

In atrial fibrillation, LA strain is indeed reduced, whether paroxysmal or persistent. However, after radiofrequency or pulsed field ablation, it is unclear whether electrical normalization is accompanied by true mechanical recovery. This remains an area for further study, but we do know that LA strain is generally abnormal in AFib, though the therapeutic implications post-ablation are not fully established.

If there are no further questions, we will conclude this session on echocardiography. Please join me in giving a big round of applause to all three speakers. Thank you very much.

My most humble and loving pranams at the Lotus feet of our beloved Mother Sai. Sairam to all. Thank you very much for this opportunity to talk a little bit about how imaging helps in the early recognition and management of congenital heart disease.

Throughout the day, we've heard a lot about coronary artery disease, even in patients as old as 100. Now, let's shift focus and discuss heart disease in babies and how individuals born with congenital heart disease grow and struggle throughout their lives.

In fact, congenital heart disease is the most common defect that a baby can be born with, with a prevalence ranging from 7 to 9 cases per 1,000 live births. A few decades ago, only 15% of babies born with moderate or severe congenital heart disease survived to adulthood. However, in the 1950s, the advent of cardiopulmonary bypass enabled us to perform extensive intracardiac repairs. Advances in pediatric cardiology and interventional cardiology have since led to over 90% of these babies surviving to adulthood.

Survival has improved so much that, since about 2012, there are more adults worldwide living with congenital heart disease than children. When we talk about the prevention of heart disease, we often look for the cause. The causes of congenital heart disease are complex and not very well understood. While we presume a genetic link, only a few genes have been shown to be associated with specific diseases. It's likely a combination of genetic and environmental factors. There are a few autosomal dominant diseases with a 50% transmission rate, where genetic counseling and prevention play a role. For the most part, however, it is hard to prevent congenital heart disease, so our focus is on preventing and mitigating its complications.

With more babies living to adulthood, many struggle with complications of congenital heart disease. They may have residual hemodynamic lesions, pulmonary hypertension, arrhythmias, infections, heart failure, and premature death, among other issues. One of the cornerstones in managing these complications is imaging.

How does imaging help in the management of congenital heart disease, and what are its goals? Imaging allows us to detect cardiac malformations early—sometimes even before a baby is born, while still in the womb, and as late as at autopsy. At any point in a person's life, congenital heart disease can be detected, but imaging aims for early detection. It helps assess both cardiac anatomy and physiology, guides surgical, catheter-based, and medical decisions, and supports long-term monitoring of these patients.

The key imaging modalities include echocardiography, cross-sectional imaging such as MRI and CT, and other techniques. We'll focus on the first two, which are essential for imaging congenital heart disease.

Echocardiography has several benefits. As demonstrated yesterday at the medical camp, it can be performed with a device as small as a phone, making it portable and widely available. There is worldwide expertise, and it provides excellent temporal resolution, allowing visualization of heart structures as they move. Echocardiography uses no radiation and has excellent spatial resolution, which helps visualize small structures. It enables the imaging of shunts, assessment of physiology (such as pressure gradients), and evaluation of valvular pathology. However, echocardiography is limited by difficult imaging windows and Doppler angle limitations.

MRI offers the advantage of providing extensive information non-invasively—data that previously required invasive catheterization. For instance, MRI can evaluate multilevel valvular obstruction and provide comprehensive flow data. It has no radiation exposure and is so accurate that it has become the reference standard for assessing ventricular volumes, mass, and function. MRI can also characterize tissue, such as identifying cardiac edema and scar formation, which previously required pathological examination. MRI assists with surgical planning through 3D imaging. However, MRI requires a large machine, is time-consuming, often necessitates breath-holding, and is affected by metallic artifacts.

CT scans are rapid and provide excellent spatial resolution, similar to echocardiography, allowing visualization of small structures, such as coronary arteries. CT also offers additional information on lung parenchyma and is less affected by metallic artifacts, such as mechanical valves. It produces 3D images and provides some data on volumes and function, though not as accurately as MRI. The disadvantages, especially for young patients who need sequential imaging, include exposure to radiation and the requirement for iodinated contrast agents.

Focusing on very early detection, fetal echocardiography is an example of a regular screening ultrasound of a baby. It's remarkable how much information can be gleaned about the tiny fetal heart during a dedicated fetal echo, typically performed at about 18 to 22 weeks of gestation. We usually perform this in patients at high risk for having babies with congenital heart disease, such as those with a family history or maternal exposure to teratogens. This provides extensive information on structural abnormalities and aids in delivery planning and early neonatal management.

Why is early recognition of congenital heart disease important? Early recognition helps prevent severe complications, improves survival and quality of life, enables appropriate timing for surgery or intervention, and prevents delayed presentation with heart failure, advanced pulmonary hypertension, and other issues.

Let's better understand this with a few examples. Consider a simple congenital heart disease: secundum ASD, a hole between the two atria. Many of these are small and, if left alone, do not cause significant problems. However, a patient who presented at age 72 with a secundum ASD showed a severely dilated right ventricle and severe tricuspid regurgitation, resulting in right heart failure. Early detection and repair could have prevented these complications, but at this stage, closure is difficult due to enlarged left atrium and high left-sided pressures.

Another example is patent ductus arteriosus, which is easily detected by echocardiography early in life. If a sizable patent ductus arteriosus is left untreated, it can lead to Eisenmenger syndrome and significant complications, such as secondary erythrocytosis, brain abscesses, and pulmonary hemorrhage. These complications can be prevented with early detection and closure of the PDA, either percutaneously or surgically during infancy.

For moderate complexity congenital heart disease, consider Tetralogy of Fallot. This condition involves deviation of the conoventricular septum toward the pulmonary side, leading to four defects: VSD, overriding aorta, pulmonary stenosis, and resulting right ventricular hypertrophy. Repair typically involves removing tissue in the RVOT or pulmonary valve and closing the VSD, often leaving the patient with severe pulmonary regurgitation. Imaging, such as MRI, helps assess regurgitation fraction and ventricular volumes over time, guiding the timing for pulmonary valve replacement. Replacing the valve too early may require multiple replacements over a lifetime, while delaying replacement can lead to irreversible right heart failure. Imaging also helps determine whether percutaneous or surgical valve replacement is appropriate.

In severe complexity cases, such as transposition of the great arteries (where the pulmonary artery arises from the left ventricle and the aorta from the right ventricle), surgical techniques have evolved. Previously, repair involved a complex atrial switch procedure, but now the arterial switch operation is performed, including coronary reimplantation. For example, a patient in her early 20s presented with a circumferential perfusion defect and scar visible on MRI. Further imaging revealed osteal stenosis due to coronary reimplantation, which was successfully treated with surgery. This demonstrates how imaging guides management decisions.

While imaging is central to the early recognition and management of congenital heart disease, we must acknowledge limited access to advanced imaging in some regions. There is a significant need for specialized pediatric and congenital cardiac imaging training, which is challenging to obtain. Looking to the future, advances in artificial intelligence are being applied to cross-sectional imaging, and 3D modeling now allows for the creation of physical heart models for surgical planning. Additionally, prenatal detection and interventions, even before birth, are being developed for congenital heart disease.

In conclusion, imaging is essential for the early recognition and management of congenital heart disease. Echocardiography is the first-line modality, while MRI and CT are crucial for complex cases and for guiding management. Early diagnosis improves outcomes and reduces complications, and ongoing advancements continue to enhance care for these patients.

Thank you, and Sairam. I am happy to take any questions—there's not much time, but I'll do my best.

OK, ladies and gentlemen, sorry for the delay. I have no conflicts of interest to declare.

The objectives of my presentation are to describe the available transcatheter techniques for preventing structural and functional damage to the heart. The focus will be on balloon angioplasty and transcatheter occlusion of various defects, including atrial septal defects and patent ductus arteriosus. Historical aspects and other cardiac defects are not included due to time limitations.

This is an example of a balloon across the pulmonary valve during the initial phase of inflation. With subsequent inflation, you can see the “waisting” of the balloon disappear completely. Here is an example of a patient with pulmonary stenosis prior to balloon dilatation; you can see a small area of contrast flowing across the stenotic pulmonary valve, which becomes widely open following the balloon dilatation.

In this slide, I show the pulmonary valve gradient drop following balloon valvuloplasty. The right atrial pressure increases slightly, while the right ventricular pressure decreases significantly (P < 0.001). This is an example of a Doppler study with the old Doppler: the gradient measured by Doppler was 92 mmHg, and immediately after balloon valvuloplasty, it dropped to 17 mmHg and remained stable at follow-up.

This is an example of an atrial septal defect with a right-to-left shunt prior to balloon dilatation. Following balloon dilatation, the shunt reverses, indicating improved right ventricular compliance. Some patients develop what is called infundibular constriction. This is an angiogram of a patient in whom I performed balloon dilatation; fortunately, in most children, this infundibular constriction improves. If the gradient exceeds 50 mmHg, I start them on beta blocker therapy. Very few of these patients require surgical intervention. This is an example of flow velocity across the right ventricular outflow tract before and immediately after balloon dilatation, where infundibular constriction developed. You can see the triangular pattern, which disappears at follow-up.

This slide shows the results of balloon valvuloplasty at follow-up; the pressure gradient remains similar to the immediate post-valvuloplasty measurement. All slides include references for the source material. For example, this one was from 1998. Every slide is marked with the date, location, and method. This shows the size of the heart before, immediately after, and at follow-up. You can also see the reduction in tricuspid regurgitation at follow-up in those patients who had it initially.

Late follow-up results are also very good, with gradients even lower than those measured immediately after and at the intermediate stage post-valvuloplasty. Event-free rates following the procedure are very high.

Next is aortic balloon valvuloplasty. Here is a catheter in a newborn, with the balloon catheter positioned across the aortic valve. You can see the waisting as the balloon is inflated, which disappears with full inflation. These are the pressures in the left ventricle and aorta; you can see the gradient before and after balloon dilatation. After the procedure, the left ventricular and aortic pressures are very similar.

In a group of patients, the peak gradient fell significantly, and this is reflected in the percentage reduction of the gradient across the aortic valve. At follow-up, there is a slight increase in the gradient across the aortic valve at intermediate term, compared to that seen with primary valvuloplasty. The development of aortic insufficiency is notable due to its long-term adverse effects. Although there was no immediate increase in aortic insufficiency post-procedure, about one-third to one-fourth of patients developed aortic insufficiency at follow-up.

This slide shows the position of the catheter across a coarctation before and after full inflation of the balloon, and the results of balloon angioplasty for aortic coarctation. You can see the fall in the gradient. The procedure is equally effective in neonates, infants, and children, as shown in this slide. Here are some angiographic examples: in an infant, some irregularity is present, but the aorta becomes more uniform in size after balloon angioplasty. In a child and an adolescent, you can see severe coarctation that is completely opened up following balloon dilatation.

Pressure gradients across the coarctation are measured before, immediately after, and at follow-up; you can see that relief of the obstruction persists. Here are examples of severe coarctation immediately after and at follow-up, in both infants and older children. This graph shows the fall in the gradient, but unfortunately, in infants, recurrence is quite high. Aortic remodeling also takes place, as seen in this series of images, with the aorta becoming more uniform.

We have also performed balloon dilatation in postsurgical aortic recoarctation. You can see the fall in the gradient and improvement in the diameter of the coarcted segment. I will show a couple of examples: before, immediately after, and at follow-up. In a group of patients, the mean coarctation gradient drops from approximately 50 mmHg to the low teens, and at long-term follow-up, it remains low.

We will now discuss closure of septal defects and patent ductus arteriosus (PDA). Several devices have been used over time; we initially used the button device. Here, you can see the device and the defect, and in another child, after device placement, there is no more shunt.

More recently, we have been using transesophageal echocardiography to define the size of the defect and septal rims, and then place the device across the atrial septum. In this video, after disconnecting the wire, the device assumes a more natural position. This is a different device where we used intracardiac echo; you can see the left atrial and right atrial discs after the device is disconnected from the wire. The position of the Amplatzer device in a child shows the septal rims within the device components, indicating good stability.

For PDA, several devices are available, most commonly coils, vascular plugs, and the Amplatzer ductal occluder. Here is a PDA echocardiogram showing the Doppler flow, and after closure, you can see there is no PDA. This is an example of a coil placed across the PDA, and an angiogram showing no residual shunt. Here are a couple more examples: PDA before and after coil placement. In another case, an Amplatzer device was placed in a large PDA, resulting in no residual shunt. Here is another, smaller PDA, again successfully closed with a device. In another child, we placed an Amplatzer vascular plug, with no residual shunt.

We will now briefly discuss stents. There are two types: balloon-expandable stents, which are expanded by inflating a balloon, and self-expandable stents. In children, we mostly use balloon-expandable stents. Here is an example of a patient with severe left pulmonary artery stenosis; after stent placement, the LPA is widely open. There are also examples of branch pulmonary artery stenosis treated with stents, showing good results.

This is another example of LPA stenosis before and after stent inflation. In a group of patients, the pressure gradients for the entire group of stenotic vessels decrease significantly. We can assess effectiveness with perfusion scans; before, the mean was about 22% of flow to the ipsilateral lung, which increases to over 40%—closer to the normal of 48–50%.

We also use stents to open up the atrial tract. Here is a child with conduit stenosis; after stent placement, the conduit is wide open. This is another example of severe stenosis treated with a stent. This technology is also used in the Fontan pathway to avoid surgery at that time. Coarctation can also be treated with stents. Here is a very narrow coarcted segment; after stent placement, it is widely open. Another example shows coarctation treated with a stent.

Other stenotic lesions can also be treated. This is a patient who developed superior vena cava stenosis, which was treated with a stent, resulting in a wide-open vessel.

The advantages of transcatheter therapy are a shorter hospital stay—one to two days instead of five to seven days for cardiac surgery. Most procedures are performed under general anesthesia, just like surgery, but no intensive care is necessary and there is no surgical scar. There is less psychological trauma and, of course, it is less expensive.

In conclusion, balloon dilatation is still the standard of care for many reasons, with well-established good outcomes. Transcatheter closure of atrial septal defects and patent ductus arteriosus is feasible, safe, and effective. Stent therapy is useful for opening obstructed vascular lesions and maintaining patency of natural and surgically created shunts. Embolization of unwanted blood vessels is also successful, and rehabilitation of pulmonary arteries is feasible. I did not discuss some other catheter interventions, such as septostomy, percutaneous valve repair, implantation of prosthetic valves, radiofrequency ablation, and hybrid procedures due to lack of time.

If you have any questions, I have given my professional and personal email addresses here. I will leave them for a few seconds so that people can copy them if they wish.

Thank you very much for your attention.

It is a great honor to speak at the Sri Sathya Sai Global Cardiovascular Conference today. I will present the progress and challenges of robotic cardiac surgery in Japan, particularly within our publicly funded health care system.

Japan provides universal health coverage to all residents. Everyone must enroll in either employment-based insurance or residence-based national health insurance. This system covers a wide range of services, including doctor visits, hospital stays, prescription drugs, mental health care, dental and eye care, and preventive services. Importantly, patients have free access to any clinic or hospital without additional charges. This ensures equality and accessibility, but also creates unique challenges when introducing advanced technologies like robotic surgery.

There are two main types of insurance: employment-based insurance for company employees and their families, and national health insurance for self-employed individuals, students, and retirees. The standard co-payment is 30%, with reduced rates for children and low-income seniors. There are also monthly out-of-pocket caps based on income and age. For seniors aged 75 and above, a special insurance system is funded by multiple sources. Despite this comprehensive coverage, Japan’s per capita health expenditure remains moderate compared to other OECD countries.

Japan faces a rapidly aging population. With aging comes an increased incidence of cardiovascular disease, including arteriosclerosis, hypertension, and ischemic heart disease. This demographic shift increases the demand for minimally invasive and high-quality surgical options, such as robotic cardiac surgery.

There are several surgical robots available in Japan: Da Vinci, Hugo, Sarua, and Hinotori. Sarua and Hinotori are made in Japan. Robotic surgery in Japan has grown significantly. We now have over 750 Da Vinci systems and 880 Hinotori systems. In 2023, there were 900 robotic cardiac cases, and in 2024, health insurance began covering AVR and MVR procedures. This marks a major milestone as robotic cardiac surgery becomes more accessible under public insurance.

Robotic mitral valve repair is increasing worldwide, and in Japan as well. According to the SDS database, robotic approaches show lower operative mortality, shorter hospital stays, reduced major morbidities, and a lower conversion rate to valve replacement. These outcomes are not only due to reduced invasiveness, but also reflect higher surgical precision and quality.

This video shows how to repair the mitral valve. Visualization is perfect. We can measure the lengths of the chords precisely and then anchor the loops to the papillary muscle. The tips of the loops are fixed to the leaflets of the mitral valve. Finally, we place the prosthetic band around the mitral annulus. Tying a knot is challenging in robotic or minimally invasive surgery, but if you use a core knot, it becomes easier. Finally, we check the competence of the mitral valve and complete the operation.

In another operation video on P2 prolapse, after cross-clamping, we open the left atrium and check the mitral valve. We found the P2 prolapse. First, we measure the length of the segment with a sizer and decide the size of the prosthetic band. Then, we cut out the P2 prolapsed part and suture it together using fibrochlorine. The water test then shows the competence of the mitral valve. Finally, we place the prosthetic band around the mitral annulus and finish the operation.

Experience is important for mitral valve repair. We know that mitral valve repair is superior to mitral valve replacement in terms of short- and long-term outcomes. However, outcomes are significantly influenced by the number of cases handled by the facility. Figures on the left side show how experts move the tips of instruments: the left hand is green and the right hand is red. The movements are minimal. On the other hand, novices’ instrument tips move more widely, as shown on the right. These results imply that experience is important for safety and quality of surgery.

Recent data from Chen highlight the importance of minimizing residual mitral regurgitation after mitral valve repair. Even mild residual mitral regurgitation is associated with decreased survival, higher recurrence rates, and increased reintervention rates. Achieving a near 100% repair rate without mitral regurgitation is possible, but again, it requires experience and intraoperative precision.

Japan and the United States are not alone in this field. Robotic systems like SS Innovations’ Mantra 3, developed in India, are entering the global market. These systems aim to be technologically advanced, affordable, and accessible, challenging established players like Intuitive Surgical, which makes the Da Vinci systems. This global competition is expected to drive innovation and improve robotic platforms, ultimately benefiting cardiac surgery worldwide.

To summarize, robotic mitral valve repair is becoming common. Although it requires significant experience, it offers superior outcomes. We anticipate that ongoing competition in robotic technology development will lead to even better systems, further advancing cardiac surgery.

Thank you very much for your attention. Good night.

We gather today to celebrate the heart as a vital organ and to reaffirm our collective commitment to nurturing healthy hearts across the globe. This day reminds us that prevention, awareness, and compassion are the true lifelines of cardiovascular health.

Before we begin the proceedings, I would like to take a moment to acknowledge the phenomenal efforts of the students from Bhagwan Sri Satya Sai Institute of Higher Learning—Anandpur campus, Brindavan and Prasanthi Nilayam campuses—as well as Sri Satya Sai Higher Secondary School, Sri Satya Sai Primary School, and the nursing and allied health students of Sri Sai Institute of Higher Medical Sciences.

Over 650 students participated in the preventive health exhibition, contributing 150 digital posters, 100 handmade posters, 75 3D working models, and 75 interactive sessions, games, and activities. These exhibits were not only informative and insightful, but also reflected a deep understanding of preventive cardiology and a strong commitment to public education, coming from school children all the way up to Ph.D. students.

I urge all delegates and guests to visit the exhibition during the day to appreciate the value of the exhibits these children have displayed. Additionally, this morning we witnessed over 2,000 students forming breathtaking World Heart Day formations on the grounds.

It is now my privilege to introduce Sri Nimish Pandya Ji, All India President of the Sri Satya Sai Organizations India and Vice Chairman of the Sri Satya Sai Global Council, to deliver the welcome address for the second day of the conference.

Om Sri Sairam.

Offering my most humble salutations at the divine lotus feet of the Eternal Master, whom we call Bhagwan Sri Satya Sai Baba, I offer a collective prayer at his divine lotus feet, for nothing auspicious can begin without his blessings—as we all understand here in the divine precincts of Prasanthi Nilayam.

Dear brothers and sisters, welcome to the start of a great event in the history of mankind. I do not wish to sound overly dramatic, but I truly believe—and intend to prove—that this is a unique event in human history.

Perhaps I feel the need to prove my point because I have practiced law for the last five and a half decades in India. In Hindi, we say, "Begani shadi mein Abdullah deewana," so among all the cardiologists here, I wonder what a lawyer is doing. But I believe that mankind stands on the threshold of a new phenomenon—an attempt to understand what Sri Sathya Sai Baba truly was.

When the World Heart Foundation decided to celebrate its day here in Prasanthi Nilayam, I felt strongly that it was not a coincidence, but divine will. Blessed is Dr. Narula, who is part of this divine will and present amidst this great gathering.

When I met Dr. Narula yesterday, I realized that although he is a very eminent cardiologist, he has a truly lovely heart. Baba always used to say that spiritually inclined people are those who smile and are always happy. Those who are stoic, unable to smile, or unhappy in their personal lives often struggle with their own inner challenges.

Here in Prasanthi Nilayam, we are very happy to welcome you all because, in a sense, we are a unique kind of heart hospital—a divine heart hospital created by Bhagwan, who came to transform our hearts into loving hearts filled with compassion and love, so that mankind may change.

This is indeed a unique occasion, as we move beyond the physical aspects of the human heart to embrace the concept of the loving, spiritual heart. As a common man, I know that physical ailments of the heart often begin with problems of the mind—the inability to control desires, to be compassionate, to forgive. These are qualities humanity has lost, and Bhagwan came to guide and correct us. I am sure you all agree.

We believe that Bhagwan was the greatest cardiologist to help all other cardiologists, seeking to address the root causes of heart trouble. I recall as a young man bringing a delegation of doctors from Mumbai decades ago, giving Baba reports of surgeries and patient numbers. Baba responded, "That is not a good report. A good report is when there are no patients." This was eye-opening for me.

Thus, when we began service under the banner of the Sri Sathya Sai Seva Organizations worldwide, amazing things happened. Even when Swami started the heart hospital, he reminded us that love and a smile to the patient are the real cures, beyond medicine and surgery. Dr. Das, sitting here, is a recipient of that wisdom—that it is the smile, the love, and the vibration of love that matter most, especially in the medical profession.

Bhagwan always said there is good work and God's work. Good work is performance; God's work is transformation. This is especially relevant in preventive health.

The time has come, with the help of all you experts and knowledgeable people, to teach people how not to fall sick and to keep their hearts healthy. One of my seniors, the first World Council chairman of Baba's Institute, once had a conversation with Bhagwan about the definition of peace. Bhagwan related it to human physiology: a rhythmic breath, a steady heartbeat, and a rhythmic pulse are the true definitions of peace. If you master the art of keeping your breath, prayer, and pulse in rhythm, you will always be balanced and joyful. Unfortunately, we often fail to do this.

Swami taught us that the key to combating negative qualities is mastering the mind. Even the greatest academic achievers may struggle to control their own minds. The spiritual journey is not about religion; it is about teaching men and women to master their minds, which is integral to preventive health. Swami sent a message of "ceiling on desires," of selfless service—service where doership is not the goal.

Remarkably, Bhagwan started the first heart hospital completely free of charge, beginning a medical movement of free healthcare. I share with humility that the Sri Sathya Sai Seva Organization has built a massive last-mile healthcare network throughout India, supported not by corporate social responsibility or external funding, but by countless medical professionals who spend their own money to conduct weekly medical camps across the country. This spirit of unconditional love and service exists worldwide, wherever someone's heart has been touched by transformation.

All the research and analysis done by universities seeks to reach the last mile—the answer is simple: we need men and women who can love unconditionally and recognize that we are all one. The same energy that animates me animates Dr. Narula and all of us; it is the unifying factor. Regardless of religion or nationality, the process of heart repair is the same, as is the process of birth and the pursuit of happiness.

We must take a holistic approach, as urged by Bhagwan Sri Sathya Sai Baba. Things cannot work in isolation. We should dream of a conference where all doctors, regardless of specialty, come together to focus on the happiness and well-being of humanity as a whole—this is Bhagwan's vision.

I must share with Dr. Narula that while our university and school students did remarkable work here today, yesterday across India, Sathya Sai Seva children, Balvikas children, and school children took your toolkit and carried banners throughout the country, transforming the situation.

Before I conclude and hand over to Dr. Narula, whom we all eagerly wish to hear, I request my colleagues to present a glimpse of what children all over India did in honor of Dr. Narula's presence in Prasanthi Nilayam on World Heart Foundation Day. May I please have the video clip?

Dr. Narula, this is just a glimpse. My office will share the full data with you for your records and for posterity, and I request you to accept it before you leave.

I would also like to welcome Dr. Prabhakaran, who will be the next in charge. I offer him the opportunity to host the next mega Universal Conference of Medicine for the Amelioration of Mankind here in Prasanthi Nilayam—whenever you are ready, we are ready.

Jai Sairam.

Thank you, Sir, for offering us a satellite view of the inspiring activities led by the Sri Satya Sai Organization across India. After watching the videos and experiencing the preventive heart exhibitions, I am truly convinced that our future is in safe hands.

As part of the 100 years of the Sri Satya Sai Avatar, we have witnessed an impressive display of exhibits, a heart walk, and unique formations. As you mentioned, during the formations, “na bhuto na bhavishyat”—there will be no parallel for the next 25 or even 100 years. Whether it’s your seminal work on rheumatic heart disease or your global advocacy, your name is etched in the hearts of cardiologists around the world. We eagerly look forward to your talk on the global cardiovascular burden.

It’s a hard act to follow, Nimishji, but I am truly grateful to you all. I believe it was a fortunate day—after 34 or 35 years—when Dr. D.K.M. Rao called me, and we decided to do something together. I just suggested “World Heart Day.” I don’t know how that idea came, but as you rightly said, it was all preordained, the way it was decided. Within a week, we finalized everything. Dr. Mohanji immediately got involved, as did Dr. Geeta Ji, and the way everything happened within a week was remarkable. We had the Board meeting at the World Heart Federation, and I was able to present the proposal. Mohanji called me, then we had a Zoom meeting, and within a week, it was all set. I am thrilled with how it all came together—I never dreamed it would turn out this way, and I couldn’t have wished for anything better.

As I mentioned this morning during the drone formations, when they created the World Heart Federation insignia and depicted World Heart Day in such creative ways, it was unimaginable. In 25 years of World Heart Day, such a spectacle has never happened, and I don’t think it will ever be matched unless we come back here.

Thank you very much for what we have seen. As you said, everything was so well designed—and now, Ratnagar Garu has joined us. Good morning, Sir.

I first met Dr. Mohan last year at Dr. H.K. Chopra’s conference in Delhi. Before that, I hadn’t met him. It’s clear to me that everything we are seeing culminate today is by design, and I hope this marks the start of a wonderful era for all of us. As Nimishji has already invited Prabhakar, the next President of the World Heart Federation, perhaps we will host the best World Congress of Cardiology here in Puttaparthi.

My talk on the global burden of disease and prevention of coronary disease—which I’ve always said should start in childhood—will be delivered this evening. We saw this approach reflected in the World Heart Day celebrations across all Sathya Sai Seva Organization centers in the country. I always say that prevention should start even earlier, and I will cover this in my public lecture tonight. It will be my first time presenting without slides, but I will do my best, hopefully drawing some inspiration from Nimishji, who does it so well.

On behalf of the World Heart Federation this morning, I’ll just share a few words in five minutes, then invite Boriana Parwana, our CEO, to speak about the history of World Heart Day—how it started and how it has evolved. We will leave tomorrow with memories indelibly etched in our minds, something truly unforgettable—unless, as I said, we return here.

Today, on September 29, 2025, the world is uniting for the 25th anniversary of World Heart Day—the largest global health awareness platform, reaching over 2 billion people each year. This is an especially auspicious occasion as the entire world celebrates the centenary birth anniversary of Bhagwan Sri Satya Sai Baba.

Conceived by the World Heart Federation in 2000, World Heart Day has grown from a bold idea into a movement spanning continents, languages, and cultures. It is a day when science, policy, and community action converge around a single urgent cause: reducing the devastating toll of cardiovascular disease, the world’s number one killer. Only then can we hope to live fulfilling lives and ensure sustainable livelihoods for future generations with healthy hearts.

This year, World Heart Day has uniquely evolved to include science, service, and spirituality. Taking place just two days after the United Nations High-Level Meeting on Noncommunicable Diseases in New York, it offers a powerful platform for the global cardiovascular community to speak with one voice. The message is simple but challenging to implement: cardiovascular diseases claim more than 20 million lives every year, most in low- and middle-income countries. At least 80% of these deaths could be prevented through early detection, lifestyle changes, and equitable access to care.

At the World Heart Federation, we believe that with the right partnerships and financial commitment by governments, we can turn global reach into global action. Since its inception, World Heart Day has become a unique engine for change, mobilizing governments, health systems, civil society, and individuals alike. Our campaigns have shifted the conversation from awareness to advocacy and action. Last year, World Heart Day launched its first global petition calling for National Cardiovascular Health Action Plans—a vital policy tool to prevent premature deaths and reduce the economic and social burden of heart disease.

In 2024, the petition gathered more than 40,000 signatures from over 100 countries, and our digital and on-the-ground campaigns reached over 2 billion people. This convergence of advocacy and public campaigning underscores World Heart Day’s potential, not just as a communication milestone, but as a policy lever to influence decision-makers, especially since the United Nations High-Level Meeting did not deliver the outcomes most of the world had hoped for. We look forward to Baba’s blessings to achieve what is best for the underprivileged masses.

The 2025 campaign theme, “Don’t Miss a Beat,” urges individuals and leaders alike not to lose momentum. In honor of the 25th anniversary, it calls on everyone to dedicate at least 25 minutes a day for 25 days to healthy actions—physical activity, nutritious eating, mindfulness, and regular health checks. This complements Baba’s visionary prescription for health: “No hurry, no worry, no curry.” More than a slogan, it is a recipe for cardiovascular health and a reminder that every minute invested in heart health counts.

While World Heart Day is a truly global movement, India—and especially Prasanthi Nilayam—takes center stage for the 2025 celebrations. From September 27, the spiritual town of Puttaparthi is hosting the World Heart Day global celebration and the Sri Satya Sai Global Cardiovascular Conference, coinciding with the 100th birth anniversary of Sri Satya Sai Baba. This partnership highlights a powerful model of compassion in healthcare—one that delivers world-class cardiovascular care, free of cost, irrespective of gender, caste, creed, or economic status.

India’s role in World Heart Day 2025 is both symbolic and strategic. The country is home to more than 1.4 billion people and bears a staggering share of the global cardiovascular disease burden. In 2019, India accounted for over one-fifth of global cardiovascular deaths, with an estimated 272 deaths per 100,000 population—many in people under 70 years of age. Hypertension alone affects over 220 million Indians, yet awareness, treatment, and control rates remain unacceptably low.

The World Heart Day celebrations in India are a rallying point for policy advocacy, clinical leadership, and community participation over three days, featuring free health screenings, educational workshops, community walks, and a scientific symposium on cardiovascular disease prevention. Leading Indian institutions—including the Cardiology Society of India, Heart Health India Foundation, and Modern India Heart Foundation—are supporting the Sri Satya Sai Seva Organization to ensure that the World Heart Day message resonates from rural villages to urban centers.

Globally, cardiovascular disease is responsible for over 30% of all deaths and is the leading cause of premature mortality, especially in low- and middle-income countries. The probability of dying prematurely from noncommunicable diseases like cardiovascular disease can be as low as 15% in high-income countries, yet it exceeds 50% in parts of sub-Saharan Africa and remains high in South Asia. These disparities are avoidable and demand action.

I was fortunate to speak at the United Nations High-Level Meeting in New York two days ago on behalf of the World Heart Federation and our 240 member partners, where we strongly advocated for the global NCD agenda. The World Heart Federation called for governments to adopt and implement national cardiovascular health action plans, achieve 50% global hypertension control by 2050, apply at least 50% excise taxes on tobacco, alcohol, and sugary drinks, implement WHO air quality standards to reduce cardiovascular disease from air pollution, and commit to a 50% reduction in noncommunicable disease-related deaths and disability by 2050 across all ages.

This is a shared responsibility. The fight against cardiovascular disease is not the responsibility of health ministries alone. Urban planners, educators, environmental agencies, and finance ministries all have a role to play in shaping healthier societies. As World Heart Federation President, I have witnessed the extraordinary results that emerge when sectors work together—from urban redesigns that encourage walking and cycling, to school programs that instill healthy habits from an early age.

World Heart Day is a reminder that while cardiovascular disease is a global challenge, it is also a deeply personal one. Behind every statistic is a family, a community, and a story that could have been different with the right knowledge, prevention, and care.

On this special September 29, I invite the global community—policymakers, health professionals, civil society, and individuals—to join us in making heart health a universal priority. Sign the petition. Dedicate time to your own heart. Advocate for systems that make healthy choices accessible to all. The message emanating from the epicenter of Puttaparthi will be heard in every corner of the world. The Prasanthi Nilayam model, blending science, spirituality, and service, shows us that heart health is not just a medical goal but a moral imperative.

Together, let us ensure that every beat counts for every heart, everywhere. May Baba’s love be all-pervading, and may he shower his choicest blessings on all. Sarve Bhavantu Sukhinah, Sarve Santu Niramaya, Sarve Bhadrani Pashyantu, Ma Kashchid Dukh Bhag Bhavet.

Thank you. Jai Sai Ram.

Good morning, esteemed delegates. It is a great honor for me to join the leadership of the World Heart Federation—our current president and our president-elect—in what truly is, and has already proven to be, the most spectacular celebration of World Heart Day that we have ever hosted together with our partners.

As you can see from my brief bio, I am a Bulgarian journalist, and my name actually means "young tree." Yesterday, I learned from the children that the tree pose—though I wouldn’t be able to pronounce it in Hindi—is the best pose to alleviate stress in middle age, which I am approaching. So, my name is aligned with what I learned yesterday about reducing heart stress. The reason I share my background in journalism and political science is because I live by the credo: "Show, not tell." That’s exactly what you all have been doing, so thank you for that.

Over the last three days, I have counted the number of people we have lost to cardiovascular disease, and this number is 164,000. That’s why we cannot afford to miss a beat. Your efforts in showing the world how you care about people, how you care about patients, and how you care about people before they become patients are ever so important.

Professor Narula spoke about World Heart Day and its origins. I will try to show you a little bit of its impact across the world, because while India is the center of the celebrations, these events happen in every corner of the globe. We continue to receive stories on Instagram, Facebook, and all our social media accounts. In fact, the team can hardly keep up with everything coming our way.

What unites us—both the World Heart Federation and everyone gathered here—is our commitment to care, equity, and community. We believe that every person on the planet, regardless of religion, creed, nationality, and most importantly, regardless of financial means, should have access to cardiovascular health.

We heard that heart disease is the number one killer. I shared the very sad figure of the number of people who will die during these three days we are meeting. But the good news is that 80% of premature deaths are preventable, and our federation works tirelessly with societies, federations, and foundations worldwide on prevention.

The World Heart Day movement was created with prevention in mind. In keeping with my credo, I will show you the numbers rather than simply speak about the movement’s grand impact. These are actually very impressive numbers for digital media, and when compared to many other disease areas and health-related issues, they truly stand out. So when Professor Narula says this is the biggest public health event, it is not just a claim—it’s evidence-based.

We talk about equity and, with the modest budgets we have, strive to distribute grants. This information may be very useful: we provide grants to organizations that organize local activations in their countries to facilitate prevention measures in different regions of the world. And yes, we love India—that’s why we’re here.

A few years ago, we started the model of being on the ground for World Heart Day. As you can see, we were in the Philippines in 2022 together with the World Health Organization, in Ecuador after that, and last year, I was in a rural community in Ghana near the border with Togo, where we screened over 3,000 people from rural areas. Today, we’re here, and I don’t need to tell you how important and impactful this is. I want to highlight one thing that made a big impression on me—the children’s exhibition. I found it absolutely fascinating and have been sharing the images and videos not just professionally with colleagues, but also with my family and friends.

Despite sleepless nights from traveling across the world, I entered into a dialogue with one of my daughters about changing unhealthy behaviors. The demonstrations I showed her, again following the principle of "show, not tell," I hope will make her think twice next time and embrace a healthier lifestyle. I also agree with the speaker I heard yesterday, who said we shouldn’t call them "lifestyle factors" because they are actually "life-threatening factors." I really like that perspective. We must choose our words carefully, especially when our words impact many people, as I have the privilege of doing from this podium.

We know the sad numbers you are all here to address, including the higher risks in India compared to other countries. That is another reason to be here—not just for the potential and power of prevention and all the activities you do, but also because of the enormous burden cardiovascular disease places on the country.

This is the number of activations we are carrying out, and you have already heard from Professor Narula about some of them. When running a campaign like this, you must step back and consider the simplest way to reach people. It’s not about complex science—it’s about pure simplicity and reaching those who are unaware of health issues, not those who are already very conscious, with smart watches and constant monitoring. I believe this highlights the inequity we face globally. The gadgets we all have are not in the right hands, as those people are already aware of their health. I hope digital health will democratize health, enabling prevention outcomes to reach those who need it most.

We also heard about the recent UN meeting, a high-level gathering dedicated to noncommunicable diseases. That doesn’t happen often—the last time was in 2018. There was significant momentum, and most countries supported the political declaration, which, for the first time, included targets. That was extremely encouraging, and we were there with statements presented by Professor Narula to the global community. Sadly, two member states rejected the political declaration, but this is not the end of the journey—they must still officially vote. There is much advocacy to be done, and that is the job of the World Heart Federation and its members. Most importantly, advocacy and implementation happen on the ground, not just at the UN level. The work done here is, dare I say, even more important, and it will feed into global advocacy if we remain united.

This September, don’t miss a beat. Join us and people around the world to celebrate 25 years of World Heart Day. Heart disease is the world’s number one killer, taking lives both young and old, and causing one in five premature deaths. It doesn’t have to be this way. Heart disease can often be prevented. With new treatments and healthier lifestyles, millions of lives can be saved—not sometime in the future, but right here, right now.

Today, don’t miss a beat. To beat heart disease, we need you:

1. Sign our petition calling for urgent action on heart disease. Better diagnosis and treatment for high blood pressure alone could save 130 million lives by 2050. Yours could be one of them.

2. Get moving. Join our Keep the Beat Challenge. Mark the 25th anniversary of World Heart Day by moving for at least 25 minutes on 25 days in September. Stay active in your own way.

3. Spread the word. Inspire others to take part in our challenge. If you’ve been touched by heart disease, share your story. Help others see the risks before it’s too late. Your words can make a difference.

There’s no time to lose. Act now to save lives. Don’t miss a beat.

Thank you. The concept for this year’s campaign and logo was created to emphasize that this is a major year for global health. What makes this moment so important and unprecedented is the momentum we are experiencing at the UN level, talking about health again, and the commitment, unity, and courage of the community that came together at the UN. Despite the current climate, people are united and more willing than ever to sing from the same song sheet when it comes to prevention.

The petition was an interesting and somewhat risky move, linking a public campaign to a political ask and encouraging people to activate and sign something global. For us, "global" means something, though not necessarily for everyone. Signing a petition requires investment and a spiritual connection, which comes only if it’s tied to a story in your country. That’s what we aimed for this year: in each country of impact and interest—India being #1—we portray a story and a life behind our global ask, linking something sometimes ephemeral to tangible outcomes on the ground. I encourage you to sign it.

Another first for this year is our desire to start very young with awareness. Traditionally, the Federation’s audience has not been children, but we changed that because the greatest need in prevention is to reach younger audiences. We partnered with Snapchat, and today, if you open Snapchat, the main filter is ours. When you press it, you see a heart-shaped balloon that breaks, leaving a flat line—a fun but sobering message. Cardiovascular disease is the world’s number one killer, and we must do something about it.

I’ve spoken about different activations around the world. If you visit our website, you’ll see the map of activated places and landmarks illuminated in red. The Puttaparthi region—and India overall—will likely be the top location for illuminations, but we truly have them everywhere, with iconic landmarks in every country.

To show the diversity of engagement, I’ll highlight one story here: the boy you see, Lorenzo. The Italian authorities launched a stamp in his memory after he died of heart failure at a very young age.

We were all very impressed and humbled by the level of organization and engagement we witnessed—the seamless way in which the 25th anniversary of World Heart Day and the 100th anniversary of the birth of Sai Baba were represented and shared with the world. I am filled with images from every activation organized and shown to us here in India.

We continue to partner with a variety of organizations in India, including the Minister of Defence, who issued a video message, and Remo D’Souza, a dance choreographer and film director, who posted about World Heart Day on social media. These partners help us reach new audiences—especially those not already aware of cardiovascular disease.

In India, we’ve collaborated with Adani Healthcare Services, hospitals, universities, and our member CSI, which organized a joint competition. Our president and president-elect have spoken extensively to the media about World Heart Day.

This year’s theme, "Don’t Miss a Beat," was intended to combine the political push for urgent action with the inspiration from partnerships that encourage physical activity. As I mentioned, new partners help us reach fresh audiences and new places. The heart mascot Cardi V helps us engage in conversations with partners such as FIFA, UEFA, and sports clubs in India, the UK, and other countries—new territory for us.

My colleagues in Geneva are currently at the main university hospital, where we’re partnering on activities, including football events, and we also have a partnership with Decathlon, a major retailer in Europe. This is all very new and exciting for us, but we are only 25 years old and have much to learn from you. What we see happening globally is a growing desire for people to know more about their health and to take ownership of it. We can play a much bigger role in inspiring people—through knowledge, storytelling, and emotion.

What I’ve seen here, which I have never seen anywhere else, is doctors talking about spiritual health and the spiritual heart, as we learned yesterday from the children’s play. That’s absolutely unique to India. I have dedicated my life to putting emotion into what I want to see happen. I don’t believe real impact is possible if your heart isn’t in it. Seeing people who value science and evidence also embrace emotion and spirituality is very promising. It means there is hope to reduce those 80% of premature deaths.

To conclude my presentation, I’d like to share something personal. I’ll read a quote from a writer I greatly admire, the French author Marcel Proust: "The real voyage of discovery consists not in seeking new landscapes, but in having new eyes." I am the daughter of a breast cancer survivor, and my grandmother died from heart disease at 59. Every day, I see the importance of sharing my personal story.

Dear friends, ladies and gentlemen, I’ll try my best to be as brief as possible—perhaps 10 to 12 minutes. As Krishna just mentioned, the topic given to me is CKM, obesity, and hypertension as metabolic drivers for HFpEF.

Ladies and gentlemen, this is very common and truly a global tsunami today. The prevalence of CKM is 70 to 80% in our country. If you look at obesity, there are 44 million affected women and 26 million affected men. Additionally, 84% of patients are hypertensive.

My objective is to highlight morbidity and mortality benefits, and discuss drug interventions such as SGLT2 inhibitors and GLP-1 receptor agonists. The definition of CKM syndrome should be known to all of you—it reflects a cluster of metabolic risk factors along with CKD and cardiovascular disease, having a profound impact on morbidity and mortality.

This is a very important slide: Stage zero involves no risk factors, stage one is excessive dysfunctional adipose tissue, stage two is metabolic risk factors, stage three is subclinical disease, and stage four is clinical obesity. In Kerala, Delhi, and Tamil Nadu, the prevalence rates are quite high, with an overall prevalence of 5.21%. This illustrates how prevalent obesity is across different parts of our country—truly a crisis.

Hypertension, as you know, is a global epidemic. Uncontrolled hypertension is seen in 90% of cases, which is a real challenge for us. Only 10% have controlled hypertension, according to the Ministry of Health, ICMR, and WHO. The prevalence of hypertension is also rising in women compared to men. Women are competing with men everywhere. When I perform 40 echocardiograms daily, I find that 80 to 90% of patients with HFpEF are both hypertensive and obese. This is the phenotype specification based on ejection fraction—EF greater than 50%. The prevalence is highest in women, reaching almost 10% after age 65.

Common comorbidities include hypertension, obesity, and CKD. Risk factors are significant. My first study in 2007, published in the Internet Journal, showed that central obesity is the most powerful predictor of premature cardiovascular disease, with hypertension as the second component (78%). This was hospital-based data, showing higher prevalence in females than males.

The pathophysiology is well known. There is a minor difference in the metabolic pathways: with obesity, tissue dysfunction, inflammation, and stiffness are present; with hypertension, there is increased afterload, left ventricular hypertrophy, and myocardial fibrosis, ultimately leading to increased pulmonary pressures. Levels of leptin (an adipokine) are elevated, while adiponectin is reduced. These conditions are pro-inflammatory, pro-atherogenic, pro-fibrotic, and promote vascular stiffness and insulin resistance, with increased stress at the endoplasmic reticulum, mitochondrial oxidative stress, and sympathetic nervous system activation.

Hemodynamically, acute diastolic and systolic overload are common, leading to ventricular and atrial dysfunction, arrhythmias, and other issues responsible for HFpEF. HFpEF should not be misunderstood or underestimated—CKM, obesity, and HFpEF represent a quadruple jeopardy: stiff left ventricle, stiff left atrium, stiff aorta, stiff pulmonary vasculature, and stiff peripheral vessels. Inflammatory and neurohormonal activation, SNS activation, NP activation, mitochondrial dysfunction, coagulation cascades, signaling, and increased leptin are all contributing factors. Hypertension, hyperaldosteronism, and other factors also play a role, as previously mentioned by Dr. Prabhakar. These changes can lead to cardiovascular disease, heart failure, and diabetes mellitus.

Outcomes are well documented. The CHARM and PARADIGM studies have shown severe mortality and hospitalization in diabetic patients. A powerful study from our own country—the Heart Failure Study—showed that the readmission and mortality rates are high in HFpEF. Diagnosing these patients relies on echocardiography and NT-proBNP, which are cornerstones in the management of HFpEF: no echo, no HFpEF; no NT-proBNP, no HFpEF.

European and American guidelines recommend assessing LAVI (left atrial volume index) and E/e’ ratio (if above 15). In the American approach, BMI, hypertension, atrial fibrillation, and patient age are considered important, along with etiology. Other important variables include LV mass index and LAVI; if LAVI is more than 34 ml/m², it is a powerful predictor of AF recurrence and poor survival.

Fibrosis load is much higher in HFpEF, which is why we call this an atheropathy. Grade 3 and 4 atheropathy are powerful determinants of high mortality, as seen daily in our hospital. Elevated LA pressure at rest or after exercise and increased LA stiffness index are responsible for hospitalization and increased mortality. LA strain is also important; higher LA stiffness is associated with higher mortality. Reduction in strain rate is often proportional to LA size, but sometimes LA enlargement is significant even with only grade 1 MR, indicating a stiffness load. While we cannot measure this load by echo, we can measure it by CMR. If the load exceeds 20%, mortality risk is very high.

The key message: reduction in LA strain rate predicts mortality and morbidity in HFpEF. Several studies (PARAGON, TOPCAT, I-PRESERVE, PEP-CHF, and CHARM) have shown no outcome benefits. However, inhibition studies demonstrate promise in reducing MACE, hospitalization, and providing renal protection. Notably, SOLOIST, EMPEROR-Preserved, and DELIVER trials, as well as the SOLOIST trial by Dr. Deepak Bhatt, have shown definite improvements in functional outcomes. EMPEROR-Preserved, a landmark trial involving 6,000 patients over 26 months, demonstrated benefits in primary and secondary endpoints, including severe death and recurrent hospitalization for heart failure, regardless of gender, NT-proBNP, or diabetes mellitus. Renal protection is higher with SGLT2 inhibitors, as seen in the EMPEROR, IMPERIAL, and PRESERVED Heart Failure trials. Mortality benefits are observed only with empagliflozin and dapagliflozin, not with ARNI. The DELIVER trial further supports these findings, showing significant reductions in heart failure hospitalization and all-cause mortality, with a 23% relative risk reduction across all primary endpoints.

Guidelines recommend SGLT2 inhibitors as Class 1A. According to Dr. Braunwald, SGLT2 and GLP-1 receptor agonists are the shining molecules of the century in 2025, with SGLT2 inhibitors being likened to the "statin of the century." The three pillars for HFpEF management, according to ESC, are SGLT2 inhibitors, non-steroidal MRAs, and GLP-1 receptor agonists such as semaglutide and tirzepatide. GLP-1 receptor agonists have a wide spectrum of present and future applications. SGLT2 inhibitors, but not finerenone, provide these benefits. An article from Circulation highlights that improvement in left ventricular remodeling reversal and reductions in mortality and hospitalization are possible with a combination of SGLT2 inhibitors and GLP-1 receptor agonists.

Empagliflozin is superior in diabetes control, hospitalization prevention, and reduction of all-cause mortality compared to dapagliflozin, as shown in Chinese meta-analysis data and the EMPACT MI trial. The STEP-HFpEF trial in both diabetic and non-diabetic patients showed functional benefit, according to Dr. Javed Butler. Comparing tirzepatide and semaglutide, the difference is minor; both have some side effects, and most studies are with injectables rather than orals. Tirzepatide shows somewhat greater reductions in A1C and weight loss compared to semaglutide. All published studies so far, including randomized controlled trials with tirzepatide, show that meta-analyses consistently demonstrate reductions in MACE, mortality, worsening heart failure, NT-proBNP, and improved function.

AI-powered algorithms, as discussed earlier today, enable us to target upstream drivers with precision and timely therapy. We have already published three books on heart failure, hypertension, and atrial fibrillation.

To conclude, ladies and gentlemen, the health of millions is at stake: CKM, obesity, hypertension, and HFpEF are major concerns in India. SGLT2 and GLP-1 receptor agonists are iconic molecules—hit hard, hit early, hit safely, and optimize therapy before it’s too late. My tribute to the pioneers—Drs. Anker, Butler, Nassif, Abraham, Solomon, and McMurray.

Remember: Cardio-metabolic health depends on blood flow through vessels at one kilometer per hour. The secret to living longer, as emphasized here, is simple: eat half, walk double, laugh more, and love unconditionally. Thank you very much for your attention.

Good morning, and Jai Sai Ram. I have learned a lot today, and the first thing that I've learned is something special. It is said that a teacher takes your hand, opens your mind, and touches your heart. Truly, the Baba is the greatest teacher of all because he has touched everyone's hand, opened everyone's mind, and touched everyone's heart here. Thank you for having me here.

Can I have the slides, please? It's okay. Yeah.

I was asked to speak on the emerging themes in cardiovascular disease in India. As we battle cardiovascular disease currently, we shouldn't forget the future. If we forget the future, as Toni Morrison, the African-American author, said, the future extends itself, and we should not be doing that. How long are we going to suffer from the scourge of cardiovascular disease, particularly in the young?

When I think of cardiovascular disease, I think of Charles Dickens' "A Tale of Two Cities," in which the opening statement is, "It was the best of times, it was the worst of times." We need to do something about the worst of times because this is where most countries like India are, and as Dr. Reddy very elegantly said, we need to consider what we can do about that.

I'm going to think about what we can do in the future, or as we move toward the future, what we can do together. These are some of the random thoughts I put together. First, I think we need to rethink the mechanisms of disease, particularly regarding diabetes and lipids. Dr. Mohan has already discussed how the landscape for thinking about diabetes has changed and how Indians have a high propensity for diabetes for various reasons, so I won't be presumptuous and repeat his points.

Second, it's not that we get the disease only in adulthood and should tackle it only then. Instead, we should start from birth and continue until death. We need a life course model, and a great beginning has been made by focusing on children.

Third, there needs to be a paradigm shift from disease identification and treatment to maintaining health.

Fourth, we must recognize the importance of social determinants. We have discussed air pollution, for example.

Next, there is a need to apply the concept of syndemics to cardiovascular disease.

We must also reimagine the health system using frugal technologies, core design principles, new training strategies—particularly using gaming technologies—and team-based approaches. A system-wide approach will be crucial in tackling cardiovascular disease.

I'm not going to talk about all the points I've listed here due to time constraints, but I'm going to focus on three issues. The first is that the etiology of cardiovascular disease extends beyond traditional risks and risk factors. There is a significant amount of ethnic variation in its etiopathogenesis, and we need to understand why, as Indians, we are at high risk for cardiovascular disease.

For that, we need to look at a longitudinal study that is both multi-level and multidimensional, going beyond traditional risk factors to include socioeconomic status, health behaviors, and environmental context. So, when identifying cardiovascular disease in Indians, we must consider what is needed. For many years, we have relied on the Framingham risk model, viewing cardiovascular disease as an etiological, degenerative, or adult-onset condition. According to this model, there is a risk determinant, then a risk factor, and eventually the disease—so we tackle the disease at that stage. This has been the prevailing thinking for the last 60 or 70 years.

However, researchers in the UK have suggested that risk factors such as hypertension, diabetes, or cardiovascular disease can be programmed during fetal development. Studies like the Dutch Hunger Cohort and others have elegantly shown that maternal undernutrition is an important cause of cardiovascular disease in adults. What we need now is a combination of these two perspectives: both the etiological model and the early life developmental model. We should adopt a “life course model,” acknowledging the accumulation of risk across the lifespan. This risk includes both biological and social factors, such as air pollution, which is just one example.

Currently, we often focus on a single variable—PM 2.5—when it comes to air pollution, but we need to consider multiple factors. While we have demonstrated the relationship between air pollution and hypertension and diabetes, we need to show how these exposures increase cardiovascular risk across the lifespan.

I’m giving you an example of what we need to do to understand why Indians have a high propensity for cardiovascular disease. To address this, we assembled a cohort: the State of Heart population-based cohort. Dr. Mohan, Nikhil Tandan, and I are the principal investigators in India, and we have been working on this for the last 15 years. It is one of the largest, most intensely phenotyped global South Asian cohorts—sometimes called the Indian South Asian Framingham. This population-based sample includes around 21,000 adults, followed for more than 15 years and accruing almost 200,000 person-years of follow-up. It represents the megacities of Delhi (north) and Chennai (south). The study is carefully phenotyped and geocoded, and the biobank includes 400,000 aliquots of stored serum, plasma, and buffy coat, enabling future research into these relationships. Notably, this cohort is three times larger than the Framingham cohort, which is a unique selling point.

Through this work, we have shown how diabetes is prevalent and have uncovered the mechanisms of diabetes in India. However, we need to move the needle from treating disease to keeping people healthy. Contemporary medicine often starts with late disease: we identify and treat disease or, if more proactive, treat risk factors to prevent disease. Instead, we need to maintain people at low risk and keep them healthy. This is where precision health comes in, managing each individual’s unique phenotype.

Our CARS cohort has transformed into Precision CARS. Here, we are examining pathophysiological clusters such as lipids, inflammation, adipokines, thrombogenesis, and more. We are also conducting imaging studies—14,000 echocardiograms, carotid intimal-medial thickness measurements, coronary artery calcium scans, assessments of hepatic and epicardial fat, and even brain biomarkers. We are seeking to identify components that keep people healthy, determine how to sustain health, and develop an individual score to predict health status. This is the precise direction of our ongoing work.

The third area to consider is environmental determinants. I have already mentioned social determinants of cardiovascular health, but environmental determinants include five major factors. First, climate change brings extreme temperature, high humidity, floods, droughts, cyclones, and other weather extremes, as well as disruptions to food systems. These factors result in hemodynamic changes, heat stress, livelihood uncertainty, and malnutrition, all increasing cardiovascular risk. Second, various aspects of air pollution elevate risk through similar mechanisms. Third, water pollution—including heavy metals—poses a threat; for example, data from the US suggest that lead exposure causes nearly 350,000 deaths annually. Fourth, noise and light pollution are emerging areas of concern, as they affect circadian rhythm and increase stress, thus raising cardiovascular risk.

To illustrate, let me share how we have linked air pollution to hypertension. We use particulate matter 2.5 (PM 2.5), which is extremely small—about one-seventieth the width of a human hair. PM 2.5 can cross the alveolar-blood barrier, enter the bloodstream, and trigger a cascade of effects, including increased arterial stiffness, inflammation, and deposition in abdominal fat cells, all of which elevate cardiovascular risk. For example, every 25 microgram per cubic meter increase in PM 2.5 raises blood pressure by 3 to 5 mmHg. For context, the recommended annual PM 2.5 level is 5, and the daily level should not exceed 15. In Delhi, however, the annual average is 100. Reducing it from 100 to 25 could decrease hypertension rates by about 5%. This demonstrates the power of acting on social and upstream determinants.

We also observed similar trends for diabetes in both Delhi and Chennai, with a steeper relationship in Chennai, illustrating that risk plateaus at higher levels of PM 2.5. This suggests the need for action at lower exposure levels. Finally, we have shown that LDL cholesterol, total cholesterol, and triglycerides increase with rising pollution, while HDL cholesterol—the protective lipid—decreases. There is now ample evidence that air pollution plays a major role in cardiovascular disease.

More importantly, we must consider the interaction between air pollution and climate change. For instance, high temperature and high air pollution together increase the risk of death by nearly twofold. Higher levels of both factors correlate with increased mortality rates, highlighting the need to address these issues together.

Instead of focusing on one factor at a time, we should examine the cumulative effects of multiple environmental exposures across the lifespan. For instance, we are studying PM 2.5, nitric oxide, ozone, and extreme temperatures to understand how these factors collectively increase cardiovascular risk. Among pregnant women, for example, these exposures may lead to low birthweight children, who are at higher risk of future cardiovascular disease. In children, we are investigating cognition, as it is strongly linked to future cardiovascular risk. In adolescents, we are studying insulin resistance; in adults, we examine multiple cardiovascular risk factors; and in older adults, we look at vascular dementia. The goal is to assess cardiovascular risk across the entire lifespan.

We also need to reimagine the health system. Currently, our system manages one disease in one person at a time. Can we instead view each person holistically and address all their health problems collectively? To this end, we are developing an integrated, technology-enabled, patient-centered, high-impact, equitable health system intervention, with large trials underway in Nepal and India. These efforts focus on strengthening research capacities and increasing community engagement and involvement.

Let me present a typical patient: a 65-year-old female, non-smoker, admitted with high fever and cough for three days. She was referred by a family physician due to an SPO2 of 91% and a respiratory rate of 30 per minute. She was diagnosed with diabetes 15 years ago, managed on oral hypoglycemic drugs, and had percutaneous coronary intervention (PCI) with two stents for acute coronary syndrome two years prior. Her COVID-19 test was negative, but she deteriorated rapidly and died within 24 hours. The death certificate listed ARDS with pneumonia and septic shock. Was this the real cause? Her endocrinologist had recommended annual flu and pneumococcal vaccines, but her cardiologist felt they would not make a difference. She was influenced by misinformation on social media about vaccine risks. She was educated only to the eighth grade, had no social insurance, and her culture report was pending. The immediate cause of death was pneumonia and ARDS, but the underlying causes included poor access to care, low education, poor socioeconomic status, fragmented healthcare, lack of integrated care, and confusing messages regarding vaccines, as well as social determinants like air pollution.

A study published in the New England Journal of Medicine showed that following a viral infection, the risk of myocardial infarction increases nearly sixfold in the following days. These interlinked factors illustrate that we cannot treat diseases in silos—we must consider them as interconnected. This is the concept of syndemics: the convergence of two or more health conditions—often infectious diseases and noncommunicable diseases—which interact synergistically to worsen health outcomes. For example, diabetologists know that infections increase mortality risk in diabetic patients, and during the COVID-19 pandemic, cardiovascular disease patients had three times the risk of mortality. We must manage patients holistically.

Unfortunately, few patients receive flu or pneumococcal vaccines, though they are life-saving. Add to this the influence of climate change and food systems, which affect both our diets and the country’s future. To develop effective strategies, we must consider all these factors together.

Finally, Dr. Reddy spoke about task shifting and technology integration. We have created a telemedicine platform that is interoperable and can be adapted as needed. We have implemented this platform in two clinics in Tamil Nadu, providing a large number of consultations over two years and impacting many lives. Most importantly, this reduced costs for patients and improved blood pressure control, which persisted for 18 months. The technology is simple and affordable, delivering care even for patients who are elderly or unable to travel. We are conducting large multicenter trials across India to test the effectiveness of telemedicine on wheels, which requires only a 3G connection and weighs just four kilograms. This randomized trial, soon launching across 48 centers, aims to demonstrate its benefits.

We are also exploring how to integrate AI to provide remote care. One current trial is a structured, multi-component program for assisted, home-based, post-discharge care using digital technologies and guideline-directed medical therapy. Patients receive a wearable device that monitors heart rate, temperature, SPO2, and more. Community health workers can connect to specialists as needed. This system can even predict rising NT-proBNP levels within two weeks, allowing intervention before complications arise. This class-standardized trial of around 2,260 patients is funded by ICMR. Such innovations are crucial for cardiovascular disease prevention.

Ultimately, we need system-wide approaches. We must not only focus on the individual, but also change the system to create a scalable, multi-stakeholder, transformative rural healthcare model. To this end, we have adopted six medical colleges, each with a rural health training center, and are building capacity in research methods, health systems, digital health, environmental health, and sustainability—many of which are not currently in the curriculum. We are conducting situational analyses to enhance research capacity at the facility level, creating digitally enabled facilities using telemedicine platforms, building climate-resilient healthcare centers, and improving quality of antenatal and child care. At the community level, we are teaching patients how to use digital technologies and training them to become navigators for others with disease. The aim is to create a cardiovascular disease-friendly system and evaluate its effectiveness.

Lastly, we need system-wide approaches. It is important not only to focus on the individual, but also to address system-level changes by creating a scalable, multi-stakeholder, and transformative rural healthcare model. For this, we have partnered with six medical colleges. Each of these medical colleges has a rural health training center, where we are building capacity through trained staff in four key areas: research methods, health systems, digital health, and environmental health and sustainability—many of which are not part of the standard curricula.

We are conducting situational analyses to enhance research capacity at the facility level. Additionally, we are establishing digitally enabled facilities using telemedicine platforms and creating climate-resilient healthcare centers, all while working to improve the quality of antenatal and childcare (A&C care). At the community level, we are empowering individuals by teaching them how to use digital technology. We are educating and training patients to become navigators for people living with disease. In doing so, we are developing a comprehensive system that is cardiovascular disease-friendly, allowing us to assess its effectiveness.

So I will stop here because there's a lot of work to be done. He's one of my favorite poets and he said the woods are lovely, dark and deep, miles and miles to go before I sleep. But I'll tell you a positive statement also of his.
Two roads diverged in the world and I took the one less traveled by and that's all what made the difference. Thank you very much.

Good morning and Sairam to everyone in this august audience. I begin by offering my most humble salutations and pranams at the divine lotus feet—the supreme puppeteer in whose hands we are all mere puppets. I have been given a relatively tough topic; it may not be very entertaining, but as Professor Venkataram agrees, it is the need of the hour. With the burgeoning population invading the planet, nature is struggling to cope. Professor Chopraji just mentioned that our treatment strategies must shift from focusing solely on the patient. We need a broader approach: rather than waiting for disease to appear and then treating the symptoms, we should now think about how best to prevent the onset itself.

Let me proceed without taking much time. Regarding prevention—there was a time when, with a smaller population, treating individuals worked. Whether it was tribal medicine, Urdu medicine, Ayurveda, or other traditional systems, and then modern medicine, treatment sufficed. But as the population and disease spectrum increased, so did our understanding. People started considering various levels of prevention: initially secondary prevention, which evolved to primary, tertiary, and even quaternary prevention. Despite these advances, we still find ourselves unable to provide adequate care to a large majority in most parts of the world. This is where the concept of primordial prevention arose—to delay or prevent the emergence of risk factors.

Cardiovascular disease, as all the esteemed speakers before me have discussed, remains a leading cause of death. Governmental efforts have been made, though not always strong, and we still haven’t achieved balance. There was a misconception that cardiovascular disease was only associated with prosperity or high-income groups, but that's not the case. Even low- and middle-income countries are not spared. The attitude must be to nip the evil in the bud—prevent it at the earliest stage. Primordial prevention precedes even primary prevention; it is about targeting and aborting the emergence of risk factors. Economically, it may not seem attractive, but from a holistic viewpoint—considering community, nature, and the world—it is the foundation of lifelong cardiovascular health.

How do we achieve this? Various models and inspirations have emerged, focusing on lifestyle and social determinants of health. Efforts to reduce lifetime cardiovascular risk, if successful, may not seem appealing in the short term, but they are cost-effective and sustainable in the long run. These efforts lead to qualitative and quantitative improvements at all levels: individual, family, society, and nation. As previous speakers have emphasized, hypertension, diabetes, and obesity are key factors—can we postpone or even prevent their onset?

Let me touch upon some factors affecting this, starting with diet. Traditionally, dietary practices have changed from my grandparents' generation to my parents', to my own, and now to my children's. Today, everything is ready-made: whether upma, vada, or matar paneer, you just heat a pouch. There are cultural versus modified diets. For example, decades ago at Bhagwan’s hospital, a Punjabi patient was served rice for lunch. He did not eat, saying he eats rice only once or twice a year, and only as biryani. Conversely, a Tamil Nadu patient was given ragi balls as a diabetic diet. For him, it looked like elephant dung. Prescription diets must respect cultural practices—what works for one may not work for another.

Doctors sometimes prescribe rigid diets. Some say all oils and fats are poison, recommending only olive oil, which is expensive and disliked by many. Give coconut oil to a Bengali—he’ll vomit. Introduce mustard oil to my parents—they’d leave the house. Cultural practices influence not just fat consumption, but the content and method of eating food. Unfortunately, with economic growth, as Professor Mohan discussed yesterday, diabetes incidence increased. Fertilizers and pesticides have become a curse—consider the endosulfan tragedy in Kerala. Is there a solution? Not really, though Sikkim promotes organic food; I wish we all had that luxury.

Processed foods are now the norm. In my childhood, my father would buy wheat, my mother would wash it, dry it, and grind it at the mill—then make roti. Today, we buy super-refined flour; where are the fibers? My wife has never used a grinding stone; everything is ready-made. What goes into preserving these foods? Even experts may not know, nor what it does to our bodies.

There's also a mismatch in calorie consumption. As a child in the north, I saw Akhada practitioners eat 25 eggs for breakfast, a kilogram or two of chicken, and twelve parathas for lunch—while doing strenuous exercise. By age 40, many became diabetic and hypertensive, and by 42, they were gone. The problem starts in childhood—mothers force food on children, wives insist you eat to keep them happy, leading to calorie overload.

Exercise, culturally, is almost absent. In South India, exercise might mean making three rounds at the temple; in the North, even that may not happen. With automation, physical exertion is nearly nil. My grandmother’s era involved washing dishes and clothes, grinding idli and dosa for ten people—keeping her fit. Today, everything is automatic, even toilets. Physical activity has declined drastically.

Cultural bias also plays a role. In our hospital, patients come from all over India. The dietary department is asked to consider culturally oriented diets, but as doctors we may prescribe a one-size-fits-all 1200 calorie diabetic, low-salt, low-fat diet, which just doesn’t work for everyone. Rest and sleep are also lacking. On days I get four or five hours of undisturbed sleep, I thank Swami. The biggest enemy is the mobile phone, which disrupts sleep.

Stress management is vital. Stress begins at birth—the moment a baby takes its first breath. It’s inevitable, but what matters is our response, not the stress itself. Bhagwan’s teachings have shaped my approach and response to patients, providing spiritual enlightenment—an extra bonus I wouldn’t get elsewhere.

Substance abuse and dependence are issues, as is obesity. When I was young, obesity signified prosperity; today it is a curse. WHO now classifies childhood obesity as a major disease, linked to hypertension, diabetes, and dyslipidemia. The taste and smell of traditional foods are fading. Pollution—air, water, cosmic radiation—is increasing, and we struggle to do anything about it. Three decades ago, Puttaparthi was a clean, green hamlet; now, concrete jungles have replaced greenery, mirroring trends worldwide. Economic disparities and changing cultural and social environments affect us globally.

What are the solutions? Health promotion, policy controls on processed and junk foods (though often wishful thinking), afforestation, food fortification (as in the US), and legislative controls on tobacco and alcohol. During COVID, one state relaxed alcohol restrictions for a festival, resulting in three-kilometer queues and 600 crores in revenue in one week. Stringent laws to prevent environmental degradation exist only on paper.

We must consider cultural vs. cultivated food habits, vegetarian vs. non-vegetarian diets, processed vs. naturally processed foods, exercise, weight management, sleep hygiene, stress busters, and spiritualization of life. People ask me how to define spiritualization; it is an affirmation of the fourth point in the WHO definition of health.

Is there hope—a light at the end of the tunnel? Political will is lacking, at least in this country. School-based, workplace, and community interventions do work but are often underutilized. Nonprofit agencies and religious leaders could play a significant role. I want to mention, with Professor Narula’s agreement, the North Karelia Project in Finland—a pioneering community-based intervention for cardiovascular disease. By targeting cholesterol management, blood pressure control, and smoking cessation, and involving the local population, they saw the death rate from cardiovascular disease drop to one-third between 1972 and 2014. It became national policy and should be a benchmark for global replication.

Impediments to remedial measures include lack of political will, resource limitations, and stiff resistance to change. Even in remote villages thirty years ago, you could get packets of Maggi noodles—MNCs have promoted unhealthy junk and processed foods. What’s the takeaway? Primordial prevention should be part of WHO advisory and made mandatory worldwide, with collaborative initiatives between nations, religious, cultural, and political leaders, use of digital technology for information dissemination, and robust legislation and mandatory policies. This is urgently needed for all non-communicable diseases. Results are not instant, but it is a cost-effective, long-term strategy. A multi-pronged approach, with legislative, community-based, and healthcare-based collaboration, is the answer to reducing the global burden of cardiovascular and other non-communicable diseases.

I conclude with the universal, eternal message from Bhagawan Sri Sathya Sai Baba: His popular slogan, “Hari Wari Kari,” aptly covers all risk factors for cardiovascular disease. His earnest appeals for purity of food, cessation of vices, ceiling on desires, and emphasis on spiritualization of life affirm the fourth point in the WHO definition of health.

I end with profound respect to the universal Messiah, mentor, and motivator, Bhagawan Sri Sathya Sai Baba. Please allow me two more minutes, as I would be remiss not to mention my four decades of association with this institution, including nearly two decades with Bhagawan himself. When this celebration was conceptualized, there were many meetings and much brainstorming among Professor Akshay, Professor Krishna Rao, and others. When it was decided to invite the World Heart Federation for its 25th anniversary and Bhagwan’s 100th year of advent, it seemed like wishful thinking. Yet, thanks to Professor Jagat Narula for accepting our invitation and choosing Puttaparthi as the destination, it became reality. On behalf of everyone, I express profound thanks to Professor Narula and hope that the Golden Jubilee celebration will also be held here. Many of us may be in the ethereal plane by then, but we can watch from above.

My thanks also go to Doctor Krishna Rao, who dedicated himself completely to this conference—living, breathing, and sleeping with it, his phone and computer constantly buzzing with messages and coordination. He is a true, silent worker, and if today’s event is a thundering success, he deserves a standing ovation. For the past ten days, he and his family have camped here as though it were his own daughter's wedding. That is true dedication.

During deliberations, the concept of hard work and an exhibition emerged. A brilliant idea was suggested by someone I call a pocket-sized nuclear bomb, and Krishna Rao Sir immediately embraced it. That person single-handedly coordinated everything, inspiring schools, colleges, and institutions to participate. The result was a wonderful exhibition. It was noted that if medical students had been given the same project, the outcome wouldn’t have been as beautiful. Seventh and eighth grade students explained concepts we didn’t understand even in medical school, and most had never seen Sathya Sai Baba in person. Their inspiration was immense.

I was disappointed to learn that the exhibition would close today at 3:00 PM. I appeal to everyone, by whatever means you can, that this exhibition should be retained at least until Bhagawan’s 100th birthday so every visitor can see it. If wishes were horses, beggars like me would ride—this should be preserved for posterity. At the 50th anniversary, people should see what was present 25 years ago. Let us give a standing ovation to those students, teachers, and mentors for their wonderful work.

One more standing ovation is due for the “pocket-sized nuclear power”—Doctor Vidya. She is a dynamo, managing clinical duties and organizing all of this with remarkable energy. I would feel guilty if she did not receive a thunderous round of applause.

Lastly, over the past two days, I felt a tinge of regret that Bhagawan was not physically present. I believe he would have been the happiest person. Having known him intimately, I am convinced that, even in his ethereal form, he is supervising us, and the success of this program is his. Thanks also to the current managing trustee, Sri Ratnakarji, for his boldness in allowing this celebration despite Navaratri. I thank him and offer one more round of applause.

Being the sacred nine-day festival of the Holy Divine Mother, I thank all of you and end with “Jai Sai Ram.”

Sairam. Good afternoon, everyone. Om Shri Sairam. Humble pranams at Swami's Divine Lotus Feet. Sitting amongst us right now is Iyer Sir, who has already covered most of what I intended to discuss. I am not sure how qualified I am to speak on the topic of epigenetics. Perhaps my only qualification is that I first heard the word "epigenetics" two decades ago when Dr. Krishna Rao was teaching a class during our first year in cardiology. These classes, held between Puttaparthi and Bangalore, have continued even now.

During one of those classes, I asked my senior, "Genetics, Sunatha epigenetics?" and he responded, "No." Even today, I am still trying to fully grasp the impact of epigenetics. Another reason I might be here speaking on this topic is to reflect on how much we could all benefit if we adopted a healthy lifestyle and made lasting changes in our lives.

The promise is that 80% of cardiovascular disease is preventable. This premise has been reiterated over the last two days, and Iyer Sir has made my work easier because he has already spoken about most of my slides. We seem to always be discussing the same essential points: we need to be more active, quit tobacco, ensure healthy sleep, eat better, and manage our weight, blood sugar, blood pressure, and cholesterol.

But what exactly is epigenetics? We are all born with a specific set of genes—our DNA sequences—but it is the environment that we provide for our genes that allows them to manifest, either as disease or as health. The phenotypic expression of our genes is determined by this environment. For example, twins are born with the same genes, but if one smokes and the other doesn't, or one eats healthily and the other doesn't, their outcomes will be different. So, it is not just our genes, but the environment we provide them, that determines the final expression and outcomes.

Epigenetics is the study of heritable changes in gene expression that are not due to changes in the DNA sequence. There are many epigenetic mechanisms and pathways commonly involved in the day-to-day disease problems we encounter as cardiologists. Just yesterday, we had a talk on inflammation—an epigenetic pathway involved in vascular dysfunction leading to atherosclerosis, heart failure, and diabetes. People often think diabetes is only due to diet, but the evidence shows that epigenetics plays a role. Almost everything Iyer Sir discussed—pathways, signaling, metabolism—are all ultimately epigenetic pathways.

We have histone modification and other mechanisms that impact and lead to heart failure, diabetes, high blood pressure, and left ventricular hypertrophy (LVH). Recently, we have discussed microRNAs (miRNAs) and their impact on the heart, including arrhythmias, cardiac function, and LVH. There are numerous mechanisms involved in cardiovascular disease. For instance, a slide published in 2010 showed many available miRNAs. The IHL is doing a lot of work on miRNAs, and there is significant scope for further research in epigenetics. These mechanisms can lead to cardiomyopathies, heart failure, and various pathogenic pathways.

Ultimately, it comes down to both positive and negative factors. On the negative side, we have pollution, family history, toxins, dietary patterns and habits, alcohol, smoking, infections (recently discussed as "syndemics"), exercise, medications, and proper diet and nutrition, which can positively influence our genes. Pollution—whether air, noise, climate, or chemical—has been proven to cause heart disease, vascular disease, strokes, hypertension, atherosclerosis, coronary artery disease, and metabolic issues like obesity. These biological and biochemical pathways can be explained by not providing our genes with a healthy environment.

Stress is another risk factor. Acute stress can lead to myocardial infarction, but chronic psychological stress also has significant impacts, leading to epigenetic modifications. Do we have hope? Is there a solution? The answer is yes. Much has already been discussed, but I will highlight a few points. For example, curcumin is a simple component known to reduce inflammation. There is data showing curcumin can reduce inflammation, impact cholesterol, reduce platelet aggregation, decrease triglycerides, and reduce cytokines. The questions remain: how much, in what form, and these answers still need exploration. We know turmeric has been part of our diets, but the colors used today may not always be true turmeric. It's better to return to our roots—to our parents’ and grandparents’ time—when food was prepared differently, leading to reduced oxidative stress and improved nitric oxide availability.

Vitamin C also plays a role. During the COVID-19 pandemic, there was a resurgence of people consuming vitamin C, which favorably reprograms the epigenome. It has been shown to reduce atherosclerosis, though this is not often emphasized to patients. We typically say statins cause plaque regression, but even simple things like vitamin C can help. Exercise has strong cardioprotective, epigenetic benefits. Sleep, as mentioned by Epigenetics Sir, is important; deep, quality sleep matters. Sleep deprivation and poor sleep quality can lead to changes in gene expression and increased stress. Sunlight exposure is limited for us as cardiologists, and mindfulness, meditation, and pranayama are also beneficial. Epigenetic therapeutics are already in place, with drugs like statins and aspirin helping patients move toward precision epigenetics. The future will likely discuss this further, though there are challenges—such as what happens when we exercise for three months and then stop, or when we make dietary changes and then discontinue after a few months. Sometimes we revert to old habits, and epigenetics reasserts itself.

We could simply follow Swami's advice regarding food, heart, and mind. Swami has said it is the primary responsibility of every individual to prevent heart disease by regulating food and other habits, emphasizing that prevention is better than cure. If one's food habits are properly controlled and regulated, there is little room for cardiac ailments. Swami has asked us to focus on the spiritual heart and vitamins. Swami said that vegetarian food should be balanced and wholesome, containing liberal doses of vitamin C and vitamin E, available in vegetables such as carrots. These vitamins can help prevent heart ailments to a large extent. This morning, we carried placards with the same message. Swami also advised avoiding fried food, noting that birds and beasts do not suffer from cardiac and digestive ailments as humans do. The cause can be traced to the natural food animals consume, unlike humans who eat various fried and cooked foods, becoming slaves to their palate.

Swami told us to eat the right type of food, avoid fatty substances, consume leafy greens, and reduce worry, hurry, and "kari." Swami said that man today is a victim of worry, which is caused by lack of contentment. Even the rich are not content despite their wealth, and worry causes hurry, both of which lead to ill health.

The theme of today's conference has already been covered over the last two days. These are our do's and don'ts. I would like to end with a prayer to Swami, asking that He bless us all as cardiologists, doctors, and His chosen physicians, so that we take care of our own health as much as we advise our patients. Sairam, thank you.

It's very difficult to talk about AI and ML when you're experiencing hunger pangs. AI is not absolutely insane, and ML is not "mother-in-law." I have my slides on the screen, so why is a doctor here talking about AI and ML? I'm not from the DMACS department. I learned about AI and ML because I thought it was necessary. I wanted to present this at a real-world conference, thanks to Swami for giving us this stage, because we need to discuss this topic not just in terms of clinical reality, but also in terms of how we approach research in India. That's why I called it "From AI to SAI."

We have a lot of honest research. This is the Satya Sai organization, and we need to talk about the truth. We read books from the West and make our own assumptions, but we are different. Southeast Asians are a different breed; we die young and have different risk factors, but all my textbooks are by American authors. When will we have our own research? Unless we collaborate with them, learn how they conduct research, and then apply it to ourselves, that last part gets left out.

Do they all mean the same? This is all verbose, and I don’t want to bore you at 1:00 in the afternoon. But ML is a larger part of what is called AI, and then you also have machine learning and deep learning. So, are we really crystal ball gazing? Whenever I start talking about this at conferences—where there aren't many doctors—everyone asks, "Are you crystal ball gazing into the future? Are you telling us what's going to happen? Are you going to give us predictive models?" Yes, because these models have been derived from Satya Sai hospitals here and in our hospital in Whitefield, and they speak the truth.

Just to make a point, and I often mention this when HK Chopra is present: we always create risk models. Who is going to die? What do we use? We use a statistical method called regression. We look at those who have died, go back, and identify risk predictors. We say that when a patient has a heart attack today, what is his risk of dying after one year? Are you saying your treatment has no benefit at all? No. What we use is called jackknifing; we try to project, but that's not ideal.

That's where ML comes in. When you have too many variables—like hypertension, diabetes, youth, family history—how do they interact? Even with propensity analysis and multivariate regression, you might be right 70% of the time. How does ML help? This isn't about teaching ML; I learned it, but I'll tell you how we apply it. Since we're short on time, I'll focus only on the models.

We rarely consider the third factor: the human concept of time. We know the variables and the risks, but we don’t know how they change over time linearly. That’s what ML tells us. We received an award paper for this—I’ll just show you four award papers we've received. It’s not to brag, but to show you our work.

We have a disease called HOCM, where the heart becomes very thick, and we're always told these people can die young—and they do. This is a modern disease. This is the first scoring system created for India. There's an American system, a Western dataset, and a Japanese system—but what about Bharat? We didn’t have one. So, we developed a flow chart, analyzed those who died and those who survived, and created a heat map. My friends from DMACS know this, but it's about inter-variability. We found that if Western data says MRI shows more than 15,000 fibroses, then someone will die, but Indians die at 10,000. If they say LV strain is 15%, we die at 12%. We are a different breed. This needs to be applied to us.

How did we do it? We used Python charts and cluster plots. The important thing is the score and its accuracy: it’s 85% accurate. You can almost predict who’s at risk of losing their life, which is crucial. More importantly, 23% of first-degree relatives who never knew they had HCM were actually identified. You can save these lives. This mortality benefit isn’t found in Western books because it applies specifically to our patients.

Let’s look at a few more scores. We know, and I have Neelam Madam here, that we often perform congenital heart disease surgeries at 14, 15, or 20 years of age. In the West, it's done at three, four, or five years of age because they detect cases much earlier. How does this affect us? Because we operate late, our children and young adults die. This paper discussed RV-PA coupling—how the heart and lungs are functionally linked. We derived a new model using machine learning. Again, I won’t bore you with statistics, but it’s a risk model we started with and have now validated. This is again the first in India and possibly the first in the world. We validated it and gave it to our surgeons. My wife is a cardiac anesthetist; she knows how to use it to get better results because this is Indian data. There’s no comparable Western data.

Again, the statistical model's accuracy is phenomenal. ML isn't just about "hot stuff"; it's about looking inward. Research is really searching within yourself. Someone said, "See all this insight." We never looked within; we just applied Western data. It doesn’t work for us.

Another award paper from last year deals with mitral stenosis—rheumatic heart disease. Dr. Jagat Sir has written books on this, and when it persists, the valve becomes stenosed, so we use a balloon to open it. This paper is the first anywhere in the world to show how this procedure applies to us. What is the chance of success on that day? Should I alert my surgeon that the patient might deteriorate and need surgical backup? No such paper has been done before because this is a study on Indians. Again, I’m not bragging, but the predictors we get from our lasso regression are completely different from what Western books tell us.

When we apply and validate the model, the accuracy is tremendous. We know whether we'll face difficulty or trouble in the cath lab. This is how we use it. All of this is done by machine learning. We analyze all the intervariable interactions—how each factor works with another. The number of combinations is amazing. I get more than 200,000 combinations when working in Python. So I know exactly: if this and this and this, or if you have a diabetic patient but not a young age, and so on. It's all about multivariate analysis.

With this, you can provide precision medicine for each patient, which I believe Vidya will discuss immediately after me. This is how we get to precision medicine: what is this patient's risk—not for a population, not for a cohort.

This is the composite base score, the balloon success evaluation score—again, the first in literature. Validated, scored, and accurate more than 87% of the time. So my surgeon is ready in the OT, knowing what to do if things go wrong.

Another award paper—again, not to show off awards, but this is something that woke people up. In the same CM analysis, we detected something called an electromechanical window, a simple measurement in echocardiography that can be done at the bedside. It tells us the actual risk of dying. How accurate is it? We created and validated the score.

So when we went ahead and validated them, I’ve given you five more. I bribed you, Praveen, so I’ll finish in two minutes. The point is, when we use a hyperplane—called a hyperplane in a support vector model—I just need three or four factors to tell if a patient is at risk; more than 90% of the time, it’s accurate. Again, this is HCM, a deadly disease. In our department, we plan to put in an ICD because we need to ration resources; we don't have unlimited availability, so it has to go to the right person. This is how we allocate resources.

The last paper is about who dies after a heart attack. We went back and studied this, encouraged by Dasser ten years ago, because we saw many young people dying after a heart attack, even after a successful angioplasty. Why does this happen? We reviewed all the variables and their interactions, and found that one of the most important factors was late referral. Patients were coming 12, 16, or even 24 hours later. After a "successful" angioplasty, they might die three or four days later. You can explain a lot beyond regression analysis by using machine learning.

I’ll end here because I don’t want to take too much time. Suffice it to say, many of these models are very accurate. They are derived from research on Indian patients and apply specifically to Indian patients. Let's have research in India for Indians. We cannot depend on the West.

In-hospital mortality, six-month mortality, twelve-month mortality—all of these are accurate. If you look at other scores in the literature like Cadillac, SLED, or PAMI, ours are better. My take-home message is: no victory comes without hurdles. If you’re running a hurdle race without hurdles, you’re not really competing. So we all need to do a SWOT analysis. Our strength is that we need research in India. Our weakness is that we struggle to conduct research in India. We need more grants for research because the data that applies to us is unique to us ethnically. Western data cannot be extrapolated.

Opportunities are abundant because we have a large and fertile population for research. The theme is: can we prevent? Yes, we can prevent death—and prevention of mortality is a strong marker in medicine. Threats? None. We have Him with us. There are no threats; we just need more multicentric studies. We will provide all these patented models developed in our hospital to the global council. I want these models to be used worldwide. Of course, they apply mostly to us, but I’m sure Chandra Mani Sir is here—SEA is a different population, Southeast Asians die young, and we need to know why. This could help us potentially, because ML shouldn’t be limited to the math and computer science departments. We must learn at least a bit or at least collaborate.

This is for my teachers: Kashif, who taught me AI; Dr. Dash, who encouraged me; and of course, the IISC Bangalore, where I trained. I believe this is authentic data—real world numbers. Let’s move forward and acknowledge that we are a different breed. IHL is also moving in this direction; they also want to do research because we all agree: we cannot extrapolate Western data for ourselves. Thank you so much.

Om Sri Sairam. I offer my most humble pranams at the divine lotus feet of my dearest Swami. I thank the organizers for giving me this opportunity, and I hope I do justice after such a dynamic speaker, Dr. Prayaksar. He has made my job a little easier because he has already given you examples of the wonderful studies that have been done in our Swami’s hospital using the concept of precision medicine, which takes personalized medicine to the next level.

We all know variety is the spice of life; each one of us is completely different. As William Osler said, if we do not understand the variety among us and treat patients accordingly, we are practicing medicine as a science and not as an art. So, what exactly do we mean by precision medicine? Precision medicine refers to the customization of healthcare using diagnosis, treatment, and prevention strategies. Beyond the genetic makeup—like Rita Mam also mentioned—we must include other factors that affect a patient's health, such as lifestyle, environment, and clinical data. It is not a one-size-fits-all model; it is truly precision medicine.

For instance, precision medicine is extensively covered in oncology. Researchers have studied each receptor that contributes to cancer and developed very specific, targeted therapies. Precision medicine is widely developed in oncology, but how can we apply this in cardiology?

Imagine going to your favorite shopping mall. Would you choose a shirt off the rack, or would you have a personalized fashion designer select the color and size that fits you perfectly? That, in short, is the essence of precision medicine. Traditional medicine involves giving one treatment and observing the patient’s response or any adverse effects. But with the available data from genomics and other “omics” in medicine, we can now determine which specific therapy will suit each particular patient, considering all the relevant factors.

The different “omics” in precision medicine include metabolomics (the assessment of small molecules or metabolites in biological samples), transcriptomics (such as mRNAs and miRNAs), genomics (the interaction of all genes in the human genome), and proteomics (the study of all the proteins that make up our bodies). Artificial intelligence, including machine learning and deep learning, also plays a significant role, as Sir elaborately explained. Technology has further affected therapeutic interventions, such as specific genome editing therapies for genetic diseases, stem cell therapy, and robotics. Data for developing these interventions are collected from wearables, sensors, and implanted biosensors.

For example, in the study of cardiomyopathy, the genetic background of an individual must be combined with environmental factors like lifestyle, acquired factors, and various comorbidities. These, together, produce a phenotype for conditions such as cardiomyopathy. The outer circle of this phenotype might include traits like LV wall thickness or LV ejection fraction, but the genotype includes rare and common variants, morbidities, lifestyle, and ethnicity. All these contribute to how we target treatment for each patient.

As Sir explained, precision medicine requires developing data for culturally diverse groups, such as Indians and Asians, which differ from the widely available Western data. This involves recruiting cohorts of patients, specific data collection, curation, analysis, and reporting with the help of AI and ML, followed by validation of findings. This process leads to more precise diagnoses, treatments, and follow-up for better safety and outcomes.

Let me quickly share examples of how precision medicine has been used in cardiology. Genetic variants are linked to diseases like familial hypercholesterolemia and specific hypertrophic cardiomyopathies. Biomarkers can help stratify risk and guide therapy decisions. Drug therapy can be tailored based on genetic makeup—for example, clopidogrel resistance is significant in Asians. By identifying which groups are susceptible to adverse drug reactions, we can reduce these risks. Data-driven risk prediction and targeted therapies, such as PCSK9 inhibitors and newer treatments for amyloidosis, have also been implemented in our hospitals.

In cardiomyopathies—whether restrictive, hypertrophic, or arrhythmogenic—precision management involves gene-based therapies, addressing modifiable factors, and targeted rehabilitation. One particular study showed that 30 to 40% of hypertrophic cardiomyopathy patients are obese, suggesting a different phenotype compared to lean HCM patients. This is an example of how precision medicine is evolving to target specific therapies for patients.

Transthyretin cardiac amyloidosis is a well-known example in cardiology. Precision medicine has enabled molecular-level understanding of the disease and advances in non-invasive diagnostic techniques, allowing us to detect cardiac amyloidosis without histological confirmation. It has also revealed the prevalence of cardiac amyloidosis in other diseases, such as aortic stenosis. Treating both conditions simultaneously leads to better outcomes. New therapies include gene silencers like patisiran, stabilizers such as tafamidis and diflumicel, and emerging “remover” treatments.

There are many pending questions that precision medicine can help answer, particularly in heart failure and hypertrophic cardiomyopathy, with new drugs like mavacamten. In children, glycogen storage disorders can now be treated with specific gene therapies, such as agalsidase beta. Non-invasive imaging has contributed greatly to precision medicine in diagnostics, with PET scans and near-infrared spectroscopy aiding in the management of coronary artery disease.

Other vascular diseases, such as connective tissue disorders (Marfan syndrome, Loeys-Dietz syndrome), can now be treated with targeted therapies for familial and genetic disorders. Arrhythmias, many of which are gene-specific, have been extensively studied—especially syndromes like Brugada syndrome. The current and future areas of precision medicine include genetic testing, autoantibody titers, specific gene therapies, and improved risk stratification to prevent sudden cardiac death.

In conclusion, the benefits of precision medicine in practice are improved safety through reduced adverse effects and drug interactions, enhanced outcomes by selecting the right treatment for the right patient at the right time, and long-term cost-effectiveness. However, challenges remain, such as high costs, limited access to genetic testing, the need for clinical education and data interpretation infrastructure, and ethical and privacy concerns related to genetic data.

I thank all of you for this opportunity. As Mam said, we started this journey about 20 years ago. We may be progressing slowly, but we are moving steadily and will soon advance quickly. In the coming years, I hope we have many more studies from our institute and our country, enabling us to practice healing guided by each person’s unique blueprint—personalized, precise, and powerful. Thank you, Sairam.

Sairam, what an honor and a joy it is to be here with all of you. I’m honestly a little speechless at my reaction to this weekend’s activities, so I’ll need to get back to everyone later with my true feelings about this. It feels surreal to be here with you all on World Heart Day, standing on this stage. It truly is an honor.

We were told to plan for 10 minutes, but I gave myself 9 minutes because I consider myself a poor planner. By the end of these 9 minutes, I hope you’ll be able to: describe the steps for performing hands-only CPR, assess at least three training methods for hands-only CPR, and create a basic action plan for yourself.

During these 9 minutes, something else will happen: around 90 people across the world will suffer cardiac arrest. Of those 90, only one out of ten will survive—meaning we will lose about 81 people. Much of this loss is because, in many cases, bystander CPR intervention does not occur. I believe we can do better for each other.

I want to bring this issue to light because, despite all your training and years of caring for cardiac patients and their families, each of us has the power to save a life. Today, I want to talk a little about cardiopulmonary resuscitation and how we arrived at current practices.

In earlier times, people used primitive methods for treating cardiac arrest, such as swatting patients with stinging nettles and applying hot ash to the abdomen in hopes of warming the soul. Over time, our colleagues around the world continued to develop scientific techniques for resuscitation. For example, Swiss physician Paracelsus introduced the bellows method in 1530, and variations of this technique lasted for over 300 years—arguably similar to what we do today.

Some more unique developments came later. On the left, you can see the inversion method, which was popularized in 18th-century England for drowning victims. In the middle is a Russian technique involving snow burial, and on the right—perhaps my favorite—you simply put the victim on top of a horse. As the horse trots, the chest is compressed.

Progress continued over the centuries, with contributions from all over the world. A Scottish surgeon documented the first mouth-to-mouth resuscitation; a Danish veterinarian restored a chicken’s heart rhythm with an electrical shock; and German, American, and Austrian scientists all advanced the field. This culminated in 1957, when a team from Johns Hopkins developed the first portable external defibrillator—arguably one of the most important life-saving tools we can bring to our communities today.

All this development led to 2008, which was a great year personally (I graduated secondary school and left my parents’ house), but also a pivotal year for CPR. The American Heart Association, our leading experts in CPR research and training, announced that hands-only CPR has the same outcomes as traditional CPR and mouth-to-mouth resuscitation for bystander intervention. They launched a campaign to raise awareness about hands-only CPR, introducing a new slogan: “Push hard and fast in the center of the chest.” This became a powerful call to action, encouraging everyone to act in emergencies.

Next, I’ll play a video from the American Heart Association. This is the actual training video we use in our communities. Please note, it’s only 90 seconds long—perfect for reaching youth whose attention spans may be short.

If you see a teen or adult suddenly collapse, it’s important to act fast. Helping save a life is easier than you might think—just start hands-only CPR. First, ask someone to call 911 and get an AED (automated external defibrillator), or call 911 yourself and put your phone on speaker so the operator can assist you. Then, position yourself directly over the victim. Place the heel of one hand in the center of the chest, with your other hand on top. Push hard and fast in the center of the chest until help arrives. Aim for 100 to 120 compressions per minute—which is about the same tempo as the song playing in the video. Remember: call 911, ask someone to get an AED, then push hard and fast at the center of the chest until help and the AED arrive.

In the interest of time, I’ll keep moving forward. As you can see, hands-only CPR is an extremely simple method. In just 90 seconds, I’ve taught hundreds of children under age 10 how to perform chest compressions. It’s easy for us to spread this knowledge.

Not only is hands-only CPR simple, but bystander CPR outside the hospital is a critical step in the adult cardiac arrest chain of survival. As our electrophysiology colleagues mentioned yesterday, AED use is critical for survival in many cases of cardiac arrest. But what if an AED isn’t immediately available? Even when one is present, it may take several minutes—sometimes up to 10—to locate it, open the box, and begin using it. Every second wasted lowers the chance of survival.

A victim of cardiac arrest isn’t always guaranteed help from bystanders. Studies show that people who receive bystander CPR outside the hospital are two to three times more likely to survive cardiac arrest. Your chance of survival depends on those around you. Unfortunately, less than 50% of cardiac arrests are witnessed, and of those witnessed, less than 50% receive bystander CPR.

If it’s so easy and so necessary, why don’t more people step in to perform CPR? In many regions, bystander CPR rates are below 20%. In Rochester, NY, we’re striving to raise our rate to even 25%. In India, studies show bystander CPR rates ranging from just 1.3% to 10%.Clearly, the rate of bystander CPR is very low, with studies reporting figures between 1.3% and 10%.

What if we could help people break down these barriers? What if we could all be part of the mission to remove these obstacles, help clear people’s thoughts, and help them realize that the ability was within them all along?

So, how do we bring this to our communities? We use a variety of methods, which vary depending on the region and available resources. For example, in partnership with the American Heart Association and the University of Rochester, we deployed a CPR kiosk. This kiosk does not require a trainer; it is entirely virtual and comes with a practice dummy. While this option is quite expensive and not accessible to everyone, I wanted to show a more affordable alternative. I brought a training tool with me that costs about $40—perhaps you could find it for less. It’s just half of a mannequin, and the bag inflates it for use anywhere. If we can get AEDs to all of our villages, I believe we can get these, too.

In the middle, if you’d like to scan the QR code on the screen, it links to a Spotify playlist developed by the AHA. All of the songs on the playlist are between 100 and 120 beats per minute, which is the rate needed for chest compressions. This has been very successful, especially because younger generations may not be familiar with “Stayin’ Alive” by the Bee Gees.

We’ve also deployed some of these go-bags across libraries throughout our region. Partnering with community organizations is also a powerful tool. Obviously, resources, organizations, and partners will vary in every region, but we can all leverage what we have to make an impact. The screen shows some examples of where we’ve made a difference—including festivals, fairs, and even professional sports events. The Buffalo Bills, for instance, have helped us spread the word on hands-only CPR. We were able to play our 90-second video during halftime at one of our NFL games.

Now, moving quickly in the interest of time, I’d like to share a video with you:

“We got to hole 5, and my dad had just finished his drive. As he was walking back, he collapsed on the cart path. I ran, grabbed my phone, and called 911. The operator told me I needed to perform CPR because my dad’s color had turned purple. No one else there knew how to do CPR—I was the only one. So I started performing CPR and kept going for about 3 to 4 minutes nonstop. I know he couldn’t hear me, but I kept telling him to breathe, to wake up, and I did everything I could. I actually don’t remember anything about that day; my memory was wiped from the day and even the night before. I think I woke up a couple of days later and asked, ‘What am I doing here?’ When they told me I had suffered a cardiac arrest, I was shocked because I’d had no symptoms before this.”

“The first time I saw Jack, I was told what had happened. I didn’t even know he knew CPR, so I was incredibly surprised. It was extremely emotional. He gave me a couple of handshakes, squeezed my hand, and repeatedly thanked me. I’m grateful I learned CPR. At first, I never thought I’d use it, but the fact that I did—and was able to perform it on my dad—shows anything can happen at any time, and I’m extremely grateful I learned it.”

You have now seen not just one, but two of Dr. Rao’s patients with success stories. This all happened because our community encouraged our youth to learn CPR. We still have work to do, so I want to wrap up by challenging you to take action today. This is not complicated—none of my slides were as complex as some others you’ve seen during this conference. These are things you can do right now. I challenge you all to do something about this problem, because it will not improve unless we all work together. My challenge to you: teach one person hands-only CPR in the next 30 days. If you don’t know how, I’m happy to show you. On the screen, you’ll find QR codes for more information. The American Heart Association offers first aid and CPR training in over 100 countries and works with more than 150 organizations worldwide, through partnerships, scientific collaboration, advocacy, and quality improvement.

Bring my humble salutations, at lotus feet of the Divine Master Bhagwan Sri Sathya Sai Baba said.

Respected dignitaries, delegates, and my dear students, Sai Ram to all and good afternoon.

In continuation with my friend Miss Emily, I would like to discuss how a patient is managed and given instructions after undergoing cardiac surgery at our hospital. Swami, in his discourse at the inauguration of our institution on January 19, 2001, emphasized universal health care for all.

Let me share a few highlights of our hospital’s discharge procedures. In the year 2024-2025, our institution in Bangalore performed 135 coronary artery bypass graft surgeries, 207 valve surgeries, 482 congenital heart surgeries, and 125 other surgeries, totaling 949 cases.

This holistic preventive cardiology conference focuses on the three levels of prevention, with our focus on secondary prevention. As we know, secondary prevention centers on early detection and treatment of health conditions. It aims to reduce complications, improve recovery, and prevent recurrence for those at high risk or already living with disease through medication or lifestyle changes.

With this in mind, I’d like to discuss the role of our hospital’s medical professionals in supporting patients after discharge. We focus on various dimensions of lifestyle modification—what I prefer to call “life-threatening factor changes”—including dietary guidelines, physical activity, sleep and relaxation, personal habits, surgical site management, medication adherence, follow-up care, referrals, and counseling. The counseling department plays a major role in our hospital. Emergency preparedness is also critical, and we focus on warning signs of another attack. One key prevention aspect is BLS, as Miss Emily demonstrated. Our medical staff and students are trained in this, as you can see in the cardiac exhibition demonstrations.

Now, let’s review some protocols for patients after cardiac surgery. While these are well-known, it is important to recall and reinforce them in our daily lives and to educate patients. Swami’s principles include: avoid hurry, worry, and curry; remove cream from milk; limit coffee and other beverages; and prefer a vegetarian diet. In Bangalore and other major Indian cities, many people are switching to vegetarian diets for longevity. We recommend buttermilk, fruits, and vegetable salads. According to Dr. Mohan’s 2021 research, following nine dietary points—including reducing carbohydrates—can help prevent cardiac complications.

The next aspect is physical activity. Swami emphasized physical activity, and we heard today that by 2050, the World Heart Federation aims to prevent 80% of premature cardiac deaths by reducing life-threatening factors. Walking is the best exercise: start with 5 minutes before meals, and increase gradually to 3-4 kilometers over 30-40 minutes. Patients should avoid lifting, pushing, or pulling heavy objects. We share these tips upon discharge.

Sleep and relaxation are also essential. Sleep is heart medicine. We need to relax our minds, get 6 to 8 hours of sleep at night, and rest for 1 to 2 hours in the afternoon. Many medical personnel, for example, have lost their lives due to lack of sleep while working long hours. Please reflect honestly—how many of us had 8 hours of sleep last night? We must care for our own health, too.

Other important advice includes: avoid bathing in very cold or hot water after cardiac surgery; stop smoking; manage weight and maintain an ideal body weight (e.g., if your ideal is 62 kg, try to stay close to that value without drastic changes); and control chronic conditions like diabetes and hypertension. I often tell my students that diabetes and hypertension are like husband and wife, and their “child” is renal failure—an effective way to highlight the dangers to patients. Medication safety is also emphasized: if you experience chest pain, sit down and take the recommended medication.

Finally, patients are encouraged to see a physician if they experience cardinal signs or symptoms—chest pain that becomes more frequent or unbearable, shortness of breath at rest or during walking, swelling in the feet, dizziness, severe headache, or repeated fainting. There are also specific protocols after valve surgeries, such as anticoagulation therapy (which another speaker will discuss in detail), endocarditis prophylaxis, gradual return to activities, and monitoring for valve-related complications like arrhythmias and clotting.

At Sri Sathya Sai Hospital, our care model is holistic. We encompass physical, emotional, and—importantly—spiritual support, along with patient and family counseling, free follow-up camps and health education programs, telemedicine, and an emphasis on discipline, faith, and preventive lifestyle.

In conclusion, adherence to precautions ensures safe recovery. Hospital protocols improve outcomes and prevent recurrence. To summarize Swami’s message: “Life is a journey from I to we. By caring for our own hearts—physically, mentally, and spiritually—we become instruments of love, harmony, and selfless service to others.”

I sincerely thank Swami, the organizers, our institution, and my well-wishers for giving me this wonderful opportunity. Thank you, and Jai Sai Ram.

I would like to offer my humble pranams at the Lotus feet of our Lord. I would also like to thank our organizations for giving us the opportunity to present at this celebration of the 100th year of the advent of our Poorna Avatar.

Advances in medical imaging over the last two or three decades, along with significant developments in high-performance computing in the past twenty years, have placed us in a position to present dynamic simulations of heart valves, such as the mitral or aortic valve, under various disease scenarios. These simulations provide objective information to cardiologists and cardiac surgeons, aiding them in making optimal decisions for patient treatment.

We began this effort when I was a faculty member at the University of Iowa, starting the dynamic simulation program from scratch about twenty years ago. Our collaboration included expert computational scientists and numerous doctoral students working on different aspects as the program developed over the years. We also acknowledge the support and collaboration from our cardiac surgeons and cardiologists at the University of Texas Medical Sciences at Houston, as well as the funding agencies whose support made this work possible.

All imaging and physical data used in our studies were obtained only after clearance from the Institute of Human Subjects Review Board, and no personal identification information was received. Our workflow starts with clinical images, regardless of the imaging modality used for diagnostic purposes. From these images, we identify the region of interest—for example, for the aortic valve, we focus on the valve structure, the ascending aorta, and the left ventricle. We segment these regions and create a three-dimensional geometry, which we then input into our fluid-structure interaction simulation program.

For example, when simulating the aortic valve opening during isovolumic contraction and ejection, we consider the closed valve and the rise in ventricular pressure. As the ventricular pressure exceeds the aortic pressure, the valve opens and blood rushes through, causing further movement of the leaflets. This constant interaction between blood and leaflets is simulated from the fully closed to the fully open position using a computer-intensive program. We divide the duration into very small time steps, and at each step, a fluid solver calculates the blood flow, a solid solver computes the leaflet motion, and the interaction between blood and leaflet is resolved for accuracy. We iterate at each time step until the results converge before moving on to the next.

I will now present two examples. On the left is a reconstruction from a patient with moderate aortic stenosis. We reconstructed the valve, part of the ascending aorta, and the left ventricle. Our focus was on the phase when the ventricle is contracting and pressure increases; we conducted these computations after the mitral valve was closed to reduce computational time, treating it as a continuation of the endocardium. We then simulated contraction by computing the end-diastolic and end-systolic volumes for that particular patient and the heart rate at the time of imaging, applying a Gaussian relationship to mimic the contraction process. Currently, our simulations use patient images from individuals without symptoms of coronary artery disease.

On the right is a patient with Turner’s syndrome, featuring a bicuspid aortic valve shown in the expanded view. Two leaflets are fused with a raphe, while one leaflet is free. This patient also has a dilated ascending aorta and an elongated arch. In the simulation for the patient with moderate aortic stenosis, we computed a maximum jet velocity of about 3.9 meters per second and a pressure drop of approximately 40 millimeters of mercury across the valve. Following TAVR implantation and a repeat simulation, the maximum velocity decreased to 1.7 meters per second and the pressure drop to about 15 millimeters of mercury. Comparison of our predictions with actual physiological data before and after TAVR showed strong correlation.

For the patient with Turner’s syndrome and a bicuspid valve, the valve was restricted and did not open fully, resulting in jet-like flow and considerable energy loss across the valve and the elongated arch. Although this patient was not treated, we demonstrated the predictive capability of our simulation by performing a virtual commissurotomy, freeing the leaflets. This led to a wider valve orifice and significantly reduced energy loss, although the elongated region continued to exhibit energy loss, limiting improvement in flow deceleration.

Currently, we are focusing on moderate aortic stenosis. Typically, patients with moderate aortic stenosis are assessed at rest for clinical parameters, but a study by one of our collaborators involved a cohort of about 20 such patients subjected to dobutamine stress testing. About 40% demonstrated severe energy loss across the valve, raising the question of whether intervention might benefit these patients. We were challenged to see if our simulation could mimic a stress test; we increased heart rates from the baseline of 70 beats per minute to 80, 90, and 115 beats per minute. Our simulation showed that with increasing heart rate, the emerging jet became stronger and impacted the aortic arch wall. Shear stress calculations at the arch wall indicated that higher heart rates produced significant regions of elevated shear stress, which studies show can induce further dilation and even aneurysm formation. We also observed high stress concentrations in the leaflets at elevated heart rates. Our predicted pressure drop and flow rate matched well with actual medical data. Based on these findings, we propose that virtual stress testing could help stratify patients with moderate aortic stenosis who are at high risk of deterioration and may benefit from intervention. We plan to pursue this hypothesis in the near future.

Now, I will hand it over to Doctor with Akhil, who will discuss our ongoing studies on left ventricular motion.

Humble pranams at Bhagawan’s Lotus feet. At the outset, let me thank Doctor Krishna Rao Garu. To continue in line with Doctor Iyer Sir’s remarks—he called me at 1:00 AM while planning the schedule, and his tireless work is clearly reflected in the grandeur of this event. There is a saying that the best way to reach a man’s heart is through his stomach, and I’m sure most of us are thinking more about food than the heart right now!

I come from the Department of Mathematics and Computer Science, and much of what Doctor Prayag Sir has explained covers our area. I would like to summarize a few points and emphasize that this work is in collaboration with Professor Chandran Sir. I want to decode one main idea mentioned by Doctor Prayag Sir: “AI to SAI.” When we refer to artificial intelligence, we are essentially talking about statistics. However, statistics must be approached carefully. For example, one statistic claims that one in every five people is Chinese—yet looking around this room, that doesn’t seem accurate! Instead of artificial intelligence, perhaps we should focus on “attention intelligence,” and Swami has beautifully guided us toward spiritual attention intelligence. I believe that should be the theme of our discussions, which has been beautifully highlighted.

We are using some AI techniques, with the hypothesis that early detection is possible. Of course, we obtained ethical clearance and collected data from our super-specialty hospital, which is a gold mine for research; I encourage visiting doctors to explore it for research purposes.

Our main hypothesis is to replace the crude, hypothetical models of the left ventricular region—often assumed to be a parabolic hemisphere or inverted Gaussian—with patient-specific models. We use cubic spline interpolation and are exploring geometric and dynamic problems. We have implemented and strengthened the results from a noteworthy paper, accounting for ethnicity by combining data from Western databases with data from our super-specialty hospital. This allows us to optimize the results for our ethnic data sets and achieve very good accuracy.

We have also simulated the left ventricular region, and this work is ongoing. We hope to integrate fluid and structure interactions using AI and computational methods.

Thank you.

Loving pranams at the Lotus feet of our most beloved Lord. At the very outset, I am extremely thankful to the organizers, especially Doctor Krishna Rao, Doctor Uday Kiran, Doctor Chandran, and my good friend Mr. Shavan, for making me part of this wonderful event. It is a blessing to be here.

I will briefly share the bare minimum details of our recent work. We are attempting to integrate AML and DL methods with CFD for left ventricle flow dynamics, in collaboration with my colleagues from ITBHU. This is ongoing work, and I will share a few details.

First, integrating ULDL methods with computational fluid dynamics involves several important steps, each of which is a significant research area. The first is data generation, which is not trivial; we are currently investigating and refining the quality of data for AML research. Next, it is crucial to identify useful biomarkers for disease diagnosis; we cannot use just any feature, and this selection is itself a research focus. Incorporating these into an AML model and validating it is another essential step. Finally, deployment and successful application complete the process.

Machine learning methods, especially regarding data generation, follow a basic workflow: collecting large amounts of data, dividing it into training and test sets, building and training a model, and then deploying it. Obtaining data for ventricular analysis is challenging in academia, especially for rare diseases. To address this, we employ reduced-order or surrogate models, which are state-of-the-art in generating clinically valid data for ML methods. These models allow rapid data generation for isolated cases and provide supplementary data for ML algorithms.

Using these models, we compute important metrics such as LV pressures, stresses, and strains computationally using minimal patient data. The left side of our model shows how we transition from high-fidelity computational models to low-fidelity surrogate models, which are fast and effective for data generation and ML input. The right side showcases insights into flow dynamics generated by surrogate models, both as biomarkers and ML data. We produce strain and Q-criterion values, lambda values, and other hemodynamic biomarkers essential for disease diagnosis. These are visualized in different views.

Importantly, we generate strains from surrogate and reduced-order models, providing valuable data for ML analysis in clinical diagnostics. High-fidelity model solutions can now be obtained quickly using surrogate and ML models, and we validate these clinically. For example, pressure-volume loops generated by both high-fidelity and surrogate models are physiologically significant and clinically useful. High-fidelity models may require thousands of CPU hours for one cardiac cycle, but ML models can complete this in about 11 CPU seconds—a tremendous advantage. Similarly, predicting stress distribution drops from 20 CPU hours to about 12 CPU seconds with ML methods.

Deep learning can also be used for automation in LV diastolic evaluation. There is a flowchart for developing LV and AI models, which I will skip for brevity. Echocardiograms from numerous patients are classified by Doppler modes, and important diastolic parameters are evaluated through mathematical algorithms, resulting in grading of diastolic dysfunction (Grade 1, Grade 2, Grade 3). This algorithm has been successfully deployed and tested.

On the Y-axis is the AML method’s evaluation of E velocities and E prime velocities, which match very well with manually and clinically validated values. Another comparison shows that the E/A ratio calculated by ML models closely aligns with manually calculated clinical values. Therefore, ML methods are promising for deployment. However, caution is needed: the confusion matrix shows a good match between manual and AI-calculated values, but some disparity exists compared to clinical prior assessments. Notably, derived guidelines outperform manually derived assessments, indicating promise but also a need for careful validation.

In summary, AI-based approaches for automatic LVDF assessment using echocardiography are feasible and can enhance clinical diagnosis, but caution is advised. The final take-home message is that AI offers speed, accuracy, discovery, personalization, and potential for the future, which we can leverage.

With that, I offer my gratitude to Bhagwan at the Lotus Feet. Sairam.

Sairam, everyone. I offer my humble pranams at Swami’s Lotus Feet. I know I am the last speaker between you and the food, so I will try to keep my remarks to 30–45 seconds. First, I thank Doctor Krishna and the organizing committee for giving me this opportunity to present something unique, which has materialized with Swami’s grace.

I will skip the next slide, as the past two days have covered these topics extensively. My focus is on future directions, especially as we are bombarded with artificial intelligence. At work, we are exploring a new direction called artificial super intelligence, which promises benefits not only for the medical community but also for the financial industry and others.

The National Institute of Standards and Technology (NIST) in the US has recently published API protocols for AI models. API stands for Application Protocol Interface, which facilitates communication with AI models and data transfer. We use APIs regularly, often unknowingly, during financial transactions and other activities. When NIST released this protocol, it caught my attention because it lacked guardrails based on Swami’s foundational principles. I reviewed the protocol, identified the do’s and don’ts, and pointed out potential issues. With Swami’s grace, the institute responded positively, accepting all my observations, which are now being incorporated into the revised protocol coming to market soon.

The future lies in ethical and explainable models. If models are not built on strong foundational principles, their decisions may be skewed and potentially harmful, even if the tools appear sophisticated. With Swami’s insight, I was able to contribute to these fundamental models and protocols. At work, I handle terabytes of data for sanitization and various applications. Ensuring APIs are explainable and free of ethical bias is crucial.

In the interest of time, I will pause here and express my gratitude to Swami and my fellow team members, who have done an exceptional job not just discussing concepts but also making them a reality. Thank you, Sairam.

Dr. Sathya Swaroop Patnaik

Good afternoon. Sairam, offering my prayerful salutations. Greetings to the speech of our beloved Bhagwan and my esteemed faculty. Sir, may I request you to proceed with the presentation?

In the next few minutes, I will discuss the initiative of anticoagulation clinics, a unique outreach seva undertaken in Odisha. In fact, our hospitals are among the few that continue to follow up with patients far beyond simply providing a discharge summary. Most hospitals follow up only until discharge or perhaps for a few visits afterwards.

However, through the SRB program and the Sri Sathya Sai Seva Organizations, our hospitals follow up with patients, especially cardiac patients, until their last breath. This is crucial because these poor patients, who have undergone surgery, often face challenges in valve maintenance due to a lack of knowledge, financial constraints, limited lab facilities, and sometimes a casual attitude toward their health.

Through the Sai Rehabilitation Program, thousands of patients have been followed up, not only in Odisha but also across the country in many states. In Odisha, we have introduced anticoagulation clinics where, once a month, clinics are set up for patients who require regular tests. Patients can visit these clinics to have their tests done.

We have established these clinics in 11 locations throughout Odisha. Typically, patients come to the clinic, have a blood test, and then, via teleconference, a local doctor connects with a cardiologist. The cardiologist advises on medication dosage, prasadam is served, and the patients happily return home. The advantage is that we use point-of-care machines, so results are available within a minute, drastically reducing wait times. Normally, when a patient travels to the capital or district headquarters, it takes an entire day, and they may not even get to see a cardiologist. Here, results are immediate, and within an hour, the cardiologist is available via teleconference. The machine is portable and used at multiple centers with low maintenance needs. While there have been some challenges with the machine, we have overcome them over time.

In summary, the SRV clinics are a great blessing for patients, doctors, and Sevadal volunteers. It is truly a unique community outreach effort that increases patient compliance. For us volunteers and Sevadal, it is a successful organizational initiative and an expression of our gratitude to Bhagwan for the thousands of patients in our state who have received new life in these hospitals. Our aim, our prayer, and our centenary offering is to achieve zero mortality due to patient negligence. Thank you—this is our humble offering. Sairam.

Regular follow-up has a significant impact on the outcomes of post-cardiac patients, as we have just seen. Now, to elaborate on how healthcare reaches remote and inaccessible areas, I invite Dr. Sanjay Agarwal to speak.

Dr. Sanjay Agarwal

Sairam. Om Sri Sairam. My most humble pranams at the lotus feet of Bhagwan Sri Sathya Sai Baba. Not taking much of your time, I would like to discuss our outreach programs and introduce a short video we wish to share.

Anantnag, Pahalgam, and Srinagar in Kashmir are some of the challenging places where we felt inspired to provide medical services. We traveled to Srinagar, Pahalgam, and Anantnag—places where Bhagwan Sri Sathya Sai Baba visited in 1956. We even found the houseboat where Swami had stayed and spent a night there ourselves. This video highlights some activities of the Sri Sathya Sai Seva Organization and the Sri Sathya Sai Central Trust in Ladakh.

Leh Ladakh is a remote area with very limited medical facilities. There is only one government hospital, but now, thanks to our organization and the trust, there is also the Mahabodhi Hospital—Sri Sathya Sai Hospital. We have provided significant equipment and sent doctors to conduct regular camps in Leh and Ladakh.

The managing Buddhist monk at Mahabodhi Hospital, revered All India President Sri Nivesh Sir, respected managing trustee Ratnagar Sir, and the Central Trust team from Puttaparthi all visited. This was just one year ago.

We supplied the hospital with essential equipment, including a modular operating theater, laparoscopic tools, radiology setup, and various wards. The hospital now boasts the latest technology. The Central Trust assisted in equipping this hospital.

Similarly, we have ventured into the Andaman and Nicobar Islands, sharing our medical services across India—from north to south, east to west. Our organization provides medical services even in the most remote areas, with the support of the Central Trust and the Sri Sathya Sai Seva Organization in every state.

Recently, we held medical camps in Leh and Ladakh, where last month alone, we treated around 800 patients. Surgeries, including knee and hip replacements, were conducted by a team from Bangalore in this small 30-bed hospital, which now includes an ICU.

I just wanted to highlight that the Sai Seva Organization operates in every district and state in India, delivering medical services to far-flung areas with the blessings of Bhagwan Sri Sathya Sai Baba. While the government is making progress, much remains to be done since there is still a lack of medical services in some places. However, the situation has improved significantly compared to 20 years ago, during Swami’s time. Back then, we were sent to villages with no medical services at all. Now, we focus on areas where facilities exist but are either underutilized or overburdened.

Thank you very much, Sairam, and thank you to my dear colleagues for such a beautiful presentation and for adhering to the schedule. It is a great privilege to stand before our beloved Bhagwan—even a single minute in His presence means a great deal to us. Dr. Ram Manohar Rao, the National Medical In-Charge, has clearly summarized in his last slide how all these activities reach people throughout India. Thank you very much. Sairam.

We offer ourselves at Bhagawan's divine lotus feet. Esteemed healthcare experts, respected elders, and loving Sairam to all of you.

On behalf of the researchers from the Department of Chemistry and the Department of Biosciences at Sri Sathya Sai Institute of Higher Learning, we extend our gratitude to the organizers for giving us this opportunity to present a prospective study that resulted from our collaboration with the Cardiology Department of Sri Sathya Sai Institute of Higher Medical Sciences.

The study, titled “Integrating Psychosocial and Sleep Dynamics Improves Long-Term GRACE Risk Prediction After First Myocardial Infarction,” had two primary objectives. The first was to answer the question: Does integrating psychosocial and sleep variables into the GRACE score improve long-term risk prediction?

As we know, the GRACE score is primarily a risk stratification tool used during triage, where doctors must prioritize patients—especially when several arrive at the same time. During the early days of my clinical study, I was in the CCU and observed two patients: one receiving oxygen support and multiple cannulas. I asked the doctor if that patient would survive, and he pointed to the patient smiling in the next bed, explaining that he was actually more critical because his LV was only about 20. That was when I realized that a cardiologist’s perspective is very different from that of a layperson. The GRACE score considers variables such as age, heart rate, systolic blood pressure, creatinine level, Killip class (cardiac failure level, classes I to IV), cardiac arrest at admission, ST deviation at admission, and troponin levels. This model, developed in the early 2000s and validated on more than 40,000 patients, effectively stratifies patients into low-, medium-, and high-risk categories for up to six months, guiding treatment accordingly.

However, in Southeast and South Asia, most patients who suffer myocardial infarction and undergo revascularization experience a secondary event within three years—about 15 to 50%—and there is no structured way of monitoring these patients over time. That is why we decided to capture more than 40 parameters from patients recruited in the Cardiology Department.

Methodologically, we recruited 350 patients, capturing their demographic and socioeconomic details, medical history (such as diabetes, blood pressure, whether they had NSTEMI or STEMI), and calculated their GRACE score. We also assessed psychosocial parameters using GAD-7 and PHQ-9 questionnaires. Notably, these questionnaires were developed for Western populations, and we found them challenging to administer in our setting. For example, the PHQ-9, which assesses depression, asks about interest, concentration, and appetite over the past two weeks—questions that are difficult for many patients to answer. Upon consulting a psychiatrist from NIMHANS, we adopted a binary approach for the questions and analyzed each item individually, rather than summing the scores, which improved the significance of our findings. We were able to identify anxiety and restlessness more clearly.

Sleep was also a significant factor. We evaluated sleep quality by asking whether patients felt refreshed upon waking, what time they went to sleep and woke up, and how often their sleep was interrupted. Out of the 350 patients recruited, we followed 51 patients, and 95 of them experienced a second event within five to five and a half years. After statistical analysis—including univariate Cox regression and multivariate analysis of significant variables—we moved to our second objective: showing the importance of longitudinal data.

Most studies are based on baseline data collected at admission, with little follow-up. We followed patients at one month, six months, and one year post-admission, asking them to return to the hospital for assessment of LVF, GLS, cortisol levels, glucose levels, and repeating the questionnaires. This yielded interesting findings, which Brother Bhargav will now present.

Title

Hello everyone, and thank you, brother, for laying out the context. Regarding our findings, our cohort consisted of about 319 patients, and during a median follow-up of approximately five and a half years, 94 patients—nearly 30%—experienced major adverse cardiac events. The right panel displays the robustness of our follow-up. Most patients fell into the lowest GRACE risk category, yet many still developed events, some within a year. This highlighted the limitations of GRACE and justified testing whether adding in-hospital or longitudinal data could improve long-term risk predictions.

We examined the various factors captured, and the top panel shows significant predictors among the in-hospital variables. These were combined into a multivariate model, which distilled down to four variables, including GRACE score, cortisol, postprandial glucose, and the GAD-7 questionnaire (relating to restlessness). Similarly, longitudinal data showed that sleep interruption, sleep quality, LVF, and global longitudinal strain were significant during follow-up. We combined these significant predictors with baseline data to create a list of nine variables that were significant predictors in our cohort.

We compared how these models predicted events from one to five years and found that the enhanced model outperformed GRACE and other baseline parameters. Extensive literature shows that anxiety, depression, and sleep fragmentation drive sympathetic overactivity and inflammation, both of which are associated with the current risk in myocardial infarction.

Based on our findings, the key message is that repeated, simple measurements of depression, anxiety, and sleep quality can meaningfully improve the risk prediction of myocardial infarction. In practice, these can be integrated into routine healthcare with minimal effort. Simple yes-or-no questions are effective in our setting, where lengthy or stigmatized questionnaires may be less culturally acceptable. With the rise of mobile health tools and wearables, such monitoring can be scaled even in resource-limited environments. Most importantly, this approach enables dynamic, personalized secondary prevention rather than a one-size-fits-all model.

This study would not have been possible without the support of various organizations and well-wishers, to whom we express our sincere thanks.

In conclusion, there are four recommendations based on discussions with Dr. Ayar and other senior doctors:

1. Every MBBS student should be able to read an EKG, as late referral is a major reason patients succumb. Early administration of basic thrombolytic agents, particularly in rural areas, can reduce damage before patients reach tertiary care centers.

2. Regarding sleep disorders, some non-sedative medicines, such as melatonin-based medications (e.g., Melocet), can help individuals achieve restful sleep. If incorporated into follow-up care—just as we control blood pressure, diabetes, and hyperlipidemia—this could be beneficial due to minimal side effects.

3. The question of whether to opt for stenting or medical management is important, as some patients discontinue medications due to affordability. This practical consideration must be addressed by doctors when making treatment decisions.

4. There is a need to develop indigenous questionnaires for assessing depression and anxiety, tailored to our population rather than relying solely on Western models. This should be initiated using Delphi models and collaboration among experts as soon as possible.

Thank you so much. Sairam.

Pranams at the lotus feet of Bhagwan Saima.

Respected elders, sisters, and brothers,

I am going to speak on the topic of well-being, stress, burnout, depression, and cardiovascular health. We all seek Bhagwan's blessings for our presentations, and that is very important.

Let me start with two stories. The first story is about a cricketer. Fifty years ago, cricket matches would last five days, and even now, some matches are played in that format. There was a one-down batsman who came to the crease because the opening batsman was out early. He had received a telegram, which he put in his pocket before starting to play. Before lunch, he scored his first century. Before tea, he scored his second, and before stumps, he scored his third century. Someone reminded him about the telegram. He replied, “Yes, I received a telegram. I know what it is about. My mother is no more.” His mother had been ill, and he suspected the news, but he knew that if he read the telegram, he would not be able to play. This story shows that death can cause 100% stress.

In the same story, this man later lost his young wife and was left with two sons. Instead of crying and lamenting, the sons started singing songs in praise of Bhagwan. Someone questioned them, “Are you mad? Your wife has just passed away, and you are singing?” They replied, “That is how we deal with it.”

Let us now look at some positive aspects of well-being and cardiovascular health. We often say that well-being and happiness are needed by everyone. We want to experience ‘suk’ (happiness), but often, we encounter ‘duk’ (sorrow)—sorrow, sorrow, and just a little bit of happiness. We find ourselves in such situations.

The chronic stress response has various causes. Often, it is the framework of the mind that creates stress, and when stress accumulates over time, it can lead to burnout. As the saying goes, “One can burn out only if one is burning earlier”—meaning stress has built up over a period. In this weakened state, stress can cause hypertension, ulcers, and heart problems. Therefore, burnout is a much more serious form of stress.

What are the consequences of burnout? In organizations, job performance declines. We lose self-worth and passion, face increased health risks, and can develop cardiovascular disease (CVD).

Depression can result from prolonged stress and burnout when a person is unable to cope. Depression is a serious mental disorder; the opposite is mania. The negative effects include sadness, impaired thinking, darkened perception, and a lack of action. Stress, anxiety, and depression often lead to acute coronary events and heart failure because, over time, a person cannot help themselves and requires support.

The heart and brain are connected; we cannot consider heart health in isolation. If we allow both to work together, it leads to positive outcomes.

Global studies show that depression affects 32.3% to 47% of people, while cardiac issues are around 57.7%. In the Indian context, depression ranges from 20% to 35%, with stress being 50% higher than average. This increases the risk of CVD, and burnout is seen in 21% to 27% of people.

There are coping strategies, such as mindfulness and cognitive therapy. Both are important and have provided significant benefits to many people. Ideally, one should avoid stress, burnout, and depression. However, if one does experience these states, it is important to seek help and recover as soon as possible.

What is mindfulness? It is meditation, breath awareness, balance, stress reduction, and awareness of body and soul. As Bhagwan says, do not be anxious about the results—perform your job efficiently, with devotion and peace. These are some effects of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).

In conclusion, well-being, or ‘suk,’ is an integral part of health. Heart health, stress, burnout, and depression are modifiable risk factors, meaning there is always a chance to improve. Mindfulness and coping strategies can improve cardiovascular health. Sairam.

At the outset, Om Sairam, I am grateful to Baba for this opportunity. I would say it is a privilege to be standing here and giving a short presentation. Over the next 10 to 12 minutes, I will be talking to you about heart-healthy dietary strategies in rural settings.

When I was given this topic, I was a bit surprised—why focus on rural settings? We already have enough problems in urban areas. Why am I being asked to emphasize rural contexts? However, multiple reviews and analyses indicate that ultra-processed foods are consumed at rates as high as 56% in urban populations, and the gap between urban and rural populations is narrowing. Hence, there is a pressing need to address this burning issue of dietary strategies in rural areas.

Another set of data from the WHO and FAO clearly tells us that we need to consume 400 grams of fruits and vegetables daily. Yet, neither high-income nor low- and middle-income countries are meeting these standards. So, what is really happening? Around 80% of the 437 million people with cardiovascular-associated disability-adjusted life years suffer from conditions that can be prevented by addressing modifiable risk factors. Preventive cardiology, therefore, is not just a point of action—it is a global imperative.

There is a wealth of evidence showing that several food ingredients play a vital role in vascular health, endothelial function, lipid profiles, blood pressure management, weight loss, and more. Today, I will present on the importance of both the quality of diet and the timing of meals in preventive cardiology.

It is well known—it's not rocket science—that plant-based diets help reduce cardiovascular disease risk by 16 to 22%. Consuming 7 to 10 grams of fiber daily can reduce this risk by another 10 to 15%. But what is the main reason behind these plant-based diets? It’s not just the fiber; the most important component, I would say, is the polyphenols. For example, when we advise patients to consume a colorful plate, we mean including anthocyanins in beets, lycopene in tomatoes, flavonoids and phenolic acids in leafy greens, and the various spices we use. There is a lot of talk about turmeric, but remember, there is an acceptable daily intake. You should not consume more than 3 milligrams of curcumin per kilogram of body weight, and curcumin only has its anti-inflammatory effect when consumed with piperine—so turmeric should be paired with black pepper to be bioavailable. Additionally, do not exceed 3 grams of turmeric per day, as it can negatively impact the liver and gallbladder. So, when choosing certain spices, we must consider their acceptable daily intake and potential toxicity.

What do these polyphenols do? They scavenge free radicals, prevent platelet aggregation, and have thrombolytic effects, among other benefits. Another study followed 90,000 subjects for 22 years and found that the source of fat in the diet is very important. When replacing simple carbohydrates and saturated fats from animal sources with monounsaturated fats (MUFA) from plant sources, there is a lower risk of cardiovascular disease. Unsaturated fats can come from avocados, olives, or canola oil, but more commonly in our context, from pumpkin seeds, sesame seeds, flax seeds, and so on.

Much research points to the benefits of plant-based diets: fiber, antioxidants, and polyphenols deliver anti-inflammatory effects. Interestingly, vegetarian diets impact markers like HSCRP and HOMA-IR, as well as other metabolic variables, more favorably compared to pescatarian or vegan diets. Numerous studies show positive effects on cardiometabolic health and all-cause mortality. The USDA Dietary Guidelines 2020–2025 and the American Association of Family Physicians support these findings.

The take-home message from the CARDIA study, which followed participants for 30 years without intervention, is that those adhering to a healthy plant-based diet and consuming very few adverse foods (such as saturated fats, trans fats, and unhealthy sugars) had a 52% lower risk of cardiovascular disease compared to others. Whether it’s the AHA, ACC, or GACC recommendations, all emphasize plant-based diets. An extension of the plant-based diet is the Mediterranean diet. In India, AIIMS has introduced an Indo-Mediterranean diet using Indian ingredients rather than Western ones.

The Mediterranean diet has been supported by studies like the PREDIMED RCT, which showed that subjects on a Mediterranean diet with unsaturated fats and nuts had a 30% relative risk reduction in myocardial infarction, stroke, and cardiovascular death. Guidelines from the ACC and AHA recommend this diet as the most effective eating pattern for primary prevention of CVD, reducing risk factors and overall mortality.

Another extension is the DASH diet. To summarize, the DASH diet is similar to the Mediterranean diet minus the red wine, with further reduction in sodium intake to as low as 1,500 milligrams per day. This leads to reductions in LDL cholesterol, blood pressure, and all-cause mortality. Larger and longer RCTs are still needed to fully establish its benefits. The DASH Sodium Trial assigned subjects to three groups with varying sodium intake (3,450 mg, 2,300 mg, and 1,150 mg), and found that lower sodium intake alongside the DASH diet led to a 14% reduction in ASCVD risk. The DASH diet is recommended by the JCC guidelines, emphasizing reduced salt intake and low-fat dairy.

The world often discusses low-carbohydrate diets. According to the National Lipid Association, when carbohydrates are reduced, they are replaced by protein or fats, and it is crucial to choose the right fats. If the wrong fats are chosen, data shows increased LDL cholesterol. Twenty-three meta-analyses through April 2023 show that low-carb diets promote weight loss and reduce triglycerides, with increases in HDL cholesterol, but also raise LDL cholesterol. Seventeen meta-analyses of 68 RCTs confirm that ketogenic diets are associated with a clinically meaningful increase in LDL cholesterol. The AHA, ACC, and JCC agree that low-carb diets should not be the first line for CVD prevention. If used, they should emphasize plant-based proteins and unsaturated fats, and overall diet quality cannot depend on a single macronutrient.

Intermittent fasting is another area of interest. Forty-eight systematic reviews over 10 years suggest that intermittent fasting leads to weight loss and improvements in LDL, triglyceride, and HDL cholesterol. However, a recent abstract by Sebastian et al. (2024), based on NHANES data following 20,000 subjects for 8 years, found that those with time-restricted eating patterns of less than 8 hours had a 91% increase in CVD mortality, though this was not peer-reviewed. Later, a peer-reviewed study by Chen et al. followed 19,831 subjects (both diabetic and non-diabetic) for 8.1 years and found an even higher mortality—131% in non-diabetics and 224% in diabetics—among those following less than 8 hours of eating compared to 12 to 16 hours. This is meaningful data. Another important factor is aligning diet with the circadian rhythm. Cortisol peaks in the morning, ghrelin at 8:00 AM, 1:00 PM, and 6:00 PM, suggesting breakfast should be between 8:00 and 9:00 AM. Adiponectin peaks at 11:00 AM, and insulin at 5:00 PM, with leptin at 7:00 PM, supporting the idea of an early dinner, or "Jain dinner" in the Indian context.

The ACC and AHA suggest that while early time-restricted eating may increase CVD mortality, following the Okinawan approach of eating only until 80% full ("hara hachi bu") can help reduce obesity, triglycerides, LDL, and total cholesterol, as it takes about 20 minutes for the brain to register fullness.

In conclusion, one of the cardinal principles of Sri Sathya Sai Ideal Healthcare is to emphasize preventive care through education, awareness, and early intervention to prevent illness. I request everyone who can, please stand up to take a small pledge:

• I pledge to reach one and teach one.

• Control salt—delete extra sodium from my diet.

• Control, Alt, Delete: remove processed snacks high in fat, salt, sugar, and sugar-sweetened beverages, and replace them with plant-based diets.

Thank you very much for your patient listening.

Thank you, Ram, thank you, everyone, and thank you to our beloved Swami for this opportunity to stand before you and speak.

I will speak briefly, as I know we are short on time, about how we are serving the underserved population in America by bringing Swami's message and teachings on healthcare to those who have been left behind.

As you may know, the healthcare system in America is insurance-based and largely private. For those without access to care, the system is tiered and limited. I did not realize this when I moved to America in my early twenties. I was fortunate to work at the Mayo Clinic for my residency and fellowship. I would often say to my husband, Abiram, that the patients here are dressed so nicely—so different from London, where I was born and raised. Because of this, we started setting up some free medical clinics with colleagues. However, my heart always drew me back to the population that did not receive the care provided at these beautiful institutions in the U.S.

In 2019, I was blessed to come across a facility in Rochester, Minnesota, which serves the underserved. It is a long story, but Swami invited me to speak in 2009 at the Spirituality and Healthcare Conference, and that was when my work shifted to integrative medicine. Mayo Clinic was introducing a complementary and integrative medicine fellowship and asked me to be their first fellow. I initially resisted because I had already trained in medicine, but Swami has his own way. When I received the invitation to speak in 2009, I knew that spirituality in healthcare was my calling.

So, I began working with the underserved population at Zumbro Valley Health Center, a mental health facility that serves the poorest of the poor in America—including the homeless, those recently released from jail, and others who have been left behind and do not have access to care. Sometimes, even when they have insurance, they do not avail themselves of care due to mental health and substance use issues. In America, poverty looks different from that in India; here, mental health and substance use often result in homelessness. There is a great deal of drug use among this population, and our facility strives to provide a compassionate model of care. We are based in Minnesota and serve surrounding counties.

We have a comprehensive model of care for adults, families, and young children. Unfortunately, as mental health needs have increased, so too have the number of clinics in Rochester. We do our best, providing patients with care coordinators or case managers who can visit patients' homes, help them take medications, accompany them to medical appointments, and assist with grocery shopping and food needs. We offer both inpatient and outpatient clinics. I work alongside our psychiatrists, and when I started in 2019, I focused on internal medicine—seeing patients with COPD exacerbations, diabetes, and fungal infections. Very quickly, I realized that this population was dying prematurely, not only from mental health issues but also from preventable cardiovascular disease, which remains largely untreated in most mental health facilities. Patients in our population die about 25 years younger than the average person, and this is preventable.

Smoking cessation is probably the most important intervention we can offer. Educating our staff and clinics about tobacco cessation is crucial. We know that helping people quit tobacco not only improves cardiovascular health but also enhances mental health by reducing anxiety and depression. Furthermore, patients who quit nicotine are more likely to recover from substance abuse. We have now integrated tobacco cessation services into all our outpatient and inpatient areas and have trained licensed tobacco treatment specialists on staff. With Swami’s grace, Mayo Clinic and the American Lung Alliance have provided this training for free, something that would typically cost about $3,000 per staff member.

We have also reviewed the literature. For example, a study published in the Journal of the American College of Cardiology in 2022 shows that while smoking in the general population has declined significantly, patients with severe and persistent mental illness—such as psychotic disorders, major depression, and bipolar disorder—continue to smoke at much higher rates. These patients face increased cardiovascular risk factors, including dyslipidemia, hypertension, metabolic syndrome, obesity, and sleep apnea.

Our patients are often afraid to visit large hospitals for their medical care. Even though Mayo Clinic is nearby, and there is another clinic in town, our patients feel judged and uncomfortable in those environments, even when they have insurance. We aim to bring care directly into our facility, so patients have someone they trust and are more willing to accept and understand both physical and mental healthcare. Patients with mental health illnesses often do not receive guideline-based treatment for cardiovascular disease prevention. For example, if they have a myocardial infarction, they are less likely to undergo coronary revascularization compared to those without mental health disorders. Additionally, antipsychotic medications prescribed for these conditions can cause metabolic syndrome, further increasing cardiovascular risk.

Over the past few years, we have introduced a metabolic clinic within our mental health facility for patients with obesity. Unlike the poverty seen in India, our patients of the lowest socioeconomic status in America are often obese due to lack of access to healthy food, relying instead on fast food. High body mass indexes are common. We have created a healing space with education on cardiovascular disease reduction and regularly measure lipid profiles and A1Cs. We have also introduced stress management techniques.

The most important intervention I want to share is our Mantra Repetition Program. We have incorporated Swami’s teachings about the mind, body, and spirit—addressing physical disease through the metabolic clinic, the mind through mental health services, and the spirit through spiritual practices. We have also published on our work. For example, we asked our patients what therapies they use, and they mentioned prayer, spirituality, and music. We have brought all of these evidence-based programs into our facility.

Earlier this year, we published in Mayo Clinic Proceedings on the positive effects of Reiki on happiness and well-being, including its use in reducing staff burnout. As Swami teaches us, Namasmaran—repetition of the name—is a powerful practice. We use a list of short phrases, such as "Om Shanti," "Om Prema," and "Bismillah Rahman Rahim," and ask patients to practice them silently throughout the day. We trained our staff, and a year later, they still practice these techniques, reporting improved interpersonal relationships both at home and at work. Our patients have reduced their use of alcohol and marijuana after participating in our eight-week Namasmaran and mantra repetition program. This evidence-based program has been in existence for about 20 years.

To illustrate the impact, we had a patient who reduced his fasting glucose and improved his cholesterol levels, and we published these results this year with the mantra repetition program. We should not be shy, as physicians, to discuss spirituality in healthcare.

With that, I will stop due to time constraints. Thank you so much. Sairam.

Om Sri Sai Ram. We offer our humble pranams at the divine lotus feet of our beloved Master and the Doctor of Doctors, Bhagwan Sri Satya Sai Baba. I also want to thank Swami personally for allowing me to share the stage with one of my role models, who not only inspired my interest in cardiology but also taught me how to be a PSI cardiologist—seeing and treating the Swami within all of our hearts.

We've been given the topic of "Lifestyle Prescription for a Healthier Heart." Due to time constraints, we'll provide a brief outline, but most of the important topics have already been covered. Up until now, we've learned that the body is the temple of God, the heart is His throne, and the world is His mansion. We cannot separate these three entities; we must treat all three as one.

So, we want to examine this topic through the lens of both the physiological and spiritual heart. Many of the speakers have discussed both aspects, and we want to compare and contrast them, while also highlighting their similarities and how they interact.

As we heard from the primary school children yesterday, they beautifully demonstrated how the physiological heart works, pumping blood to the entire body. The spiritual heart is also a pump: its function is to circulate love throughout our bodies and our environment, much like blood is sometimes called "liquid love." This love has no form; it is an energy—a divine energy that must be spread throughout the entire environment, purifying it and allowing us, our communities, and the world as a whole to function properly.

If we want to save our hearts and make them healthier, we need to protect against their enemies. For the physiological heart, we talk about modifiable and non-modifiable risk factors. These have been discussed extensively over the last two days, so I will keep it brief. Modifiable risk factors account for about 50 to 70% of overall cardiovascular disease events and mortality. The enemies or risk factors for the spiritual heart are the six enemies: anger, greed, lust, jealousy, pride, and delusion. When these enter the heart, there is no space for love. And what is love? Love is God. We must ensure these do not enter our hearts. When they do, any act we perform becomes tainted and impure, spreading negativity around us.

As for the prescription, we want to focus on primary prevention. For the physiological heart, we emphasize diet, exercise, and medication. For the spiritual heart, these are also important, but instead of medication, meditation is the answer.

Focusing on primary prevention, we all know the adage: "An ounce of prevention is worth a pound of cure." We've also heard at length about the increasing prevalence of cardiovascular disease in people under 40, especially here in India. Pathological and histological studies show that atherosclerosis begins early in life. If we address modifiable risk factors in the young and conduct more aggressive risk stratification, we can hope to prevent disease from occurring in this group. Unfortunately, there are no large-scale randomized controlled trials to prove the benefit of early intervention, as such studies are costly and methodologically challenging.

Swami has said, "Start early, drive slowly, and arrive safely." No age is too early to begin primary prevention. For the spiritual heart, parents are the child's first teachers; they instill positive qualities from a young age. It is said, "A family that prays together stays together." Children should be enrolled in Sai spiritual education classes, or any spiritual education that fosters the five basic human values: love, truth, right action, nonviolence, and peace (Satya, Dharma, Shanti, Prema, and Ahimsa). These qualities strengthen children as they grow and protect them from negative influences.

We just heard a great talk from Doctor Bajaj, so I won't belabor the point. The fundamental concept is to eat foods in as natural a state as possible, without processing, refining, or preservatives. Regarding smoking cessation, after one year of quitting, the excess risk of coronary artery disease decreases by about 50%. After 15 years of not smoking, the risk of congestive heart failure, coronary artery disease, and stroke is the same as that of a non-smoker. For the spiritual heart, diet consists of all that is absorbed by the five senses or Karma Indriyas. Sight, sound, taste, and smell are all very important.

Regarding exercise, it's essential to quantify what is being done. We use the FIT mnemonic: frequency, intensity, time, and type of activity. We've listed recommendations for how much time to spend at different exercise intensities. Exercise for the spiritual heart is also very important; all actions done through the five organs of action are considered exercise. The most important is selfless service—"the hands that help are holier than the lips that pray." The tongue is also important; our speech should be soft, loving, empathetic, and full of compassion. We should visit holy places, as they carry spiritual energy that helps us. However, the mind is the master of all these; we must learn to control it, to let go and let God. We must accept rather than expect. "Gratitude is the best attitude." All these practices help us control the mind, allowing unity of thought, word, and deed.

Now, regarding medication for the physiological heart, it mainly involves HMG CoA reductase inhibitors, or statins. In primary prevention for high, moderate, and low-risk patients, statins reduce the risk of stroke, myocardial infarction, cardiovascular death, and all-cause mortality. Other medications discussed over the weekend are mainly for secondary prevention or niche populations.

In place of medication, meditation is needed for the spiritual heart. One of the most important things we all do—but rarely control—is breathing. We breathe from birth to death. One essential realization about breathing is "soham." The word "soham" consists of two Sanskrit syllables: "so" (that) and "aham" (I am). Soul is inspiration; hum is expiration. Together, "soham" means "I am that," or "I am the divine principle." I am divinity; the Lord is within me; God is me; I am God. As mentioned, mindfulness and Namsmaran (chanting God's name) are also very important, and meditation in the form of light meditation and other practices is beneficial.

In conclusion, it's vital to work with our patients on their physiological hearts, but their hearts cannot be truly healthy unless they also care for their spiritual hearts. Our training has focused more on the physical heart, but we must remember that the spiritual side is also important. We need to practice these principles ourselves if we expect our patients to do the same.

Each of us is a cell, and together we form a limb or organ. Our community and society are organs in the vast entity called Vishwa Virat Swaroop, the Almighty God in all His forms. It is crucial to care for our physical heart, our spiritual heart, and, by practicing these values, to take care of the "world heart," which is especially important to emphasize on this World Heart Day.

Thank you, sir. Now we have a panel discussion on the challenges and opportunities in cardiac care in Nepal by three speakers. May I please welcome Dr. Milan Gautam, Senior Consultant Cardiologist in the Department of Interventional and Clinical Cardiology at Nepal Med City Hospital, Kathmandu; Dr. Chandramani Adhikari, Consultant Cardiologist and Associate Professor at Shahid Gangalal National Heart Center, Kathmandu; and Dr. Narayana Gautam, Senior Consultant Cardiologist at Bibhuti Healthcare, Nepal.

Om Sri Sai Ram. My humble pranam to the lotus feet of Bhagawan Sri Sathya Sai Baba and respected audience. Thank you for staying with us so late today. We have two different topics to discuss. First, the challenges currently faced in Nepal. Our first speaker, Dr. Milan Gautam, please.

Good afternoon, everyone. My humble prayers to the two Babas present here—Sri Sathya Sai Baba and my own father, whom I call Baba. I feel I am the luckiest person here, guided by both. This is my first time in Puttaparthi. My presentation is, I believe, going a thousand years back compared to what our esteemed speakers have presented.

I have a wide background: I did my PhD in Japan in stem cell regenerative treatment. Now, I work as a cardiologist in Nepal, and I will further try to explain the spiritual connection to the heart. The next speaker will continue with this theme.

Good evening, esteemed colleagues and guests at the Sri Sathya Sai Global Symposium. My career combines the precision of medical practice in the catheterization lab with insights gained from the ancient teachings of Pasupatinath. Today, I will discuss how the principles of our Swami and Shiva's symbolism can complement modern cardiology to support holistic heart health. I share this as someone who has experienced both scientific and spiritual perspectives, aiming to improve patient care through their integration. All the images in my presentation have been created from my own perspective using AI.

In my daily work, I see heart rhythms in the lab that remind me of the deeper pulse I sense at sites dedicated to Shiva. Our ancestors lived longer due to a balanced lifestyle, unlike today, where we face imbalances—such as disruption of time (Mahakala), worry, ego, ignorance (Avidya), and inflammatory diets. The CVOS concept provides practical links. OM chanting stimulates the vagus nerve, improving heart rate variability and promoting relaxation through parasympathetic activation.

The Tandava dance represents the heart’s systole and diastole phases, and the third eye supports intuitive decision-making in medicine. Shiva’s vibhuti symbolizes detachment, which can lower cortisol levels from stress. Importantly, his blue throat, Neelkantha, represents resilience against toxins, similar to how our cells use autophagy for detoxification. Studies show that mindfulness practices reduce inflammatory cytokines by 15 to 25%, enhancing endothelial function in patients with CAD.

Shiva in his Nataraja form illustrates the Tandava as creation during systole, preservation in diastole, and potential disruptions as arrhythmia. This parallels the heart’s 100,000 beats per day, and the damaru mimics the SA node’s rhythm-setting role. The Ganga flowing from Shiva’s head suggests efficient circulation and toxin removal. From a scientific view, yoga improves autonomic balance, reducing blood pressure and heart rate. OM chanting further supports parasympathetic activation, leading to better heart rate variability in short sessions.

A healthy heart maintains this balanced rhythm; in disease, stress and worry increase cortisol and disrupt it. In patients with CAD, yoga has been shown to lower blood pressure by 5 to 10 mm Hg and improve vascular function, benefiting heart rate variability—an aspect aligned with the damaru’s role, often affected in conditions like atrial fibrillation due to chronic stress.

The Shiva lingam symbolizes the start of creation, much like the embryonic heart tube formed from stem cells around 21 days of gestation. Shiva’s light represents the origin of life, and the moon on his head suggests a calming influence that reduces stress during development. Stem cells allow regeneration, similar to cycles of renewal. Prenatal yoga helps improve fetal heart health by lowering maternal cortisol levels.

Congenital heart defects can also be seen as incomplete development, addressed through regenerative therapy that reflects this cycle. A recent trial indicated that prenatal yoga reduces maternal stress and lowers fetal cardiovascular risk by 10 to 20% by improving heart rate variability and epigenetic effects. The calming aspect, like the moon’s influence, helps minimize stress-related epigenetic changes in early cardiac function.

The heart’s vascular network follows fractal patterns similar to Shiva’s mandala, while his three-pronged trident represents the balance of the sympathetic, parasympathetic, and enteric nervous systems. On a biochemical level, ATP production cycles regulate the Tandava. Excessive inflammatory food, such as curry, can disrupt this, but resilience like Neelkantha’s helps manage it. Yoga reduces markers such as high-sensitivity CRP by almost 20%, and a balanced diet inspired by Sattvic principles decreases oxidative stress. Health involves clear flow, like Ganga’s purity. Disease causes blockage from distress and poor habits, which can be addressed by lifestyle changes. These fractal patterns in coronary arteries support efficient energy and nutrition distribution.

Kundalini energy rises like an electrical signal in our heart. Rudra’s power helps counter arrhythmias, like a defibrillator. The third eye, linked to the pineal gland, controls circadian rhythms and cardiac function, and detachment reduces the effect of haste. Meditation improves heart rate variability and OM chanting stabilizes electrical activity. In diseased states, worry decreases heart rate variability. Practices such as yoga lower the risks of atrial fibrillation. Recent data show OM chanting increases heart rate variability by 15 to 30% through parasympathetic effects, with vagal stimulation helping to restore order, similar to defibrillation.

Atherosclerosis involves unbalanced destruction with inflammation from diet, akin to unmanaged toxins. Ignorance (Avidya) contributes to disease. Compassion, as in Rudra, builds resilience against stress, cytokines, and blood pressure. Mindfulness practices reduce these. Calming influences like the moon symbolism help manage psychological stress. Incorporating balanced nutrition supports healing. Evidence shows these practices lower cardiovascular mortality by controlling inflammation, treating ignorance as the root cause of plaque, and stress as an overactive brain response.

Beta blockers can be correlated with providing calmness, similar to stillness. Combining them with OM chanting can enhance results. The trident represents intervening in disease with renewal through procedures such as stenting, and regenerative yoga as an add-on to medication improves patient outcomes. Stem cell therapy offers new growth, focusing on purity and detoxification. Treatment for diseased hearts emphasizes passion. A meta-analysis showed yoga in rehabilitation after major cardiac adverse events decreases MACE by 20 to 30% after bypass surgery. The third eye concept is intuitive in diagnosis via the vagus heart-brain connection and compassion. Our Swami’s teachings support emotional healing. Shiva’s blue throat, as a symbol of detoxification and mediation of inflammatory markers, promotes coherence, reducing cardiovascular risk. Stem cells provide long-term repair.

In conclusion, Shiva’s principles guide us to balance time, pressure, mental stress, worry, calmness (third eye), and diet (Sattvic choices) for better health. Yoga and meditation help prevent and treat cardiovascular disease, reducing events by 15 to almost 40% in high-risk groups. Each heartbeat connects us to this idea. Let us integrate these practices to improve outcomes. Thank you very much.

Thank you, Dr. Milan. Now I request Dr. Chandramani Adhikari, Senior Consultant and Cardiologist.

First of all, I’d like to thank the organizers for giving me this opportunity to present on the challenges and opportunities in the management of STEMI in Nepal. This is my first time in this holy place. Without further delay, I'll start my presentation.

As previous speakers discussed the difficulties in interpreting guidelines from Western to Eastern contexts, I will share the problems we are facing in the management of STEMI in Nepal. Apologies for this technical hitch. Nepal is a small country between India and China, with an area of 147,000 square kilometers and a population of 30 million. Despite being a small country, Nepal is extremely diverse in terms of topography—almost 75% of Nepal's land area is covered by mountains or rugged hills. This topography brings challenges in managing acute STEMI in the country.

Let me introduce Nepal to you all. Nepal is famous for its beautiful temples and holy shrines: Pasupatinath, Muktinath, and Lumbini, the birthplace of Buddha. It is also known for its beautiful mountains, the Himalayas, and Mount Everest.

When it comes to STEMI, the true incidence is still unknown because we don’t have nationwide data. Based on hospital databases, however, there has been a significant increase in STEMI patients in recent years. According to the most comprehensive European STEMI registry, the incidence rate is 58 per 100,000 per year. If we apply that calculation to Nepal’s population (about 30 million in 2078 Vikram Samvat), there would be around 17,000 STEMI cases per year.

We know that after STEMI, patients should be managed with primary PCI—this is the aim of every guideline. However, implementing this guideline in our context is very difficult. I will share the challenges. According to data from Shahid Gangalal National Heart Centre, where I work, we offer both primary PCI and thrombolytic therapy to our patients. From 2001 to 2012, only 24% of patients underwent either primary PCI or thrombolytic therapy. From 2001 to 2017, this increased to just 28%. In the country’s largest registry, primary PCI or thrombolytic therapy was given to only 37% of patients. The reason is that most patients arrive late at the hospital, beyond the window for reperfusion therapy.

In our study, out of 299 patients with typical chest pain, only 23% recognized it as cardiac in origin and presented to the hospital. Others attributed the pain to different causes, delaying care. The second issue is system delay: inability of caregivers or doctors to recognize STEMI, lack of availability of primary PCI and thrombolytic therapy, and long distances to reach facilities with these interventions. For example, cath labs are only available in a few cities in Nepal, and most places do not have them.

Let me share an example from Mugu: a 38-year-old male smoker experienced chest pain in the morning. The nearest hospital was 8 hours away, and Mugu is 670 kilometers from Kathmandu, taking about 12 hours to reach. He went to the nearest hospital after 8 hours and was found to be in bradycardia. He received atropine, noradrenaline, and other support; the hospital was at 2,990 meters above sea level. The next day, he was transferred to our hospital after 28 hours of distress. He was hemodynamically unstable, and we performed primary PCI, including thrombus aspiration and balloon dilation, and treated with 2B3A inhibitors. He required a pacemaker and, after six months of therapy, I met him again at our camp. He had survived acute STEMI without thrombolytic therapy or timely PCI.

Another case from the Everest region: an 58-year-old Sherpa, smoker, hypertensive, experienced chest pain for four hours and came to the hospital in the evening. He was diagnosed with acute inferior wall MI. There was no thrombolytic therapy available, so he spent the night at the hospital. It takes 8.5 hours to reach Kathmandu, the nearest place for primary PCI. The hospital was at 2,430 meters altitude. He was planned to be rescued by helicopter, but due to bad weather, the helicopter couldn’t land. After 18 hours of chest pain, he finally reached the National Heart Center and underwent primary PCI.

Why don’t patients get reperfusion therapy in Nepal? Primary PCI is often unaffordable or unavailable, and thrombolytic therapy is also lacking. Many healthcare facilities have medical officers who cannot analyze ECGs, and patients often present late. To address this, we have initiated a Viber group where doctors in local hospitals send ECGs to cardiologists at the National Heart Center for interpretation. This has enabled treatment in remote areas, with some patients brought to the cath lab for PCI. Nearby hospitals have also started thrombolytic therapy. The hub-and-spoke model, used in India, Sri Lanka, China, Egypt, Mexico, and Canada, is being considered for Nepal.

In conclusion, the challenges of STEMI care in Nepal include many young patients, late presentation for reperfusion therapy, unavailability of thrombolytic therapy in many centers, and limited access to PCI. However, opportunities exist: awareness programs by organizations such as the Cardiac Society of Nepal, increasing availability of thrombolytic therapy at district hospitals, new cath labs, and the hub-and-spoke model appear feasible and applicable in our settings. Thank you very much.

Om Sri Sairam, loving Sairams to one and all. It is my great honor and privilege to deliver this vote of thanks on behalf of the organizers of the Sai Medical Camp, the Sai Global Cardiovascular Conference, and the World Heart Day celebrations.

At the outset, I bow in deep gratitude to our beloved Bhagwan Sri Sathya Sai Baba, the guiding light and source of inspiration behind every step of this journey. His unseen hand and boundless love have touched countless hearts and made this grand offering possible.

Two years ago, in December 2023, a small idea emerged to prepare an offering for Swami’s medical mission as part of the centenary celebrations. With Swami’s grace, many individuals and institutions have worked tirelessly to bring this vision into reality. Today, we witness how that seed has blossomed into this remarkable event.

On this blessed evening, it is my privilege to acknowledge them all. Let me start with institutional gratitude to the Sri Sathya Sai Central Trust and its managing trustee, Sri Ratnakar, for their wholehearted support in developing this international medical event; to the Medical Planning Committee led by Dr. V Mohan for their dynamic leadership; to the World Heart Federation, represented by Dr. Jagat Narula and Mrs. Barjana, for choosing India and Prasanthi Nilayam for the 25th anniversary of World Heart Day, coinciding with Swami’s centenary celebrations; and to the WHF team, including Suzanne and Varini, for their dedicated support.

Our thanks also go to the Sri Sathya Sai Seva Organization India, led by Mr. Nimish Pandya, for spreading the World Heart Day message across the country; to the SSSM Institute of Higher Medical Sciences in Prasanthigram and Whitefield, the Sri Sathya Sai General Hospital, Sri Sathya Sai Mobile Hospital and Nursing College for their tireless work organizing the preventive cardiology exhibition; to the volunteers and health professionals who served in medical camps and outreach projects; and to the Sri Sathya Sai Institute of Higher Learning, its vice chancellor, faculty, and students for their participation in the conference and events.

We are grateful to the Sri Sathya Sai Media Center for their exemplary support and documentation of this historic event, and to the Sai Vishram catering team for nourishing us throughout. Special acknowledgments to our renowned speakers from India and around the globe for their months of preparation and for sharing their wisdom and expertise. Thank you to the event organizers and subcommittees for meticulous planning and dedication, and to the volunteers and support staff whose selfless service made all the difference. To our delegates and audience, thank you for your presence and engagement; we trust you will carry these learnings back to your communities, spreading Swami’s message of love, compassion, and preventive health.

A very special word of gratitude to Dr. Krishna Rao, the main organizer of this event, whose tireless dedication and meticulous planning have been the driving force behind the conference’s success. I also wish to thank his wife and children for their support over many months and years.

In closing, let us remember that this event is not just a celebration but a call to action—to spread awareness, serve with love, and live healthier, heart-conscious lives. May we all continue to work together in unity to reduce the burden of cardiovascular diseases and build a healthier and happier world. Finally, we warmly invite everyone to join the World Heart Day cultural celebrations in Kulwant Hall, organized by the students of SSSIHL and the Sri Sathya Sai Media Centre under the guidance of Professor Raghavendra Prasad Garu and Director Sundar.

On behalf of the organizing committee, I extend heartfelt thanks to each and every one of you. May Swami’s blessings be with us all. Wish you all a safe journey home and Sai Ram to all of you.

We request everyone to proceed to the mandir because the program is about to start. I request Dr. Akshay Kalathia to continue. Om Shanti, Shanti, Shanti.