Br. 3. Dis. Chest (1976),




Azad Medical

70, 251



College and Associated Irwin New Delhi, India

and G. B. Pant Hospitals,

Chronic car pulmonale is more prevalent in northern India than in the south. It is equally common in men and in women and accounts for 20% of all admissions for heart disorder in Delhi. In a study of 766 patients (239 men and 527 women) carried out over a 15-year period there were some striking sex differences. Some 75% of men and lOoJo of women smoked. The women came from the poorest class and all of them cooked from an early age over smoky and primitive fireplaces in ill-ventilated huts, while only 7% of the men cooked their own food. Chronic bronchitis and bronchiectasis were the commonest associated lung disorders in both sexes. The women developed heart failure lo-15 years earlier and showed more severe congestive failure with larger hearts and greater derangement of pulmonary function. It is concluded that the cause of chronic car pulmonale in women in Delhi was damage to the lungs from exposure to smoky cooking fuels from girlhood onwards, followed by repeated chest infections.

differences between the Observations over nearly two decades (1955-74) o f some striking clinical features of chronic car pulmonale in men and in women in Delhi has resulted in

this paper. Chronic car pulmonale is very common in Delhi and north India, accounting for nearly one-fifth of admissions to hospital for heart disease (Padmavati 1958). This is an unusual finding in a non-industrial area and ranks amongst the highest in the world for this condition. It is much less common in south India. Prevalence in the two sexes in Delhi is almost equal (1.2 M : 1 F) (Pa d mavati & Pathak 1959) whereas in other parts of the world there has been a male preponderance (5 M : 1 F) (Spain & Handler 1946). In Delhi the age of onset of heart failure is much younger in women than in men.

Patients and Methods The study of women began while one of the authors was working in a women’s hospital; 527 women were seen between 1958 and 1970 and 239 men between 1968 and 1974, a total of 766 subjects. The difference in sample size arises from the different durations of observation. A study was carried out from 1958 to 1970 to establish causes which were suspected from initial observations. Chronic car pulmonale was considered to be present if this was the diagnosis of the clinician recording the case. * This study was supported in part by Grant No. HE-06232 Health, U.S. Public Health Service, Bethesda, Maryland, USA.

from the National




S. Padmavati and R. Arora RESULTS

Prevalence In a general hospital in Delhi with about 50 000 admissions annually from 1950 to 1955, chronic car pulmonale was diagnosed in 0.3% of general medical admissions and in 17% of all cardiac admissions (Devichand 1959; Padmavati & Pathak 1959). General admissions included a large number of infectious illnesses and it is perhaps more informative to record admissions for chronic car pulmonale as a percentage of cardiac admissions. The male to female ratio in both groups was 1.2 : 1. In a special hospital for cardiac patients car pulmonale accounted for 7% of 3936 admissions between 1966 and 1974, with a male to female ratio of 2 : 1. This lower proportion and higher ratio in the heart hospital arose because patients with car pulmonale are more likely to be admitted to general hospitals and because there were fewer beds for women patients. In a general hospital for women with about 1000 medical admissions annually, car pulmonale was responsible for 5% of medical admissions between 1958 and 1962. Cor pulmonale was diagnosed in about one-tenth of patients with heart disease and accounted for about 10% of all deaths and about 20% of deaths from heart disease (Padmavati & Joshi 1964; Padmavati & Kumari 1967). Income, occupation and housing (Table I) Nearly all the women and nine-tenths of the men were in the lowest income group, earning less than Rs. 200 per month. The women generally came from a slightly lower Table Occupation

Cooking Dusty surroundings Sedentary Others

I. Occupation Men




7 22 36 14

100 24 1 12

income group than the men; 51% of the women lived in mud houses and 16% had cattle in the rooms; only 37% lived in ‘pukka’ houses. The men, on the other hand, lived in ‘pukka’ houses of brick or wood in 77% and in mud houses in 20% of cases. The occupations have been classified somewhat arbitrarily as considered important. While all the women did housework which included cooking, some of them were engaged in part-time work on building sites or in sewing and weaving. Only 7% of men admitted to cooking. Both men and women who worked on building sites were involved in carrying earth and stones and this meant exposure to dust for several hours during the day. Weaving also involved work in an atmosphere of cotton fluff. Thus equal numbers of men and women were in dusty occupations while cooking was done by all the women and by only a few of the men. Smoking habits (Table II) Some 75% of the men and only 10% of the women were smokers; the women smoked mostly the hookah (hubble-bubble). It is a common sight in Indian villages for men,


Sex Diferences in Chronic Cor Pulmonale Table II. Smoking Smoking habit Cigarettes

Bidi Hookah Mixed Total


Men (%)

Women (%I

24 17

0.2 3

2 32

5 1.8



women and children to sit around the hookah and pass it around for a few puffs for each person (Fig. 1). The men smoked cigarettes, bidis (powdered tobacco wrapped in tobacco leaf and usually the size of cigarettes), the hookah or all three; 36% of men and only 3% of women admitted to smoking for more than 20 years and 7% of men and less than 1% of women lo smoking for more than 10 years.

Fig. 1. Three




hookah in a smoking


in an Indian


Cooking fuel (Table III) As domestic air pollution was thought to be an important cause of car pulmonale it was studied in detail. The fuel used was dried animal dung cakes (from cows, oxen, buffaloes and horses) to start the fire which was kept going mostly with wood and sometimes with coal. A typical smoky fireplace is shown in Fig. 2. The nuisance of blowing on smouldering wood or coal to coax the fire to light and the stinging and watering of eyes has to be seen to be believed. The men used more coal, gas and kerosene than the women and less animal dung, because they were not so poor. As stated earlier only a few of them cooked.


S. Padmavati Table Fuel

Fuel used




Women (%I


Animal dung Wood Coal Gas and kerosene


and R. Arora

27 32 35 6

2. A typical

smoky Indian

63 25 12 -


Age incidence (Table IF) The patients under 20 years of age were all women and those between 20 and 40 were mostly women. Most of the men were over 40 years of age. The women seem to develop car pulmonale early in life and die young. Table Age

Less than 20 21-30 3140 41-50 51-60 More than 60


Age incidence


10 (4%) 44 (18%) 108 (45%) 52 (22%) 25 (10%)



2 87 168 144 87 39

(0.4%) (17%) (32%) (27%) (17%) (7%)

2 (0.2%) 97 212 252 139 64

(13%) (27%) (33%) (18%) (8%)

Duration and nature of respiratory symptoms Symptoms lasted longer in men than in women. Winter cough was complained of by more men (26%) than women (9%). Men gave a history of cough for more than 10 years more often (46%) than did women (10%) b u t more women (61%) than men (48%)


Sex Diffeerences in Chronic Car Pulmonale

complained of cough for one to five years. Some 19% of men and 5% of women presented with copious expectoration. About 6% of both sexes gave a history of bronchial asthma. The incidence of orthopnoea was similar in both sexes (men 47%, women 46%). Paroxysmal dyspnoea was commoner in men (9%) than women (2%). Family history A family history of bronchial asthma was obtained in 2% of women and 0.7% of men and of chronic lung disease in 6% of men and 4% of women. Aetiological diagnosis (Table V) Chronic bronchitis and emphysema were the main conditions associated diagnosed in both sexes, followed by bronchiectasis. Pulmonary tuberculosis was seen in more women than men. Table

V. Associated


Men 168 (70%) 50 (21%) 10 (4%) 11 (5%) -

Chronic bronchitis Bronchiectasis Bronchial asthma Pulmonary tuberculosis Pneumoconiosis


Women 328 108


(62%) (20%)

496 158

26 (5%) 64 (12%) 1

(65%) (21%)

36 (5%) 75 (10%) 1

Physical findings The women were in poorer physical condition than the men and both sexes had low body weight in relation to height. Body surface area for males with chronic car pulmonale was 1.4 ma and for women 1.2 ma; the corresponding figure for age and weight matched


3. A woman











S. Padmavati and R. Arora

normals are 1.6 ms and 1.4 ms respectively. The majority of the women were ‘blue bloaters’ while the men were mostly ‘pink puffers’, to use loose terms. All patients were in congestive heart failure and the women showed more florid signs such as oedema (women 42%, men 30%) and ascites (women 37%, men 1Oo/o). The typical appearance of the emaciated, dark-skinned cyanotic women (Fig. 3) was very striking. An overinflated chest was not a striking feature in the women. The men showed the typical barrel-shaped chest (Fig. 4), sometimes said to be evidence of emphysema.

Fig. 4. A man with with this diagnosis



car pulmonale’


of those males referred


Haematocrit. Polycythaemia was less common in women than in men, probably because of poorer nutrition. A haematocrit of less than 42% was seen in 50% of women but in only 11% of men. Polycythaemia was diagnosed in 23% of men but only 7% of women. Electrocardiogram. Electrocardiographic present in three-quarters of all patients.


of right




Radiography (Table VI). The cardiothoracic ratio was more often increased in women and many patients had enlarged hearts on admission, which returned to normal size after treatment. Enlargement of the pulmonary artery segment on oblique and lateral radiographs was more obvious in women. Emphysema, as shown by depressed diaphragm,

Sex DijSerences in Chronic COYPulmonale Table




Lung function and blood gas studies





23 41 36 26 73 8

8 44 48 45 79 10

54 40 6 22 89 23

72 24 4 44 82 39






Women Patients

3.5 (108) 89 (98) 490 (59) -

Paz (mmHg) of subjects


Women (%)



Vital capacity (litres) FEVr (% predicted) PEFR (ml) PCOZ (kPa) PCOZ (mmHg) POZ (kPa)




Normal heart size Border-line cardiac enlargement Heart size over 60% of cardiothoracic Enlarged pulmonary artery segment Right ventricular enlargement Left ventricular enlargement Emphysema Moderate Severe Not significant Pulmonary fibrosis Bronchiectasis Acute pulmonary infection




1.54 (131) 44 (130) 129 (113) 6.8 (103) 51 (103) 6.9 (103) 52 (103)

Normal 2.55 (147) 81 (140) 339 (111) -

1 .o (159) 52 (140) 104 (71) 6.5 (126) 49 (126) 6.4 (126) 48 (126)

in parentheses.

bullae and hypertranslucent lung fields, and acute pulmonary were also commoner among women. Pulmonary function tests. Considerable present in both sexes (Table VII).






on admission



DISCUSSION Chronic car pulmonale is commoner in Delhi and northern India than in southern India for many reasons. The climate in the north is different from that in the south, with cold and severe winters, dust storms, fog and smog. There is a higher incidence of chronic bronchitis in northern India. In Delhi among 1648 textile workers and university employees there was a 6% incidence (Viswanathan 1964) compared with 8% in the United Kingdom (Fletcher et al., 1964). Cigarette smoking is prevalent all over India and must be a contributory cause of bronchitis in men, but not in women, as only 10% of them smoke cigarettes. The women are, however, exposed to smoky primitive fireplaces from childhood. They gave a


S. Padmavati

and R. Awua

shorter history of cough and expectoration; the onset of car pulmonale was lo-15 years earlier and they showed more severe congestive heart failure, greater cardiac enlargement and greater derangement of pulmonary function with a severe loss of exercise tolerance. Autopsy findings in women showed pulmonary disease, though cough and expectoration may not always have been important symptoms. Incomplete oxygenation of animal dung cakes leads to production of carbon monoxide, carbon dioxide, nitrogen dioxide and sulphur dioxide, some of which are respiratory irritants (Padmavati 1974). Wood and coal used in these fireplaces are just as smoky. Exposure to such fumes eventually leads to lung damage and frequent respiratory infections, mostly untreated because of poverty and lack of medical aid. Right ventricular hypertrophy and heart failure result. Exposure to such fumes in girls and women must be considerably greater than in men. From this study it appears that in Delhi domestic air pollution is probably the cause of the higher prevalence of car pulmonale in women than in men and the early exposure of the younger age of onset. It is of interest that in recent years the cow dung gas plant, utilizing animal manure for cooking gas, has come into prominence because of the fuel crisis. The plant consists of a feeding tank, fermentation well and cistern for collecting gas (Fig. 5). It is estimated that five head of cattle are necessary to produce sufficient





5. A cow-dung

cooking gas for a family of five or six each day. of this system, which is now also being tried economical source of fuel. Only time will tell pulmonale will be lowered by the installation of the goverment of India. Requests

for reprints

to Dr

S. Padmavati,


gas plant

India has become an area for the study out in other parts of the world as an whether the prevalence of chronic car such plants in rural areas as planned by





Sex Diffeerences in Chronic COYPulmonale


REFERENCES (1950) Etiology and incidence of heart disease in India. Ind. Heart J. 2, 117. C. M., JONES, N. L., BURROWS, B. & NIDEN, A. H. (1964) American emphysema and British bronchitis, a standardized comparative study. Am. Rev. resp. Dis. 90, 1. PADMAVATI, S. (1958) A five year survey of heart disease in Delhi. Ind. Heart J. 20, 33. PADMAVATI, S. (1974) Cor pulmonale in India. In Cardiovascular Disease in the Tropics, ed. A. 6. Sharper, M. S. R. Hutt and 2. Fejfar. London: British Medical Association. PADMAVATI, S. & JOSHI, B. (1964) The incidence and etiology of chronic car pulmonale in Delhi. DEVICHAND FLETCHER,

Dis. Chest 46, 457. PADMAVATI, S. & KUMARI, S. (1967) Medical causes in death of women, an S-year study. J. Ass. I’hyscns Ind. 15, 413. PADMAVATI, S. & PATHAK, S. N. (1959) Chronic car pulmonale in Delhi. A study of 127 cases. Circulation 29, 343. SPAIN, D. M. & HANDLER, B. J. (1946) Chronic car pulmonale. 60 cases studied at autopsy. Archs int. Med. 77, 37. VISWANATHAN, R. (1964) Chronic bronchitis emphysema syndrome. Incidence, etiology and natural history. Ind. J. Chest Dis. 6, 171.

Sex differences in chronic cor pulmonale in delhi.

Br. 3. Dis. Chest (1976), SEX DIFFERENCES IN CHRONIC IN DELHI* S. PADMAVATI Muulana Azad Medical 70, 251 COR PULMONALE AND R. ARORA College an...
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