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Can a Credit Card-Sized Monitor Help India Battle Its Heart Disease Epidemic?

Cardiovascular disease is the leading cause of death in India. Neha Rastogi's portable electrocardiogram wants to end that.
Technician Namken Lhama examines a man at the Eye Clinic in Jomsom, Mustang District, Nepal, in 2014.

In 2012, Neha Rastogi's father-in-law started experiencing intermittent chest pains. Doctors detected blockages in three of his arteries; he had been on the brink of a heart attack.

Rastogi's in-law was put on medications to unclog his blood vessels, but his chest pains didn't stop immediately. Every time he felt uneasiness, Rastogi's husband would have to rush him to a hospital, sometimes in the wee hours of the morning. "Every episode of chest pains used to scare us and we used to worry that it [was] something severe," Rastogi recalls now. She started researching home-based heart monitors for her father-in-law, but was unimpressed with the quality of portable heart monitors. Most were meant for fitness purposes.

Frustrated, the Rastogis took matters into their own hands. Neha and her husband, Rahul, transformed their bedroom into a lab and put their engineering expertise to use (Neha was previously a technical analyst with Hewitt; Rahul was a design engineer who went on to work at Samsung). "We took the standard [electrocardiogram] technology and applied it to a micro circuit," Neha says.

Together, they produced a prototype of a portable electrocardiogram (ECG) in 2013. After rigorous consultations with doctors and patients, the couple rolled out the final product on online marketplaces like Amazon India last year. Since its March of 2016 launch, Rastogi's company, Agatsa, has sold more than 400 of its portable Sanket ECGs. The price of one device is just under $200 (roughly Rs. 10,000).

A cheap and portable ECG like Sanket could be a revelation for millions of Indians who are grappling with high costs of the private health-care system, especially at a time when the public-health machinery is failing to meet the demands of the nation's one billion plus population. It stands to have the most impact in India's villages, which house 70 percent of the nation's population, and where hospitals and doctors are scarce.

In India, cardiovascular disease is the leading cause of death, accounting for a quarter of all mortality. Yet cardiovascular disease is a catch-all phrase for a multitude of conditions that affect the heart and circulation, such as coronary heart disease, angina, heart attack, congenital heart disease, and stroke. Over 60 percent of cardiovascular disease patients are of South Asian descent, and a study published earlier this year in The Lancet Global Health found that people in South Asia who were diagnosed with heart failure were at a greater risk of dying after a year compared to individuals in other regions like Southeast Asia and South America.

Because cardiovascular disease can be so broad, and because symptoms can be sudden and life-threatening, an ECG has become the standard of care when a patient complains of any kind of chest pain, be it heartburn or heart disease. A traditional ECG is administered by a doctor, or in the case of many emergent patients, at a hospital or emergency room, after unexplained chest pains have manifested.

Rastogi's ECG is far simpler. All one has to do is to place their thumbs on a metallic sensor laid across the small rectangular device the size of a credit card that can easily fit into a pocket. The ECG graphs are then generated on the companion SanketLife app on the user's smartphone.

When suspicious symptoms, such as chest pain, sweating, or breathlessness, appear, a patient can quickly determine if it's a serious problem such as irregular heartbeat or something relatively innocuous like heartburn. This is less tedious than getting an ECG test at a hospital, Rastogi says, where electrodes are strapped to a patient's body to record their heart's electrical activity, and they also have to undress.

Rastogi says Sanket's current iteration is almost as efficient as the big hospital ECG machines. "Eighty percent of cardiac problems can be diagnosed by this thumb-based product," Rastogi says. Moreover, the SanketLife app connects patients with physicians who can provide immediate feedback on their ECG reports for a small fee (less than $3).

Rastogi has even conducted a study to evaluate the device's efficacy. Sanket's team summarized the results in a paper in The Journal of Advanced Research in Medical Science Technology last year. The authors wrote that Sanket's accuracy was on par with hospital ECG machines that can cost between Rs. 20,000 to 200,000 (anywhere from $300 to over $3,000).

General practitioners, like Mumbai-based Vivek Satpurkar, have found the device useful for their private practices. "Even patients as young as 25 are now having cardiac problems in India, so it can be tricky to determine whether symptoms are heart-related," Satpurkar says. When he does detect a cardiac problem through Sanket, he refers that patient to a specialist.

Rastogi finds the device is especially important for patients who've undergone an operation. "A person who has had his surgery needs to be handheld for three months after the surgery," she says. "Patients can talk to doctors through the app. It makes them confident."

Sanket isn't a first-of-its-kind clinical grade heart monitor. In fact, this type of portable ECG technology has already been introduced in the United States. In 2014, the Food and Drug Administration cleared a finger-based heart monitor, Kardia Mobile, developed by the American company AliveCor. It's now available for purchase in more than 25 countries through online marketplaces and costs $99 in the U.S. A spokesperson for AliveCor tells Pacific Standard that 20 million-plus EKGs have been recorded using Kardia Mobile.

It remains to be seen if Sanket can make a difference in rural India—incidentally, where it could have the most impact. A large proportion of India's population lives in its hinterlands where Internet connectivity is patchy or non-existent.

Sevith Rao, founder of Indian Heart Association, a non-profit working on awareness and outreach about heart disease, says Sanket has "tremendous potential" to reach India's rural populations, as doctors are in extremely short supply in India, especially in its villages. According to the country's medical watchdog, there is one government doctor available for almost 1,700 people. Smaller public-health hospitals, called sub-centers and primary health centers, do not typically have specialists. People with cardiac ailments are referred to larger district hospitals or community health centers. Larger hospitals serve multiple villages, and people often have to travel long distances to get to them. Sanket cuts down unnecessary referrals to distant district hospitals by allowing local practitioners to track cardiac symptoms in-house.

Rastogi has already started testing the waters in rural India. Last year, she collaborated with a non-profit, Tata Trust, to bring Sanket to 45 primary health centers in the northeast Indian state of Tripura. Government doctors, who sometimes have only basic medical training, have been using them for over a year to check for heart problems in patients. If they detect something serious, patients are referred to a bigger hospital with specialists. Rastogi says she has received positive feedback from the primary health centers and is in talks with other governments to undergo similar collaborations.

Though Rastogi hopes to bring Sanket to rural India, she cites a lack of Internet infrastructure as a significant barrier to accomplishing that goal. "We realized how poor connectivity can affect the use of device in rural and remote areas," she says. It's difficult to upload patients' data on the company's cloud if the Internet is disconnected.

Others worry that the government is approving and adopting portable technologies too quickly, without fully thinking through the potential ramifications. Chhaya Pachauli, a prominent health activist based in the north Indian state of Rajasthan, says point-of-care devices like Sanket "can be extremely helpful in reducing disease burden," but called for more rigorous testing of the device before its use is scaled up in Tripura or other states.