Cardiac care in tier 2 & 3 cities: The road ahead

India is currently facing an unprecedented cardiac crisis, one that’s no longer limited to its metro cities. Cardiovascular diseases (CVDs) are now the leading cause of death, accounting for nearly 28 per cent of total mortality, according to various national health datasets. The most worrying trend, however, is the sharp rise in heart disease cases emerging from Tier 2 and 3 cities, regions still playing catch-up in terms of cardiac care infrastructure and expertise.

“Over the last few years, we have seen a clear shift in the pattern of patients seeking cardiac care. A large number now come from semi-urban and rural regions places where awareness is low, diagnosis is delayed, and timely treatment is often out of reach,” says Dr Rajan Thakur, Managing Director, Heart Hospital.

While metro hospitals have embraced hybrid CATH labs, AI-enabled diagnostics, and complex heart surgeries, smaller cities continue to struggle with basic cardiac facilities. The gap is no longer a future concern. It’s a present reality that demands immediate attention.

The silent epidemic in small-town India

The reasons behind the rise of CVDs in smaller cities are multifactorial: changing lifestyles, poor diets, limited physical activity, uncontrolled diabetes, tobacco consumption, and rising stress levels. But the true crisis emerges from limited access to timely care.

“I have seen patients travel over 300 km just to get a basic angiography. Many arrive days after a heart attack has occurred when the golden hour has long passed. The delay is not due to negligence, but due to lack of local facilities and awareness,” notes Dr Thakur.

Compounding the issue is a widespread lack of preventive care and routine screening in these areas. Basic diagnostic tools like ECG machines, TMT, or even skilled interpretation of symptoms are absent in many Tier 2 and 3 cities.

Challenges in building cardiac infrastructure

India’s cardiac ecosystem in smaller towns faces several hurdles:

• Infrastructure gaps: Many hospitals lack CATH labs, cardiac ICUs, and imaging tools.
• Manpower shortage: Few cardiologists and cardiac surgeons are willing to practice outside metros.
• Delayed diagnosis: Lack of training among primary care providers leads to poor early detection.
• Affordability: High costs and out-of-pocket expenditure delay or deter care.
• Low awareness: Preventive cardiology is still not mainstream in smaller communities.

“We cannot expect Tier 2 cities to be carbon copies of metro hospitals overnight. But we can and must create scalable, practical, and sustainable cardiac care models tailored for these regions,” says Dr Thakur.

What does “Future-Ready” really mean?

Dr Thakur believes that a future-ready cardiac care system is one that is decentralised, tech-enabled, and focused on prevention as much as treatment.

“Being future-ready is not just about the latest tools—it’s about accessibility, affordability, and accountability. Every district must have the capability to diagnose and manage cardiac emergencies without relying entirely on metro centers,” he emphasises.

Key strategies to build a robust ecosystem

Decentralising infrastructure

A key strategy is to empower district and secondary hospitals with basic cardiac infrastructure like CATH labs, diagnostic tools, and cardiac ICUs.

Franchise-style partnerships or public-private collaborations can accelerate this kind of localised care delivery.

Upskilling the healthcare workforce

The need for trained cardiologists is dire, but short-term strategies can help:

• Train general physicians in basic cardiac emergencies.
• Incentivise specialists with rural bonuses and academic growth.
• Set up tele-mentoring programs with senior cardiologists guiding peripheral units.

“Not every case needs a superspecialist. If a general physician can identify early warning signs and stabilize a patient, that alone can save lives. But they need structured training and real-time support,” Dr Thakur points out.

Leveraging technology and AI

Telemedicine and digital health platforms offer a cost-effective bridge between metros and remote areas.

“We use portable ECG devices and cloud-based reporting to screen patients in remote blocks. AI tools can also help detect arrhythmias and abnormal ECG patterns when human expertise is not available locally,” says Dr Thakur.

Wearables and mobile diagnostics can also help in monitoring at-risk patients in the community, ensuring continuity of care.

Prioritising preventive cardiology

India’s cardiac care strategy cannot rely solely on reactive interventions. Prevention is key.

“We conduct regular community outreach, including BP and cholesterol checks, school programs, and even local radio segments. It’s surprising how much impact simple awareness can have when delivered in local language, with empathy,” Dr Thakur explains.

Prevention needs to start at the grassroots level, through ASHA workers, teachers, and even panchayat leaders.

Supporting affordable innovation

Indian innovators have built affordable ECG, echo, and cardiac marker tools suitable for remote use. Government and industry must collaborate to mainstream these.

“The idea that quality care must be expensive is flawed. We’ve used Made-in-India cardiac monitors that cost a fraction of imported ones but deliver robust results,” adds Dr Thakur.

Price regulation for stents and generics has also helped lower treatment costs, but sustained efforts are needed.

A collective responsibility

Dr Thakur stresses that no single stakeholder can solve this problem. It requires a collaborative approach involving government, private sector, civil society, and healthcare professionals.

“Cardiac care cannot remain a privilege of the metros. Our healthcare system must mirror our population spread. Unless we invest in cardiac care in smaller cities, we are simply shifting the problem downstream,” he warns.

He recommends the creation of a Cardiac Health Index by the government to monitor regional disparities and track progress across states and districts.

Conclusion: Time to act is now

India stands at a crossroads. We have the disease burden, the demographic imperative, and the technological capability. What we need is urgency and a commitment to equity in cardiac care.

“Every second counts in a cardiac emergency. And every heartbeat, whether in a metro or a village, deserves the same chance at survival. That’s the vision we must work towards,” concludes Dr Thakur.