epidemiology of cardiovascular disease: an asian perspective rody g. sy, m.d., fpcp, fpcc, facc...
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EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE:
An Asian Perspective
RODY G. SY, M.D., FPCP, FPCC, FACCProfessor, Section of Cardiology
Dept of Medicine, UP College of Medicine
Epidemiology of
CVD in ASIA
CVD Mortality (as % of total mortality) 1995-96
0
5
10
15
20
25
30
35
40
NewZealand
Australia Chinaurban
Singapore China rural Japan Malaysia Korea
Per
cen
t o
f m
ort
alit
y fr
om
all
cau
ses Female
Male
Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80. Epidemiology of
CVD in ASIA
CHD and Stroke Mortality in Asia-Pacific 1995-96
0
50
100
150
200
250
0
20
40
60
80
100
120
140
CHD STROKEPer 100,000 population Per 100,000 population
Epidemiology of
CVD in ASIA
Female Male
Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80.
Stroke and CHD Death Rate per 100,000 person-year
0 50 100 150 200 250
Australia
France
New Zealand
Spain
UK
USA
China
J apan
Korea
Singapore
Thailand
Indonesia
Malaysia
India
Bangladesh
Pakistan
Iran
Kazakhstan
Tajikistan
Uzbekistan
J ordan
Oman
UAE
Saudi Arabia
Epidemiology of
CVD in ASIA
0 50 100 150 200 250 300 350 400
Australia
France
New Zealand
Spain
UK
USA
China
J apan
Korea
Singapore
Thailand
Indonesia
Malaysia
India
Bangladesh
Pakistan
Iran
Kazakhstan
Tajikistan
Uzbekistan
J ordan
Oman
UAE
Saudi Arabia
Ueshima H et al. Circ 2008; 118: 2702-2709.
STROKE CHD
Global Trends in Systolic BP, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
Epidemiology of
CVD in ASIADanaei G et al. Lancet 2011; 377: 568-577.
Global Trends in Systolic BP, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
2008 mean SBP, mmHg
Change/decade, mmHg
Men 128.1 (126.7 – 129.4) -0.8 (-0.4 – 2.2)
Women 124.4 (123.0 – 125.9) -1.0 (-0.3 – 2.3)
SBP ≤ 3.5 mmHg / decade in women in W Europe and Australasia ≤ 2.0 – 2.8 mmHg in men in N American, Australasia and W Europe
≥ 0.8 – 1.6 mmHg / decade in men and ≥ 1.0 – 2.7 mmHg / decade in women in Oceania, E Africa, S Asia and SE Asia
Danaei G et al. Lancet 2011; 377: 568-577.
Epidemiology of
CVD in ASIA
Global Trends in BMI, 1980-2007Global Burden of Metabolic Risk Factors of Chronic Diseases CG
Epidemiology of
CVD in ASIAFinucane MM et al. Lancet 2011; 377: 557-567.
Global Trends in BMI, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
• Mean BMI worldwide increased by 0.4 kg/m² in men and 0.5 kg/m² in women.
• In 2008, 1.46B adults had BMI ≥ 25 kg/m², of these 205M men and 297M women were obese.
• Highest in some Oceania countries (Nauru – 33.9 kg/m² in men and 35.0 kg/m² in women).
• Lowest in men in Congo at 19.9 kg/m² and in women in Bangladesh at 20.5 kg/m².
• BMI < 21.5 kg/m² in few countries in E Asia, S Asia, SE Asia and Sub-saharan Africa.
Finucane MM et al. Lancet 2011; 377: 557-567.
Epidemiology of
CVD in ASIA
Ethnic Differences in Visceral Fat and Diabetes Mellitus
Study Groups
Age-
adjusted
BMI
Waist circcm
Visceral
adipose
tissue
DM type 2 prevalence
Whites
(n=196) 26.0 80.7 62.3cm3 5.8%
African-Americans (n=193)
29.7 88.1 57.5cm3 12.1%
Filipino-Americans (n=181)
25.5 81.9 69.1cm3 32.15
Araneta, MR & Barrett-Connor, E. Obesity Research 2005
Epidemiology of
CVD in ASIA
Global Trends in DM Prevalence, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
Epidemiology of
CVD in ASIADanaei G et al. Lancet 2011; 378: 31-40.
Global Trends in FPG & DM Prev, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
2008 mean FPG*, mmol/L
Change/decade, mmol/L
Men 5.50 (5.37 – 5.63) +0.07
Women 5.42 (5.29 – 5.54) +0.09
Danaei G et al. Lancet 2011; 378: 31-40.
1980 DM prevalence*, % 2008 DM prevalence*, %
Men 8.3 (6.5 – 10.4) 9.8 (8.6 – 11.2)
Women 7.5 (5.8 – 9.6) 9.2 (8.0 – 10.5)
*Age-standardized
1980 2008
DM - Total N 153 (127-182)M 347 (314-382)M
Epidemiology of
CVD in ASIA
Global Trends in Serum Cholesterol, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
Epidemiology of
CVD in ASIAFarzadfar F et al. Lancet 2011; 377: 578-586.
Global Trends in Serum Cholesterol, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG
• Mean total cholesterol (TC) was highest in high-income region (Australasia, N America and W Europe).
• TC fell in high-income region, central and eastern Europe.• TC rose in east and southeast Asia
Farzadfar F et al. Lancet 2011; 377: 578-586.
2008 mean Cholesterol*, mmol/L
Change/decade, mmol/L
Men 4.64 (4.51 – 4.76) -<0.1
Women 4.76 (4.62 – 4.91) -<0.1
Epidemiology of
CVD in ASIA
2 4 6 8 10Cholesterol (mmol/l)
Pe
rce
nta
ge
20
15
10
5
0
AsiaMean = 4.86; SD = 1.02
ANZMean = 5.58; SD = 1.13
Distribution of baseline cholesterol among participants in Asian and Australia and New Zealand (ANZ) levels.
APCSC Int. J. Epidemiol 2003;32: 563-572 .
Epidemiology of
CVD in ASIA
3.0
2.0
1.4
1.0
0.7
4.5 5.0 5.5 6.0 6.5
CHD death
A
Ha
zard
ra
tio
3.0
2.0
1.4
1.0
0.7
4.5 5.0 5.5 6.0 6.5
P for homogeneity = 0.29
ANZ
Asia
CHD death
Mean usual total cholesterol (mmol/l)
3.0
2.0
1.4
1.0
0.7
4.5 5.0 5.5 6.0 6.5
CHD death or non-fatal MIB
3.0
2.0
1.4
1.0
0.7
4.5 5.0 5.5 6.0 6.5
P for homogeneity = 0.82
ANZAsia
CHD death or non-fatal MIC D
Ha
zard
ra
tio
APCSC Int. J. Epidemiol 2003;32:563-572.
APCSC: Relation between Cholesterol and CHD events, 352033 subjects
Ha
zard
ra
tio
Ha
zard
ra
tio
Mean usual total cholesterol (mmol/l)
Mean usual total cholesterol (mmol/l) Mean usual total cholesterol (mmol/l)
Epidemiology of
CVD in ASIA
INTERHEART: 15,152 MI Cases and 14,820 Controls
China/Hong Kong, 21%
N America, 2%
S America, 12%
ANZ, 5%S Asia, 15%
Africa, 5%
MEC, 13%
CE Europe, 14%W Europe, 5%
SE Asia, 8%
Epidemiology of
CVD in ASIAYusuf S, et al. Lancet 2004; 364: 937-52.
China, HongKong = 6086Southeast Asia = 2168South Asia = 3936Australia, NZ = 1270
Total Asians = 13460Total subjects = 27098
DISTRIBUTION BY REGION
INTERHEART:Risk Factors for Myocardial Infarction
Yusuf S et al. Lancet 2004; 364: 937-52.
Risk Factors O.R. P.A.R.
Inc. apoB/apoA 3.25 49.2
Smoking 2.87 35.7
Psychosocial 2.67 32.5
Diabetes 2.37 9.9
Hypertension 1.91 17.9
Abd. Obesity 1.12 20.1
Reg. Alcohol 0.91 6.7
Reg. Exercise 0.86 12.2
Fruits,vegetables 0.70 13.7
Epidemiology of
CVD in ASIA
INTERHEART:Mean Lipid Levels in Subjects from Asian
and other Regions
LDL-C (mg/dL) HDL-C (mg/dL)
Cases Controls Cases Controls
Asia (n=9,699) 126.8 (40) 118.6 (37) 39.2 (12.3) 41.2 (14.3)
Non-Asian regions (n=10,322)
136.2 (42.4) 127.1 (39.1) 40.8 (13.2) 42.6 (15)
South Asia (n=2,674) 125.2 (39.8) 115.4 (37.1) 32.5 (10) 33.5 (11.6)
China/Hong Kong (n=5,232)
121.6 (36) 113.8 (33.8) 41.9 (12) 44.0 (13.3)
SE Asia (n=1,546) 150.4 (47.6) 135.6 (41) 41.0 (12.5) 42.6 (15.5)
Japan (n=247) 133.6 (34.6) 133.1 (30.9) 44.2 (12.8) 56.4 (13.2)
Epidemiology of
CVD in ASIAKarthikeyan G et al. JACC 2009; 53: 244-253.
INTERHEART:Preponderance of Lower HDL-C
among South Asians
South Asians Rest of Asia P- value
Cases 82.3% 57.4% <0.0001
Controls 81.0% 51.6% <0.0001
Karthikeyan G et al. JACC 2009; 53: 244-253.
Epidemiology of
CVD in ASIA
INTERHEART: Odds ratio of first AMI in different LDL-C categories adjusted to HDL-C
levels among Asian subjects
Epidemiology of
CVD in ASIAKarthikeyan G et al. JACC 2009; 53: 244-253.
Subjects with Individual or Combined Lipid Abnormalities
Low HDL-C 26% (M<40 F<50)
High LDL-C 28%High TG 13%TG ≥200mg/dL
3% 16%
4%
3%
6%
3%
13%
No lipid disorder 52%
UNITED STATES
Ghandehari H et al. Am Heart J 2008; 156: 112-9.
Epidemiology of
CVD in ASIA
Subjects with Individual or Combined Lipid Abnormalities
Low HDL-C 26% (M<40 F<50)
High LDL-C 28%High TG 13%TG ≥200mg/dL
3% 16%
4%
3%
6%
3%
13%
UNITED STATES
No lipid disorder 52%
Ghandehari H et al. Am Heart J 2008; 156: 112-9.
Epidemiology of
CVD in ASIA
Low HDL-C 70% (M<40 F<50)
High LDL-C 11%High TG 9%TG ≥200mg/dL
56%
6%1%
7%
2% 0.4% 3%
No lipid disorder 24.5%
PHILIPPINES
Prevalence (%) of Metabolic Syndrome
NCEP Criteria (unmodified), age 35
HK Taiwan Thailand USA
Male 14.6 10.7 18.5 30.9
Female 20.9 12.1 26.5 35.3
Patel A et al. Atherosclerosis 2006; 184: 225-232.
Epidemiology of
CVD in ASIA
Proportion (S.E.) with Each Metabolic Abnormality
BP TG HDL WC FBS
Male
HK 85(3.2) 81(3.1) 88(2.7) 22(3.4) 56(4.2)
Taiwan 57(1.1) 94(0.5) 89(0.6) 14(0.8) 67(1.1)
Thailand 78(2.0) 92(1.3) 79(2.0) 20(2.0) 58(2.4)
USA 82(1.1) 84(1.0) 73(1.2) 72(1.2) 39(1.3)
Female
HK 80(3.9) 65(4.2) 95(1.7) 51(4.4) 51(4.4)
Taiwan 54(1.4) 88(0.8) 91(0.6) 38(1.4) 62(1.4)
Thailand 57(1.7) 79(1.5) 93(0.9) 64(1.6) 46(1.8)
USA 70(1.2) 71(1.2) 78(1.0) 94(0.5) 37(1.2)
Patel A et al. Atherosclerosis 2006; 184: 225-232.
Epidemiology of
CVD in ASIA
Japan Collaborative Cohort Study1988-2006
• 18,747 men and 24,263 women aged 40-79 without history of stroke or CHD at baseline in 1988-90 were followed up until 2006 (mean 16.5 yrs)
• Lifestyle behaviour scored for follwing (1 point each):– Consumption of fruits ≥ 1 intake / day
– Consumption of fish ≥ 1 intake / day
– Consumption of milk almost everyday
– Exercise ≥ 5 h / week &/or walking ≥ 1 h per day
– BMI of 21-25 Kg/m²
– Alcohol intake < 46.0 g / day
– Non-smoking
– Sleep duration of 5.5-7.5 h /day
• 1,907 Deaths – 849 strokes and 402 CHDs
Eguchi E et al. Eur Heart J 2012;33: 467-477.
Epidemiology of
CVD in ASIA
Japan Collaborative Cohort Study1988-2006
Eguchi E et al. Eur Heart J 2012;33: 467-477.
Epidemiology of
CVD in ASIA
Healthy Lifestyle Score: 0-1 2 3 4 5 6-7
Japan Collaborative Cohort Study1988-2006
• Multivariable hazard ratio (95% CI, population attributable fraction) – highest score (7-8) versus lowest (0-2)
MEN WOMEN
CVD 0.35(0.25-0.49, 52.3%) 0.24(0.16-0.36, 44.6%)
Stroke 0.36(0.22-0.58, 45.0%) 0.28(0.15-0.53, 43.4%)
CHD 0.19(0.08-0.50, 76.2%) 0.20(0.09-0.47, 34.5%)
Eguchi E et al. Eur Heart J 2012;33: 467-477.
Epidemiology of
CVD in ASIA
Lipid Goals in GuidelinesGuidelines Low risk,
0 – 1 risk factor
Moderate risk, ≥ 2 risk factors
High risk,CHD or CHD equivalents
Very high risk individuals
NCEP ATP III
< 160 mg/dL < 130 mg/dL < 100 mg/dL < 70 mg/dL
ESC / EAS 2011
No goal mentioned
≤ 3.0mmol/L 115 mg/dL
≤ 2.5 mmol/L100 mg/dL
≤ 1.8 mmol/L70 mg/dL
or 50% reduction
Epidemiology of
CVD in ASIA
REALITY ASIA: Low LDL-C goal attainment particularly in high-risk patients
82
62
38
88
74
83
67
57
80
64
42
84
53
35
83
67
63
41
37
0 20 40 60 80 100
TaiwanSingaporeS. KoreaThailandChinaMalaysiaOverall
Non-CHD & <2 risk factors(LDL-C <160mg/dL)
Non-CHD & <2 risk factors(LDL-C <130mg/dL)
CHD/Diabetes
Percentage of Population
Kim HS et al. Current Medical Research and Opinion 2008; 24(7): 1951-1962.
n = 2,622 patients recently initiated with statins
Epidemiology of
CVD in ASIA
Summary
• Asia is a very diverse region with mortality from CVD rising despite downward trend in developed countries;
• Global burden trends showed CV risk factors still rising in most Asian countries;
• Prevalence of diabetes and obesity is a major problem in the region;
• Asians may have lower serum cholesterol levels than Caucasians but carry the same risk for CHD;
• Low HDL-c is prevalent in many Asian countries;• Lifestyle modification strategies have been shown to
reduce CV events in Asians.
Epidemiology of
CVD in ASIA
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Epidemiology of
CVD in ASIA