Heavy Burden: Heavy Burden: Multiple Risk Factor Profile In Hypertension Patients Dong Zhao MD, PhD Department of Epidemiology Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing Anzhen Hospital

Free Template from Meaningful Numbers for Meaningful Numbers for Low & Middle Income Countries ♦ ♦ 85% world population; ♦ ♦ More than 80% of the global CVD deaths ; ♦ 420 million hypertension( 160 millions in China); ♦ 420 million hypertension( 160 millions in China); ♦ CHD will increase by 120% for women and 137% for men between 1990 to 2020; men between 1990 to 2020; ♦ Stroke will increase by 94% for women and 82% for ♦ Stroke will increase by 94% for women and 82% for men between 2000 to men between 2000 to 2020.

危险因素对疾病死亡率的影响 * Percentage of Mortality Attributable to Risk Factors *Based on The World Health Report Yach et al. JAMA. 2004;291: Developing countries Developed countries Blood pressure Tobacco Underweight Alcohol Cholesterol Unsafe sex Overweight Unsafe water, sanitation, hygiene Low fruit and vegetable intake Indoor smoke from solid fuels Physical inactivity

高血压患者中其他危险因素的患病率 Sedentary lifestyle Echo LVH Hyperinsulinemia Diabetes mellitus Obesity (BMI >30) HDL-C <1.0 mmol/L (<40 mg/dL) TC >6.2 mmol/L (>240 mg/dL) Cigarette smoking LVH=left ventricular hypertrophy; HDL-C=high-density lipoprotein cholesterol. Kaplan. Am J Cardiol. 1995;76: Prevalence (%) 50% 40% 40% 35% >30% >30% 25% 15%

未控制的高血压成年患者冠心病 和心血管危险因素的患病率 CRF=cardiovascular risk factors. Benner. ASH 20 th Annual Scientific Meeting. May 14-18, 2005; San Francisco, Calif. 

在男性高血压患者中心血管风险随其他 心血管危险因素的增多而升高 Systolic BP Cholesterol Systolic BP Cholesterol HDL-C Systolic BP Cholesterol HDL-C Diabetes Systolic BP Cholesterol HDL-C Diabetes Smoking Systolic BP Cholesterol HDL-C Diabetes Smoking ECG-LVH A combination of high BP and high serum cholesterol increases the risk of CHD, especially in men Adapted from Kannel. Am J Hypertens. 2000;13:3S-10S. 10-Year % Probability of Event

胆固醇水平与不同单一危险因素组合时 CVD 发病的 10 年绝对危险的比较 中国 CMCS TC  5.7 mmol/L (  220 mg/dL) 的患者 %

胆固醇与收缩压对 CHD 死亡危险的协同作用 Neaton JD, et al. Arch Intern Med. 1992;152: < Cholesterol quintile (mg/dL) SBP quintile (mm Hg) < Deaths /10,000 patient-years N=316,099

高血压伴发其他危险因素时增加心肌梗死的危险 Odds Ratio (95% CI) Smk (1) DM (2) HTN (3) ApoB/A1 (4) (1) All 4+Obes+PSAll RFs 2.9 ( ) 2.4 ( ) 1.9 ( ) 3.3 ( ) 13.0 ( ) 42.3 ( ) 68.5 ( ) ( ) ( ) Smk=smoking; DM=diabetes mellitus; Obes=abdominal obesity; PS=psychosocial; RF=risk factor; MI=myocardial infarction. Yusuf. Lancet. 2004; 364:

中国 岁人群 2 种心血管病危险因素的组合构成 1= 高血压 2= 血脂异常 3= 糖代谢异常 4= 肥胖 5= 吸烟 28% 17% 16% 10% 8% 6%5% 4% 2% 血脂异常 + 吸烟 高血压 + 血脂异常 高血压 + 吸烟

中国 岁人群 3 种心血管病危险因素的组合构成 1= 高血压 2= 血脂异常 3= 糖代谢异常 4= 肥胖 5= 吸烟 23% 21% 11% 10% 9% 6% 5% 4% 2% 高血压 + 血脂异常 + 吸烟 高血压 + 血脂异常 + 肥胖 高血压 + 血脂异常 + 糖代谢异常

The Treatment Rates of Hypertension in Selected Countries China: 28% India: 18% Turkey:17% Czech: 32% Egypt: 9% Mexico:<10 % Adapted from the numbers on Hypertension :886, Arch Inst Cardiol Mex :267 Health Soc Care Community :394, J Hypertension :1479 Hypertension :920, BMC Public Health ;1 Am J Hypertension :746 Blood Press :80, Hypertension :827 ， WHO MONICA Project. (Using total hypertensive patients as denominators) USA:41 % Canada:24 % German:58 % UK:32 % AUS:51%

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

Huge absolute numbers of people with CVDs or risk factors in China Hypertension:* 160 millions Dyslipidemia: * 160 millions Diabetes:* 50 millions AMI (hospitalized)/year 0.8 million New stroke events/year millions *

Increasing Numbers of Hypertension Increasing Numbers of Hypertension Patients in China from 1958 to 2004 Patients in China from 1958 to

Projected increase in the population aged Projected increase in the population aged 65 and over from 2000 to 2040 in more-, 65 and over from 2000 to 2040 in more-, less- and least-developed countries less- and least-developed countries (Million) (Million) United Nations Population Division( hppt://esa.un.org/unpp

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

The comparison of per capita total The comparison of per capita total expenditure on health between high income expenditure on health between high income countries and low & middle income countries Adapted from WHO World Health Report 2002 Low & Middle income countries High income countries Low & Middle income countries High income countries N=146 N=39 N=146 N=39 $ 1547

Essential cardiovascular diseases drugs Essential cardiovascular diseases drugs in developing countries in developing countries (%) Asia, Africa Caribbean (19) Latin America (19) Latin America Middle Eastern Middle Eastern Crescent(10) Crescent(10) Chokalingam & Balaguer-Vintro WHF White Book 1999 Eastern, Central Europe (18) All regions (47) (47)

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

Percentages of Developing Countries Percentages of Developing Countries Lack of National Actions on CVD Prevention (%) Not govern- Not govern- ment priority ment priority Chokalingam & Balaguer-Vintro WHF White Book 1999 No tobacco No tobacco Sale legislation No national Program of CVD prevention No national Program of hypertension No national Program of diabetes No national Program for children No national Program for women

The Increasing Numbers of Cigarette Sale in China Million 32.6 Million 33.7Million (Box)

The comparison of mean out-of-pocket expenditure % The comparison of mean out-of-pocket expenditure % of total expenditure on health between high of total expenditure on health between high income countries and low & middle income countries income countries and low & middle income countries Adapted from WHO World Health Report 2002 Low & Middle income countries High income countries Low & Middle income countries High income countries N=146 N=39 N=146 N=39

Educational Level of Physicians in Primary and Secondary Hospitals in Beijing Educational Level of Physicians in Primary and Secondary Hospitals in Beijing Primary Hospital Primary Hospital Secondary Hospital Secondary Hospital University 24% Colleges 40% Technique school 36% University 70% Colleges 19% Technique school 11% WH Wang, D Zhao Chinese J Epidemiology 2004

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

Components in CVD Prevention and Control Diets Tobacco alcohol Exercise Health Environments CAD Blood Pressure Hypertension Lipids Dyslipidemia Glucose Diabetes Weight Obesity Stroke Peripheral arterials diseases Death Disability Upstream Midstream Downstream Prevention Treatment Major cardiac procedures In China (case numbers) Up to2002 PTCA CABG Coronary Stenting Awareness, treatment & control rate of hypertension In China(2001) DF Gu et al. Tsung O. Cheng. Hypertension :920 Inter. J Cardiology :425

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

Percentage of death from communicable diseases, Percentage of death from communicable diseases, maternal and perinatal and nutritional deficiencies in maternal and perinatal and nutritional deficiencies in total death in low income countries total death in low income countries ( about 48% population in developing countries) ( about 48% population in developing countries) (%) Africa Eastern Mediterranean SE Asia The Americas Africa Eastern Mediterranean SE Asia The Americas Adapted from WHO World Health Report 2002

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers of people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments of high Tech. & high cost treatments and low cost treatments.

Percentages of the Developing Countries Percentages of the Developing Countries without Guidelines for CVDs Treatment without Guidelines for CVDs Treatment (%) Hypertension Lipid Diabetes AMI Stroke Heart Failure Hypertension Lipid Diabetes AMI Stroke Heart Failure Chokalingam & Balaguer-Vintro WHF White Book 1999

Hypertension Lipids( LDL,TG,HDL ) Diabetes Atrial Fibrillation Obesity Unhealthy life style CAD Stroke Barriers to Treatments for CVD Risk Factors or CVDs Few countries have guidelines based on their own data. Huge and still increasing absolute numbers for people with CVD risk factors or CVDs. Limited resources & Low expenditure on health Double burdens from CD and NCD Low capacity of CVD prevention & treatment. Unbalanced developments in high Tech. & high cost treatments and low cost treatments.

Components in CVD Prevention and Control Diets Tobacco alcohol Exercise Health Environments CAD Blood Pressure Hypertension Lipids Dyslipidemia Glucose Diabetes Weight Obesity Stroke Peripheral arterial diseases Death Disability Upstream Midstream Downstream Prevention Treatment Main Target Upstream determinants for CVD prevention in low & middle income countries. Smoking Health Diets Exercises Alcohol

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