EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE: An Asian Perspective RODY G. SY, M.D., FPCP, FPCC, FACC Professor, Section of Cardiology Dept of Medicine, UP College of Medicine Epidemiology of CVD in ASIA

CVD Mortality (as % of total mortality) Percent of mortality from all causes Female Male Khor GL. Asia Pacific J Clin Nutr 2001;10(2): Epidemiology of CVD in ASIA

CHD and Stroke Mortality in Asia-Pacific CHDSTROKE Per 100,000 population Epidemiology of CVD in ASIA FemaleMale Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80.

Stroke and CHD Death Rate per 100,000 person-year Epidemiology of CVD in ASIA Ueshima H et al. Circ 2008; 118: STROKECHD

Global Trends in Systolic BP, Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Danaei G et al. Lancet 2011; 377:

Global Trends in Systolic BP, Global Burden of Metabolic Risk Factors of Chronic Diseases CG 2008 mean SBP, mmHg Change/decade, mmHg Men128.1 (126.7 – 129.4)-0.8 (-0.4 – 2.2) Women124.4 (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: Epidemiology of CVD in ASIA

Global Trends in BMI, Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Finucane MM et al. Lancet 2011; 377:

Global Trends in BMI, Global 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: Epidemiology of CVD in ASIA

Ethnic Differences in Visceral Fat and Diabetes Mellitus Study Groups Age- adjusted BMI Waist circ cm Visceral adipose tissue DM type 2 prevalence Whites (n=196) cm3 5.8% African- Americans (n=193) cm3 12.1% Filipino- Americans (n=181) cm Araneta, MR & Barrett-Connor, E. Obesity Research 2005 Epidemiology of CVD in ASIA

Global Trends in DM Prevalence, Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Danaei G et al. Lancet 2011; 378:

Global Trends in FPG & DM Prev, Global Burden of Metabolic Risk Factors of Chronic Diseases CG 2008 mean FPG*, mmol/L Change/decade, mmol/L Men5.50 (5.37 – 5.63)+0.07 Women5.42 (5.29 – 5.54)+0.09 Danaei G et al. Lancet 2011; 378: DM prevalence*, %2008 DM prevalence*, % Men8.3 (6.5 – 10.4)9.8 (8.6 – 11.2) Women7.5 (5.8 – 9.6)9.2 (8.0 – 10.5) *Age-standardized DM - Total N153 ( )M347 ( )M Epidemiology of CVD in ASIA

Global Trends in Serum Cholesterol, Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Farzadfar F et al. Lancet 2011; 377:

Global Trends in Serum Cholesterol, Global 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: mean Cholesterol*, mmol/L Change/decade, mmol/L Men4.64 (4.51 – 4.76)-<0.1 Women4.76 (4.62 – 4.91)-<0.1 Epidemiology of CVD in ASIA

Cholesterol (mmol/l) Percentage Asia Mean = 4.86; SD = 1.02 ANZ Mean = 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: Epidemiology of CVD in ASIA

CHD death A Hazard ratio P for homogeneity = 0.29 ANZ Asia CHD death Mean usual total cholesterol (mmol/l) CHD death or non-fatal MI B P for homogeneity = 0.82 ANZ Asia CHD death or non-fatal MI C D Hazard ratio APCSC Int. J. Epidemiol 2003;32: APCSC: Relation between Cholesterol and CHD events, subjects Hazard ratio Mean usual total cholesterol (mmol/l) Epidemiology of CVD in ASIA

INTERHEART: 15,152 MI Cases and 14,820 Controls Epidemiology of CVD in ASIA Yusuf S, et al. Lancet 2004; 364: China, HongKong = 6086 Southeast Asia = 2168 South Asia = 3936 Australia, NZ = 1270 Total Asians = Total subjects = DISTRIBUTION BY REGION

INTERHEART: Risk Factors for Myocardial Infarction Yusuf S et al. Lancet 2004; 364: Risk FactorsO.R.P.A.R. Inc. apoB/apoA Smoking Psychosocial Diabetes Hypertension Abd. Obesity Reg. Alcohol Reg. Exercise Fruits,vegetables Epidemiology of CVD in ASIA

INTERHEART: Mean Lipid Levels in Subjects from Asian and other Regions LDL-C (mg/dL)HDL-C (mg/dL) CasesControlsCasesControls Asia (n=9,699)126.8 (40)118.6 (37)39.2 (12.3)41.2 (14.3) Non-Asian regions (n=10,322) (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) (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 ASIA Karthikeyan G et al. JACC 2009; 53:

INTERHEART: Preponderance of Lower HDL-C among South Asians South Asians Rest of AsiaP- value Cases82.3%57.4%< Controls81.0%51.6%< Karthikeyan G et al. JACC 2009; 53: 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 ASIA Karthikeyan G et al. JACC 2009; 53:

Subjects with Individual or Combined Lipid Abnormalities 3%16% 4% 3% 6% 3% 13% No lipid disorder 52% UNITED STATES Ghandehari H et al. Am Heart J 2008; 156: Epidemiology of CVD in ASIA

Subjects with Individual or Combined Lipid Abnormalities 3%16% 4% 3% 6% 3% 13% UNITED STATES No lipid disorder 52% Ghandehari H et al. Am Heart J 2008; 156: Epidemiology of CVD in ASIA 56% 6% 1% 7% 2% 0.4%3% No lipid disorder 24.5% PHILIPPINES

Prevalence (%) of Metabolic Syndrome NCEP Criteria (unmodified), age  35 HKTaiwanThailandUSA Male Female Patel A et al. Atherosclerosis 2006; 184: Epidemiology of CVD in ASIA

Proportion (S.E.) with Each Metabolic Abnormality BPTGHDLWCFBS Male HK85(3.2)81(3.1)88(2.7)22(3.4)56(4.2) Taiwan57(1.1)94(0.5)89(0.6)14(0.8)67(1.1) Thailand78(2.0)92(1.3)79(2.0)20(2.0)58(2.4) USA82(1.1)84(1.0)73(1.2)72(1.2)39(1.3) Female HK80(3.9)65(4.2)95(1.7)51(4.4) Taiwan54(1.4)88(0.8)91(0.6)38(1.4)62(1.4) Thailand57(1.7)79(1.5)93(0.9)64(1.6)46(1.8) USA70(1.2)71(1.2)78(1.0)94(0.5)37(1.2) Patel A et al. Atherosclerosis 2006; 184: Epidemiology of CVD in ASIA

Japan Collaborative Cohort Study ,747 men and 24,263 women aged without history of stroke or CHD at baseline in 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 Kg/m² –Alcohol intake < 46.0 g / day –Non-smoking –Sleep duration of h /day 1,907 Deaths – 849 strokes and 402 CHDs Eguchi E et al. Eur Heart J 2012;33: Epidemiology of CVD in ASIA

Japan Collaborative Cohort Study Eguchi E et al. Eur Heart J 2012;33: Epidemiology of CVD in ASIA Healthy Lifestyle Score:

Japan Collaborative Cohort Study Multivariable hazard ratio (95% CI, population attributable fraction) – highest score (7-8) versus lowest (0-2) MEN WOMEN CVD 0.35( , 52.3%) 0.24( , 44.6%) Stroke 0.36( , 45.0%) 0.28( , 43.4%) CHD 0.19( , 76.2%) 0.20( , 34.5%) Eguchi E et al. Eur Heart J 2012;33: Epidemiology of CVD in ASIA

Lipid Goals in Guidelines GuidelinesLow 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/L 100 mg/dL ≤ 1.8 mmol/L 70 mg/dL or 50% reduction Epidemiology of CVD in ASIA

REALITY ASIA: Low LDL-C goal attainment particularly in high-risk patients 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): 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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