Andrew To Cardiologist North Shore Hospital, Auckland, New Zealand June 2014 Cardiovascular Health in Chinese New Zealanders

Cardiovascular Health in Chinese New Zealanders - Outline CVS Health & Ethnicity Disease prevalence & incidence Risk factors Risk prediction models Pharmacogenetics Specific IssuesAction Points & Take Home Messages

STATE OF CARDIOVASCULAR HEALTH IN CHINA

Chinese Heart Health High prevalence of smoking, incl. physicians! High sodium intake Low fruit intake Urban vs. Rural – Changes in rates of CVD – Availability of medical technology – Access and health care utilization – Urbanization and related issues

DIVERSITY

Risk factors -Hypertension -Hypercholesterolaemia -Diabetes -Physical inactivity -Smoking

Diversity - Genes, Environment, Lifestyle choices Second…t hird generation Chinese Newly arrived Chinese immigrant

Acculturation

PAUCITY OF DATA

2013 Census Chinese171,411 Indian155,178 Filipino40,350 Korean30,171 Japanese14,118 Sri Lankan11,274 Cambodian8,601 Vietnamese6,660 Asian ethnic group – 2013 NZ Census Databases Death certificates Hospital discharge information Population based studies

AWARENESS – PHYSICIANS & PATIENTS

Palaniappan et al. Circ 2010

DISEASE PREVALENCE AND INCIDENCE

Disease prevalence and incidence Limited DATA! Overseas data – Lower rates of hospitalizations for IHD vs. whites – More hemorrhagic strokes – Lower prevalence of peripheral arterial disease Kaltsky et al. Am J public Health 1994 Fang et al. Ethn Dis 2004 Allison et al. JACC 2006

RISK FACTORS

Differential body fat distribution Lower mean BMI – But… similar body fatness – WHO recommendations for lowering BMI thresholds – Central distribution of body fat - ?metabolically more active Alternative arthrometric measurements – Waist circumference, waist-to-hip, trunk-to-total height distribution

Diet Favourable Less saturated fat Less animal protein Greater vegetables Garlic Black and green teas Red yeast rice Omega-3 fatty acids Unfavourable Sodium

Physical inactivity

RISK PREDICTION MODELS

Framingham risk scores - the need for calibration

Recalibration of risk prediction models J Epidemiol Community Health. Feb 2007; 61(2): 115–121

Recalibration of risk prediction models in New Zealand - PREDICT cohort Ridell et al. NZMJ 2010

Recalibration of risk prediction models in New Zealand - PREDICT cohort Original Framingham Heart Study risk prediction score overestimates risk for the New Zealand European population but underestimates risk for the combined high risk ethnic populations (Maori, Pacific and Indian) Adjusted Framingham score used in New Zealand clinical guidelines overcompensates for this underestimate, resulting in a score that overestimates risk among the European, Maori, Pacific and Indian ethnic populations at all predicted risk levels Ridell et al. NZMJ 2010

PHARMACOGENETICS

Statins CYP3A4 – Lovastatin, Simvastatin, Atorvastatin CYP2C9 – Fluvastatin, Rosuvastatin Renal – Pravastatin OATP1B1 uptake transporter (SLCO1B1 gene) – 521T>C polymophism – reduces uptake of statins from bloodstream into hepatocytes – Increases serum level, for most; except Fluvastatin; esp. Simvastatin acid ABCG2 transporter (ABCG2 gene) – 421C>A polymorphism – reduces uptake and increases exposure – Affects most statins, esp. Rosuvastatin, Atorvastatin, Fluvastatin – Explains increased risk for AE of Rosuvastatin in Chinese

Warfarin Dosing tables dependent on CYP2C9*2, CYP2C9*3, VKORC1(-1639G>A)

Warfarin

Clopidogrel AsiansWhitesAfrican- americans CYP2C19*2 (c.681G>A)55%28%24%LOF CYP2C19*317%<1% LOF CYP2C19*17 (c.806C>T)4%41%23%GOF

ACTION POINTS & SUMMARY

Action points - Individual level Recognizes the differences in Chinese vs. white population Risk factors Risk prediction model Pharmacogenetics

Action points - Population level GENERAL PAUCITY OF DATA – Recognize heterogeneous populations – Appropriate data collection – Specific Asian groups Databases Death certificates Hospital discharge information Population based studies AWARENESS