1. 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

2. Free Template from www.brainybetty.com2 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 2020. men between 2000 to 2020.

3. 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 2003. Yach et al. JAMA. 2004;291:2616-2622. 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

4. 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;76:595-597. Prevalence (%) 50% 40% 40% 35% >30% >30% 25% 15%

5. 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. 

6. 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 150-160 Cholesterol 240-262 Systolic BP 150-160 Cholesterol 240-262 HDL-C 33-35 Systolic BP 150-160 Cholesterol 240-262 HDL-C 33-35 Diabetes Systolic BP 150-160 Cholesterol 240-262 HDL-C 33-35 Diabetes Smoking Systolic BP 150-160 Cholesterol 240-262 HDL-C 33-35 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

7. 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 %

8. 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;152:56-64. 142+ 125-131 <182 182-202 203-220 221-244 Cholesterol quintile (mg/dL) SBP quintile (mm Hg) <118 118-124 132-141 34 21 13 6 23 12 8 10 6 18 11 9 6 4 17 8 8 6 3 Deaths /10,000 patient-years 245+ 14 5 6 3 12 17 N=316,099

9. 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) 512 256 128 64 32 16 8 4 2 1 Smk (1) DM (2) HTN (3) ApoB/A1 (4) 1+2+3 (1) All 4+Obes+PSAll RFs 2.9 (2.6-3.2) 2.4 (2.1-2.7) 1.9 (1.7-2.1) 3.3 (2.8-3.8) 13.0 (10.7-15.9) 42.3 (33.2-54.0) 68.5 (53.0-88.6) 182.9 (132.6-252.2) 333.7 (230.2-483.9) Smk=smoking; DM=diabetes mellitus; Obes=abdominal obesity; PS=psychosocial; RF=risk factor; MI=myocardial infarction. Yusuf. Lancet. 2004; 364:937-952.

10. 中国 35-64 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

11. 中国 35-64 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

12. 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 1995 26:886, Arch Inst Cardiol Mex 1992 62:267 Health Soc Care Community 2002 10:394, J Hypertension 2004 22:1479 Hypertension 2002 40:920, BMC Public Health 2003 3;1 Am J Hypertension 1998 11:746 Blood Press 2004 13:80, Hypertension 2001 38:827 ， WHO MONICA Project. (Using total hypertensive patients as denominators) USA:41 % Canada:24 % German:58 % UK:32 % AUS:51%

13. 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.

14. 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 1.5-2 millions *www.moh.gov.cn

15. Increasing Numbers of Hypertension Increasing Numbers of Hypertension Patients in China from 1958 to 2004 Patients in China from 1958 to 2004 1958 1991 2004

16. 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 2000 2020 2040

17. 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.

18. 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

19. 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)

20. 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.

21. 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

22. The Increasing Numbers of Cigarette Sale in China 1980 1990. 2000 15.2Million 32.6 Million 33.7Million (Box)

23. 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

24. 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

25. 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.

26. 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) 1973-95 Up to2002 PTCA 2000 180 000 CABG 1000 75 000 Coronary Stenting 30 73 300 Awareness, treatment & control rate of hypertension In China(2001) DF Gu et al. Tsung O. Cheng. Hypertension 2002 40:920 Inter. J Cardiology 2004 96:425

27. 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.

28. 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

29. 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.

30. 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

31. 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.

32. 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

33. Free Template from www.brainybetty.com33 Thank you for your attention.