1. 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

2. CVD Mortality (as % of total mortality) 1995-96 Percent of mortality from all causes Female Male Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80. Epidemiology of CVD in ASIA

3. CHD and Stroke Mortality in Asia-Pacific 1995-96 CHDSTROKE Per 100,000 population Epidemiology of CVD in ASIA FemaleMale Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80.

4. Stroke and CHD Death Rate per 100,000 person-year Epidemiology of CVD in ASIA Ueshima H et al. Circ 2008; 118: 2702-2709. STROKECHD

5. Global Trends in Systolic BP, 1980-2008 Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Danaei G et al. Lancet 2011; 377: 568-577.

6. Global Trends in Systolic BP, 1980-2008 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: 568-577. Epidemiology of CVD in ASIA

7. Global Trends in BMI, 1980-2007 Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Finucane MM et al. Lancet 2011; 377: 557-567.

8. Global Trends in BMI, 1980-2008 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: 557-567. Epidemiology of CVD in ASIA

9. 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) 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

10. Global Trends in DM Prevalence, 1980-2008 Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Danaei G et al. Lancet 2011; 378: 31-40.

11. Global Trends in FPG & DM Prev, 1980-2008 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: 31-40. 1980 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 19802008 DM - Total N153 (127-182)M347 (314-382)M Epidemiology of CVD in ASIA

12. Global Trends in Serum Cholesterol, 1980-2008 Global Burden of Metabolic Risk Factors of Chronic Diseases CG Epidemiology of CVD in ASIA Farzadfar F et al. Lancet 2011; 377: 578-586.

13. Global Trends in Serum Cholesterol, 1980-2008 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: 578-586. 2008 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

14. 246810 Cholesterol (mmol/l) Percentage 20 15 10 5 0 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: 563-572. Epidemiology of CVD in ASIA

15. 3.0 2.0 1.4 1.0 0.7 4.5 5.0 5.56.0 6.5 CHD death A Hazard ratio 3.0 2.0 1.4 1.0 0.7 4.55.0 5.56.0 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 4.55.0 5.56.0 6.5 CHD death or non-fatal MI B 3.0 2.0 1.4 1.0 0.7 4.55.0 5.56.0 6.5 P for homogeneity = 0.82 ANZ Asia CHD death or non-fatal MI C D Hazard ratio APCSC Int. J. Epidemiol 2003;32:563-572. APCSC: Relation between Cholesterol and CHD events, 352033 subjects Hazard ratio Mean usual total cholesterol (mmol/l) Epidemiology of CVD in ASIA

16. INTERHEART: 15,152 MI Cases and 14,820 Controls Epidemiology of CVD in ASIA Yusuf S, et al. Lancet 2004; 364: 937-52. China, HongKong = 6086 Southeast Asia = 2168 South Asia = 3936 Australia, NZ = 1270 Total Asians = 13460 Total subjects = 27098 DISTRIBUTION BY REGION

17. INTERHEART: Risk Factors for Myocardial Infarction Yusuf S et al. Lancet 2004; 364: 937-52. Risk FactorsO.R.P.A.R. Inc. apoB/apoA3.2549.2 Smoking2.8735.7 Psychosocial2.6732.5 Diabetes2.379.9 Hypertension1.9117.9 Abd. Obesity1.1220.1 Reg. Alcohol0.916.7 Reg. Exercise0.8612.2 Fruits,vegetables0.7013.7 Epidemiology of CVD in ASIA

18. 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) 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 ASIA Karthikeyan G et al. JACC 2009; 53: 244-253.

19. INTERHEART: Preponderance of Lower HDL-C among South Asians South Asians Rest of AsiaP- value Cases82.3%57.4%<0.0001 Controls81.0%51.6%<0.0001 Karthikeyan G et al. JACC 2009; 53: 244-253. Epidemiology of CVD in ASIA

20. 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: 244-253.

21. 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: 112-9. Epidemiology of CVD in ASIA

22. 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: 112-9. Epidemiology of CVD in ASIA 56% 6% 1% 7% 2% 0.4%3% No lipid disorder 24.5% PHILIPPINES

23. Prevalence (%) of Metabolic Syndrome NCEP Criteria (unmodified), age  35 HKTaiwanThailandUSA Male14.610.718.530.9 Female20.912.126.535.3 Patel A et al. Atherosclerosis 2006; 184: 225-232. Epidemiology of CVD in ASIA

24. 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: 225-232. Epidemiology of CVD in ASIA

25. Japan Collaborative Cohort Study 1988-2006 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

26. Japan Collaborative Cohort Study 1988-2006 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

27. Japan Collaborative Cohort Study 1988-2006 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

28. 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

29. 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): 1951-1962. n = 2,622 patients recently initiated with statins Epidemiology of CVD in ASIA

30. 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

31. THANK YOU Epidemiology of CVD in ASIA