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

2. 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

3. STATE OF CARDIOVASCULAR HEALTH IN CHINA

4. 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

5. DIVERSITY

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

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

10. Acculturation

11. PAUCITY OF DATA

13. 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

14. AWARENESS – PHYSICIANS & PATIENTS

15. Palaniappan et al. Circ 2010

18. DISEASE PREVALENCE AND INCIDENCE

19. 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

20. RISK FACTORS

21. 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

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

23. Physical inactivity

24. RISK PREDICTION MODELS

25. Framingham risk scores - the need for calibration

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

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

28. 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

29. PHARMACOGENETICS

30. 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

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

32. Warfarin

33. 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

34. ACTION POINTS & SUMMARY

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

36. 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