EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE:

An Asian Perspective

RODY G. SY, M.D., FPCP, FPCC, FACCProfessor, Section of Cardiology

Dept of Medicine, UP College of Medicine

Epidemiology of

CVD in ASIA

CVD Mortality (as % of total mortality) 1995-96

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NewZealand

Australia Chinaurban

Singapore China rural Japan Malaysia Korea

Per

cen

t o

f m

ort

alit

y fr

om

all

cau

ses Female

Male

Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80. Epidemiology of

CVD in ASIA

CHD and Stroke Mortality in Asia-Pacific 1995-96

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250

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100

120

140

CHD STROKEPer 100,000 population Per 100,000 population

Epidemiology of

CVD in ASIA

Female Male

Khor GL. Asia Pacific J Clin Nutr 2001;10(2):76-80.

Stroke and CHD Death Rate per 100,000 person-year

0 50 100 150 200 250

Australia

France

New Zealand

Spain

UK

USA

China

J apan

Korea

Singapore

Thailand

Indonesia

Malaysia

India

Bangladesh

Pakistan

Iran

Kazakhstan

Tajikistan

Uzbekistan

J ordan

Oman

UAE

Saudi Arabia

Epidemiology of

CVD in ASIA

0 50 100 150 200 250 300 350 400

Australia

France

New Zealand

Spain

UK

USA

China

J apan

Korea

Singapore

Thailand

Indonesia

Malaysia

India

Bangladesh

Pakistan

Iran

Kazakhstan

Tajikistan

Uzbekistan

J ordan

Oman

UAE

Saudi Arabia

Ueshima H et al. Circ 2008; 118: 2702-2709.

STROKE CHD

Global Trends in Systolic BP, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG

Epidemiology of

CVD in ASIADanaei G et al. Lancet 2011; 377: 568-577.

Global Trends in Systolic BP, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG

2008 mean SBP, mmHg

Change/decade, mmHg

Men 128.1 (126.7 – 129.4) -0.8 (-0.4 – 2.2)

Women 124.4 (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

Global Trends in BMI, 1980-2007Global Burden of Metabolic Risk Factors of Chronic Diseases CG

Epidemiology of

CVD in ASIAFinucane MM et al. Lancet 2011; 377: 557-567.

Global Trends in BMI, 1980-2008Global 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

Ethnic Differences in Visceral Fat and Diabetes Mellitus

Study Groups

Age-

adjusted

BMI

Waist circcm

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

Global Trends in DM Prevalence, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG

Epidemiology of

CVD in ASIADanaei G et al. Lancet 2011; 378: 31-40.

Global Trends in FPG & DM Prev, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG

2008 mean FPG*, mmol/L

Change/decade, mmol/L

Men 5.50 (5.37 – 5.63) +0.07

Women 5.42 (5.29 – 5.54) +0.09

Danaei G et al. Lancet 2011; 378: 31-40.

1980 DM prevalence*, % 2008 DM prevalence*, %

Men 8.3 (6.5 – 10.4) 9.8 (8.6 – 11.2)

Women 7.5 (5.8 – 9.6) 9.2 (8.0 – 10.5)

*Age-standardized

1980 2008

DM - Total N 153 (127-182)M 347 (314-382)M

Epidemiology of

CVD in ASIA

Global Trends in Serum Cholesterol, 1980-2008Global Burden of Metabolic Risk Factors of Chronic Diseases CG

Epidemiology of

CVD in ASIAFarzadfar F et al. Lancet 2011; 377: 578-586.

Global Trends in Serum Cholesterol, 1980-2008Global 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

Men 4.64 (4.51 – 4.76) -<0.1

Women 4.76 (4.62 – 4.91) -<0.1

Epidemiology of

CVD in ASIA

2 4 6 8 10Cholesterol (mmol/l)

Pe

rce

nta

ge

20

15

10

5

0

AsiaMean = 4.86; SD = 1.02

ANZMean = 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

3.0

2.0

1.4

1.0

0.7

4.5 5.0 5.5 6.0 6.5

CHD death

A

Ha

zard

ra

tio

3.0

2.0

1.4

1.0

0.7

4.5 5.0 5.5 6.0 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

4.5 5.0 5.5 6.0 6.5

CHD death or non-fatal MIB

3.0

2.0

1.4

1.0

0.7

4.5 5.0 5.5 6.0 6.5

P for homogeneity = 0.82

ANZAsia

CHD death or non-fatal MIC D

Ha

zard

ra

tio

APCSC Int. J. Epidemiol 2003;32:563-572.

APCSC: Relation between Cholesterol and CHD events, 352033 subjects

Ha

zard

ra

tio

Ha

zard

ra

tio

Mean usual total cholesterol (mmol/l)

Mean usual total cholesterol (mmol/l) Mean usual total cholesterol (mmol/l)

Epidemiology of

CVD in ASIA

INTERHEART: 15,152 MI Cases and 14,820 Controls

China/Hong Kong, 21%

N America, 2%

S America, 12%

ANZ, 5%S Asia, 15%

Africa, 5%

MEC, 13%

CE Europe, 14%W Europe, 5%

SE Asia, 8%

Epidemiology of

CVD in ASIAYusuf S, et al. Lancet 2004; 364: 937-52.

China, HongKong = 6086Southeast Asia = 2168South Asia = 3936Australia, NZ = 1270

Total Asians = 13460Total subjects = 27098

DISTRIBUTION BY REGION

INTERHEART:Risk Factors for Myocardial Infarction

Yusuf S et al. Lancet 2004; 364: 937-52.

Risk Factors O.R. P.A.R.

Inc. apoB/apoA 3.25 49.2

Smoking 2.87 35.7

Psychosocial 2.67 32.5

Diabetes 2.37 9.9

Hypertension 1.91 17.9

Abd. Obesity 1.12 20.1

Reg. Alcohol 0.91 6.7

Reg. Exercise 0.86 12.2

Fruits,vegetables 0.70 13.7

Epidemiology of

CVD in ASIA

INTERHEART:Mean Lipid Levels in Subjects from Asian

and other Regions

LDL-C (mg/dL) HDL-C (mg/dL)

Cases Controls Cases Controls

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 ASIAKarthikeyan G et al. JACC 2009; 53: 244-253.

INTERHEART:Preponderance of Lower HDL-C

among South Asians

South Asians Rest of Asia P- value

Cases 82.3% 57.4% <0.0001

Controls 81.0% 51.6% <0.0001

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

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 ASIAKarthikeyan G et al. JACC 2009; 53: 244-253.

Subjects with Individual or Combined Lipid Abnormalities

Low HDL-C 26% (M<40 F<50)

High LDL-C 28%High TG 13%TG ≥200mg/dL

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

Subjects with Individual or Combined Lipid Abnormalities

Low HDL-C 26% (M<40 F<50)

High LDL-C 28%High TG 13%TG ≥200mg/dL

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

Low HDL-C 70% (M<40 F<50)

High LDL-C 11%High TG 9%TG ≥200mg/dL

56%

6%1%

7%

2% 0.4% 3%

No lipid disorder 24.5%

PHILIPPINES

Prevalence (%) of Metabolic Syndrome

NCEP Criteria (unmodified), age 35

HK Taiwan Thailand USA

Male 14.6 10.7 18.5 30.9

Female 20.9 12.1 26.5 35.3

Patel A et al. Atherosclerosis 2006; 184: 225-232.

Epidemiology of

CVD in ASIA

Proportion (S.E.) with Each Metabolic Abnormality

BP TG HDL WC FBS

Male

HK 85(3.2) 81(3.1) 88(2.7) 22(3.4) 56(4.2)

Taiwan 57(1.1) 94(0.5) 89(0.6) 14(0.8) 67(1.1)

Thailand 78(2.0) 92(1.3) 79(2.0) 20(2.0) 58(2.4)

USA 82(1.1) 84(1.0) 73(1.2) 72(1.2) 39(1.3)

Female

HK 80(3.9) 65(4.2) 95(1.7) 51(4.4) 51(4.4)

Taiwan 54(1.4) 88(0.8) 91(0.6) 38(1.4) 62(1.4)

Thailand 57(1.7) 79(1.5) 93(0.9) 64(1.6) 46(1.8)

USA 70(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

Japan Collaborative Cohort Study1988-2006

• 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

Japan Collaborative Cohort Study1988-2006

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

Japan Collaborative Cohort Study1988-2006

• 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

Lipid Goals in GuidelinesGuidelines Low 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/L100 mg/dL

≤ 1.8 mmol/L70 mg/dL

or 50% reduction

Epidemiology of

CVD in ASIA

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

82

62

38

88

74

83

67

57

80

64

42

84

53

35

83

67

63

41

37

0 20 40 60 80 100

TaiwanSingaporeS. KoreaThailandChinaMalaysiaOverall

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

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

THANK YOU

Epidemiology of

CVD in ASIA