Juliana Chan, MD Professor of Medicine and Therapeutics The Chinese - PowerPoint PPT Presentation

Asian Chapter Asian Chapter Diabetes & Coronary Artery Disease in Asia: The size and urgency of the problem Juliana Chan, MD Professor of Medicine and Therapeutics The Chinese University of Hong Kong Prince of Wales Hospital, HONG KONG

Projected Global Deaths, All Ages, 2005 20 17.5 15 Deaths (millions) 10 7.6 4.1 5 2.8 1.6 1.1 0.9 0 HIV/AIDS TB Malaria CVD Cancer COPD Diabetes www.who.int/chp/chronic_disease_report/en/ and the Public’s Health

Global Mortality and Burden of Disease Attributable to CVD & Major Risk Factors for People ≥ 30 Yrs

Population Attributable Fractions (PAF) for Ischemic Heart Disease 50 47 45 45 Global Data 40 PAF, Percent 35 30 25 25 19 20 15 15 12 10 5 1 0 High Blood High Low Fruit & Physical Overweight Smoking Alcohol Use Pressure Cholesterol Vegetable Inactivity and Obesity Intake Source of Data: Ezzati M, et al. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In: Lopez AD, Mathers CD, Ezzati M, Murray CJL, Jamison DT, eds. Global burden of disease and risk factors. New York: Oxford University Press; 2006: 241 – 68. and the Public’s Health

China Prospective Study on High BP • 169,871 Chinese adults aged 40 years • Baseline BP measurement in 1991 • Reassessed in 1999-2000 • Premature death: – before 72 years in men and 75 years in women • Deaths attributable to  BP in 2005 – 2.33 million CVD deaths – 1.27 million premature CVD deaths He J et al lancet 2009

I in 3 men in China has hypertension or prehypertension Pre hypertension Hypertension Age % RR PAR % RR PAR 40-54 40 1.35 12.4 24.8 5.2 52 55-64 36.7 1.58 17.3 40.7 4.5 60 >65 32.7 1.34 9.8 47.8 2.5 42.7 Total 38.2 1.40 13 32.0 4.4 51.7 RR=relative risk PAR=population attributable risk He J et al lancet 2009

I in 3 women in China has hypertension or prehypertension Pre hypertension Hypertension Age % RR PAR % RR PAR 40-54 34.6 1.28 9 22.4 4.19 46.4 55-64 35.5 1.82 22.2 38.9 5.37 6.34 >65 31.7 1.26 7.5 50.2 2.38 41.5 Total 34.3 1.37 11.5 30.8 4.29 49.1 RR=relative risk PAR=population attributable risk He J et al lancet 2009

Number of total deaths attributable to (pre) hypertension in 2005 Premature deaths 200 400 600 800 1000 1200 1400 1600 absolute number of deaths (x10 7 ) He J et al lancet 2009

Global epidemic of diabetes  per 1998 2008 decade Fasting BG men (mmol/L) 5.43 5.50 0.07 Fasting BG women (mmol/L) 5.33 5.42 0.09 DM prevalence men (%) 8.3 9.8 1.5 DM prevalence women (%) 7.5 9.2 1.7 People with diabetes (million) 153 347 94 Danaei G et al Lancet 2011

1 in 4 has diabetes or prediabetes in China Yang WY et al NEJM 2010

Rising trends of diabetes in Asia 16 China 14 Malaysia Taiwan 12 Sinagpore Thailand 10 Philippines % Indonesia 8 6 4 2 0 1980-1995 1996-2000 2001-2005 2005-2010 Chan JC et al DRCP (submitted) Chan JC et al JAMA 2009

Migration and diabetes in different ethnic groups (2007) www.idf.org

Recent trends of obesity in Asia 40 35 30 25 % 20 Thai men 15 Thai women 10 China Hong Kong men 5 Hong Kong women Philippines 0 1990-1995 1995-2000 2000-2005 Chan JC et al DRCP (submitted) Ko GTC Chinese Med J 2009

Asians versus Caucasians (lower BMI, higher DM rate, same waist, more visceral fat) Yoon KH, Lancet 368, 2006 Tanaka S et al Acta Diabetologia 2003

Hyperglycemia and CVD risk in Asian population Asia Pacific Cohort Studies collaboration Diabetes Care 2004

3 in 4 Chinese with acute MI has diabetes or prdiabetes China Heart Survey (n=3,513) No OGTT NGT 23% 33% Prediabetes Newly diagnosed 24% type 2 diabetes 20% Previously known type 2 diabetes ~3/4 of patients have hyperglycaemia Hu DY Eur Heart J 2006

Emerging Risk Factor Collaboration 97 studies, 125 million person-years 123,205 deaths, 820,900 people Per 1000 person-yrs Men Women All Non-DM DM Non-DM DM HR All-cause death 12 29 7 23 1.8 Cancer deaths 4 7 3 4 1.25 Vascular deaths 5 13 2 11 2.32 Non-cancer 3 6 3 6 1.73 Non-vascular deaths Seshasai, SR et al NEJM 2011

Diabetes and co-morbidities Hong Kong Diabetes Registry >10,000 patients since 1995 3.7% Type 1 diabetes 96.3% Type 2 diabetes Mean age: 57.4 years Mean disease duration: 5 years Mean follow up period: 6 years cancer stroke heart failure 38% CHD A major event CKD/ESRD Death % 0 2 4 6 8 10 10 12 12 Chan JC et al JAMA2009

Predictors For CHD in type 2 diabetes Hong Kong Diabetes Registry HR (95% CI) P value Age 1.03 (1.01-1.04) 0.0002 Women 0.70 (0.51-0.97) 0.03 Smoking 1.55 (1.05-2.22) 0.01 Duration of diabetes (years) 1.04 (1.02-1.06) <0.0001 eGFR 0.62 (0.40-0.95) 0.02 ACR 1.13 (1.03-1.25) 0.01 Non HDL cholesterol 1.30 (1.15-1.48) <0.0001 Yang XL et al et al Am J Heart 2008

Predictors for heart failure in type 2 diabetes Hong Kong Diabetes Registry HR (95% CI) P value Age 1.07 (1.05-1.10) <0.001 Body mass index 1.07 (1.01-1.13) 0.02 Glycated haemoglobin 1.15 (1.03-1.28) 0.013 Log 10 urinary albumin:creatinine ratio (ACR) 2.70 (2.32-3.55) <0.0001 Blood hemoglobin 0.70 (0.61-0.8) <0.0001 CHD during follow up 2.26 (1.26-4.05) <0.006 Yang XL et al Cardiovascular Diabetology 2008

HDL-C and LDL-C for CVD disease in Chinese type 2 diabetic patients Ting R et al Cardiovascular Diabetologia 2010

Global burden of diabetic kidney disease Trends of incidence Of ESRD In Japan (1983-2000) Yoon KH et al Lancet 2006 K Waki et al 2004

eGFR and ACR predict CVD in T2 DM (4421 Chinese T2D patients 3 year FU) eGFR<60 (5-10% per year) eGFR  60 (2-5% per year) So WY et al Diabetes Care 2006

Association between CKD and CHD in Taiwanese Hsieh MH et al Am J Nephrol 208

Asians contribute to stroke and renal endpoints in RCT setting (ADVANCE) Clarke PM et al PLoS Med 2010

Majority of Asian T2D patients in Asia had complications or multiple risk factors 100% CVD Or ESRD 80% 60% CKD or  3 RF 40% 20% No CKD And<3 RF 0% Total, n=3687 HK, n=832 IN, n=788 KR, n=295 PH, n=1186 SG, n=256 TW, n=55 TH, n=275 So WY et al J of Diabetes 2011

ABC targets in Asian T2D patients Total HK India Korea Ph Sing TW Thai (3687) (832) (788) (295) (1186) (256) (55) (275) HbA 1c <7% 35.3 61.8 13.8 40.7 31.3 35.2 25.5 29.8 BP<130/80 32.3 45.6 26.0 38.3 27.2 12.9 34.6 42.9 mmHg LDL-C<2.6 34.0 39.2 44.8 33.6 20.5 29.7 20.0 52.7 mmol/L No target 32.6 14.3 38.3 28.1 42.2 42.8 40.0 23.3 achieved Any 1 target 38.7 37.1 40.6 36.6 39.2 37.9 43.6 37.5 achieved Any 2 targets 23.4 36.3 19.2 29.8 16.2 15.2 12.7 29.8 achieved All 3 targets 5.4 12.3 1.9 5.4 2.5 3.1 3.6 9.5 achieved So WY et al for JADE Study Group J of Diabetes 2011

Drug usage in REACH Registry Asia (Taiwan) versus global pattern  3 risk % Clinical CAD CVD PAD Taiwan Global disease factors number 9%71 541 496 29 91 1062 67,888 ACEI 20 23 37 12 21 21 48 ARB 42 42 41 56 49 42 25 CCB 51 52 51 41 55 57 38 Lipid Px 49 50 39 62 68 51 75 Statin 42 51 35 51 64 45 69 Other 7 10 5 10 6 7 12 lipid Px J Formos Med Assoc 2007

Majority of patients on  5 chronic medications are not compliant 90% of patients on CVS drugs 50% of patients on anti-diabetic drugs Wu J et al BMJ 2006

Protocol + team = Clinical benefits Death rate  70% All events  50% So WY et al Am J Managed Care 2003