The burden of CVD & T2DM in South East Asia: Call for action - PowerPoint PPT Presentation

Diabetes & Cardiovascular Disease: What are the challenges? The burden of CVD & T2DM in South East Asia: Call for action Pham Manh Hung, MD Hanoi, Vietnam Asian Cardio Diabetes Forum March 30-31, 2019 - Hanoi, Vietnam

Global Snapshot: The Emergence of Diabetes Nation… Diabetes is the world’s THIRD MOST POPULOUS country 1 425 MILLION have Diabetes >90% of cases are T2DM 1 by 2040 629 MILLION will have Diabetes 1 17 17 Medications Number of FDA-approved 12 Classes 12 DIABETES 4 MILLION 19 19 Combinations DRUGS 3 Number of deaths due to Diabetes 1 2 1. 2017 IDF Diabetes Atlas 2. 2013 National Nutrition Survey 3. Gourgari E et al. Journal of Diabetes and Its Complications 2017;31:1719-1727.

WHO Region South – East Asia Western Pacific 3

Number of people with diabetes worldwide and per region in 2017 and 2045 (20-79 years) IDF Atlas 2017

Diabetes is Highest in the Western Pacific Region o 1 in 11 adults have diabetes. o ~170 million people have diabetes; will rise to 208 million by 2045. o highest number of people with diabetes among the IDF regions. o More than half (54%) of them have not been diagnosed and are at a higher risk of developing harmful and costly complications. Top 5 Countries 1. China o Home to 37% of the total number of diabetics in the world. 2. Indonesia 3. Japan 4. Thailand o Highest number of deaths due to diabetes (1.7 million) among 5. Philippines the IDF regions. o Despite being the region with the highest diabetes burden, only USD 136.1 billion will be spent on treating diabetes – 16% of the total worldwide. 5 2017 IDF Diabetes Atlas

“Rising Star”: Diabetes in Southeast Asia Top 5 Countries 1. India 2. Bangladesh 3. Sri Lanka 4. Nepal 5. Mauritius o 1 in 12 adults have diabetes. o 84 million have diabetes (2 nd highest region); will rise to 156 million by 2045. o More than half (58%) have not been diagnosed and are at a higher risk of harmful & costly complications. o Second highest number of deaths due to diabetes (1.3 million) among the IDF regions. o Second lowest diabetes-related expenditure per person with diabetes (USD 9.7 billion). 6 2017 IDF Diabetes Atlas

High propotion of undiagnosed diabetes patients in SEA and WP IDF Atlas 2017

Plausible Factors for High Propensity to Develop DM Among Asians 9 Ramchandran A et al. Diabetes Research and Clinical Practice 2014;231-237.

Prevalence of Cardio-Metabolic Risk Factors in Asian Diabetics Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries enrolled between November 2007 to December 2012 YOD LOD 100% 89% 88% 86% 84% 80% 78% 80% 61% 59% 60% 35% 40% 27% 26% 25% 20% 0% 11 Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

At diagnosis of early onset T2D, Higher prevalence of macro- and micro-vascular complication in South Asian patients 18 16 14 12 10 8 6 4 2 0 European South Asian An International Journal of Medicine , Volume 95, Issue 4, 1 April 2002, Pages 241 – 246

13 2017 IDF Diabetes Atlas

Diabetes-related CV complications have declined with improved care, but substantial burden remains Pre-statin era Pre-ACEI/ARB era Trends in Age-Standardized Rates of Diabetes-Related Complications among U.S. Adults with and without Diagnosed Diabetes, 1990-2010. Adapted from Gregg et al. N Engl J Med 2014;370:1514 ‒ 23.

Initial presentation of CV diseases 16.2% in type 2 diabetes patients 14.1% Lancet Diabetes Endocrinol 2015; 3: 105 – 13

People with Diabetes are at Increased Risk of Heart Failure 2 – 5 Diabetes confers a 60 – 80% greater People with diabetes have a 2- to 5-fold higher probability of CV death and all-cause risk of developing HF 1 mortality in those with established HF 2,3 * 16 Sarwar N et al. Lancet 2010;375:2215.

Diabetes Worsens Heart Failure Prognosis LVEF ≥50% LVEF <50% 1.0 1.0 Diabetes No diabetes Diabetes No diabetes Survival proportion 0.8 0.8 0.6 0.6 0.4 0.4 RR=1.73 RR=1.41 0.2 0.2 p =0.0322 p <0.0001 0.0 0.0 0.0 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Time (years) Time (years) Kaplan – Meier survival curves of HF patients hospitalised with LVEF ≥50% (n=498) and <50% (n=754) 17 Varela-Roman A et al. Eur J Heart Failure 2005;7:859.

Higher Diabetes Prevalence in Asian than White Patients With Heart Failure Bank et al J Am Coll Cardiol 2017;5:14-24

Number of death due to diabetes IDF Atlas 2017

Prevalence of Cardiovascular Disease in T2DM Stroke MI Angina Heart Failure Atherosclerosis CAD CVD (%) (%) (%) (%) (%) (%) (%) Africa 5 NR NR NR NR 23.6 28.6 Europe 7.2 10 14.6 19 33 15.4 30 Middle East & 7.1 11.4 NR NR NR 27.4 26.9 North Africa North America & 10.9 13.6 17.2 29.5 NR 20.1 46 Carribean South & 5.5 NR NR 4.2 NR 22.6 27.5 Central America Southeast Asia 3.1 NR NR NR NR 29.4 42.5 Western Pacific 11.4 NR NR 4.3 26 23.6 33.6 20 Einarson TR et al. Cardiovasc Diabetol 2018;17:83.

CV Disease is the Most Common Cause of Death in Diabetics 60% 50% Type 1 DM Type 2 DM 40% 30% 20% 10% 0% CV Disease Renal causes Other causes 21 Morrish NJ 1 ,et al. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001 Sep;44 Suppl 2:S14-21 .

CV Death is Increased in Patients with DM +/- Other Risk Factors Diabetes No diabetes 140 Age-adjusted CVD death risk/10,000 120 100 80 person-years 60 40 20 0 0 1 2 3 Number of risk factors 22 Stamler J et al. Diabetes Care 1993;16:434.

Attainment of Glycemic Control in Asian Diabetics Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries enrolled between November 2007 to December 2012 Hong Kong (2674/12633) China (887/4495) YOD LOD India (1135/3700) Philippines (847/3770) Korea (276/1457) Vietnam (110/533) Singapore (98/272) Taiwan (14/87) Thailand (68/206) Total (6109/27153) 0 20 40 60 80 100 Percentage with HbA1c <7.0% 23 Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

Attainment of Blood Pressure Control in Asian Diabetics Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries enrolled between November 2007 to December 2012 Hong Kong (2682/12657) China (919/4636) YOD LOD India (1820/7138) Philippines (1345/5943) Korea (270/1445) Vietnam (113/590) Singapore (98/271) Taiwan (12/92) Thailand (68/206) Total (7327/32978) 0 20 40 60 80 100 Percentage with BP <130/80 mm Hg 24 Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

Attainment of LDL-C Control in Asian Diabetics Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries enrolled between November 2007 to December 2012 Hong Kong (2601/12457) China (877/4438) YOD LOD India (1181/4852) Philippines (706/3062) Korea (242/1267) Vietnam (113/585) Singapore (95/263) Taiwan (5/47) Thailand (68/205) Total (5888/27167) 0 20 40 60 80 100 Percentage with LDL-C <100 mg/dL 25 Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

Attainment of BP, Glucose & LDL-C Control in Asian Diabetics Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries enrolled between November 2007 to December 2012 Hong Kong (2598/12450) China (847/4270) India (856/3009) YOD LOD Philippine (531/2385) Korea (232/1238) Vietnam (110/527) Singapore (94/259) Thailand (68/203) Total (5336/24341) 0 20 40 60 80 100 Percentage (95%CI) 26 Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

Vietnam Total population (2016) 94,569,000 Gross national income per capita (PPP international $, 2013) 5,030 Life expectancy at birth m/f (years, 2016) 72/81 Probability of dying under five (per 1 000 live births, 2017) 21 Probability of dying between 15 and 60 years m/f (per 1 000 population, 2016) 182/66 Total expenditure on health per capita (Intl $, 2014) 390 Total expenditure on health as % of GDP (2014) 7.1 WHO statistics: https://www.who.int/countries/vnm/en/

Major cause of death 2016 in VN WHO statistics: https://www.who.int/countries/vnm/en/

Time trends of Diabetes in VN Not Aware of Series 1 6 Diabetes: 68.9% 5 4 % 3 5,4 2 2,7 1 0 2002 2007 Series 1 Data from National Survey Program of Institute of Endocrinology

Time trends of Cardiovascular Disease In- hospital Data (CAD and Rheumatic VHD at VNHI from 1990 – 2015) Grafiektitel 70 60,5 57,8 60 50 41,2 37,5 40 31,5 % 27,7 30 25,1 21,7 18,8 20 11,3 10 5,7 4,3 0 1990 1995 2000 2005 2010 2015 Year CAD VHD Internal Data of VNHI

PTMC and PCI at VNHI 5000 4712 4500 4049 4000 3500 3016 3000 2731 2500 2310 2252 2050 2000 1611 1500 1406 1368 1042 1000 988 794 719 705 610 560 553 523 509 504 510 500 491 495 461 396 348 327 322 297 255 248 246 211 182 165 147 134 95 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 PTMC PCI Data from Cardiac Cath. Lab. Vietnam National Heart Institute