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

Asian Chapter

Cardiovascular Science

and the Public’s Health

Are We On Track for 2010?

George A. Mensah, MD, FACP, FACC, FAHAChief

Cardiovascular Health BranchCenters for Disease Control and Prevention (CDC)

Atlanta, Georgia

Projected Global Deaths, All Ages, 2005

2.81.6

0.9

17.5

7.6

4.1

1.1

0

5

10

15

20

HIV/AIDS TB Malaria CVD Cancer COPD Diabetes

Death

s (

mil

lio

ns)

www.who.int/chp/chronic_disease_report/en/

Global Mortality and Burden of Disease Attributable to CVD & Major Risk Factors for

People ≥ 30 Yrs

Cardiovascular Science

and the Public’s Health

Are We On Track for 2010?

George A. Mensah, MD, FACP, FACC, FAHAChief

Cardiovascular Health BranchCenters for Disease Control and Prevention (CDC)

Atlanta, Georgia

Population Attributable Fractions (PAF) for Ischemic Heart Disease

4745

25

19

15

12

1

0

5

10

15

20

25

30

35

40

45

50

High Blood

Pressure

High

Cholesterol

Low Fruit &

Vegetable

Intake

Physical

Inactivity

Overweight

and Obesity

Smoking Alcohol Use

Global Data

PA

F, P

erce

nt

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.

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

He J et al lancet 2009

Premature deaths

200 400 600 800 1000 1200 1400 1600

absolute number of deaths (x107)

Global epidemic of diabetes

1998 2008 per

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

0

2

4

6

8

10

12

14

16

1980-1995 1996-2000 2001-2005 2005-2010

China

Malaysia

Taiwan

Sinagpore

Thailand

Philippines

Indonesia %

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

0

5

10

15

20

25

30

35

40

1990-1995 1995-2000 2000-2005

Thai men

Thai women

China

Hong Kong men

Hong Kong women

Philippines

Chan JC et al DRCP (submitted)

Ko GTC Chinese Med J 2009

%

Yoon KH, Lancet 368, 2006

Asians versus Caucasians (lower BMI, higher DM rate, same waist, more visceral fat)

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

30%

18%14%

7%

31% 23%

24%

20%

33%

No OGTT

NGT

Prediabetes

Newly diagnosed

type 2 diabetes

Previously known

type 2 diabetes

China Heart Survey

(n=3,513)

~3/4 of

patients have

hyperglycaemia

Euro Heart Survey

(n=4,961)

At least 1/2 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

Non-vascular

deaths

3 6 3 6 1.73

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

0 2 4 6 8 10 12

Death

CKD/ESRD

CHD

heart failure

stroke

cancer

%

38%

A major event

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

Log10 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)

K Waki et al 2004 Yoon KH et al Lancet 2006

eGFR and ACR predict CVD in T2 DM

(4421 Chinese T2D patients 3 year FU)

So WY et al Diabetes Care 2006

eGFR 60

(2-5% per year)

eGFR<60

(5-10% per year)

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

0%

20%

40%

60%

80%

100%

Total, n=3687 HK, n=832 IN, n=788 KR, n=295 PH, n=1186 SG, n=256 TW, n=55 TH, n=275

Level 4

Level 3

Level 2

Level 1

So WY et al J of Diabetes 2011

CVD

Or ESRD

CKD or

3 RF

No CKD

And<3 RF

ABC targets in Asian T2D patients

Total

(3687)

HK

(832)

India

(788)

Korea

(295)

Ph

(1186)

Sing

(256)

TW

(55)

Thai

(275)

HbA1c<7% 35.3 61.8 13.8 40.7 31.3 35.2 25.5 29.8

BP<130/80

mmHg

32.3 45.6 26.0 38.3 27.2 12.9 34.6 42.9

LDL-C<2.6

mmol/L

34.0 39.2 44.8 33.6 20.5 29.7 20.0 52.7

No target

achieved

32.6 14.3 38.3 28.1 42.2 42.8 40.0 23.3

Any 1 target

achieved

38.7 37.1 40.6 36.6 39.2 37.9 43.6 37.5

Any 2 targets

achieved

23.4 36.3 19.2 29.8 16.2 15.2 12.7 29.8

All 3 targets

achieved

5.4 12.3 1.9 5.4 2.5 3.1 3.6 9.5

So WY et al for JADE Study Group J of Diabetes 2011

Drug usage in REACH Registry

Asia (Taiwan) versus global pattern

% Clinical

disease

CAD CVD PAD 3 risk

factors

Taiwan Global

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

lipid Px

7 10 5 10 6 7 12

J Formos Med Assoc 2007

Majority of patients on 5 chronic medications

are not compliant

Wu J et al BMJ 2006

90% of patients on CVS drugs

50% of patients on anti-diabetic drugs

Protocol + team = Clinical benefits

Death rate

70%

All events

50%

So WY et al Am J Managed Care 2003