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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

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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

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and the Public’s Health

Projected Global Deaths, All Ages, 2005

2.8 1.6 0.9 17.5 7.6 4.1 1.1 5 10 15 20 HIV/AIDS TB Malaria CVD Cancer COPD Diabetes Deaths (millions)

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

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

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and the Public’s Health

Population Attributable Fractions (PAF) for Ischemic Heart Disease

47 45 25 19 15 12 1 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

PAF, Percent

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.

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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

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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

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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

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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)

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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

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1 in 4 has diabetes or prediabetes in China

Yang WY et al NEJM 2010

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Rising trends of diabetes in Asia

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

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Migration and diabetes in different ethnic groups (2007)

www.idf.org

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Recent trends of obesity in Asia

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

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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

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Hyperglycemia and CVD risk in Asian population

Asia Pacific Cohort Studies collaboration Diabetes Care 2004

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3 in 4 Chinese with acute MI has diabetes or prdiabetes

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

Hu DY Eur Heart J 2006

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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

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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

2 4 6 8 10 10 12 12 Death CKD/ESRD CHD heart failure stroke cancer

38% A major event

Chan JC et al JAMA2009

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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

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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

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HDL-C and LDL-C for CVD disease in Chinese type 2 diabetic patients

Ting R et al Cardiovascular Diabetologia 2010

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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

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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)

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Association between CKD and CHD in Taiwanese

Hsieh MH et al Am J Nephrol 208

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Asians contribute to stroke and renal endpoints in RCT setting (ADVANCE)

Clarke PM et al PLoS Med 2010

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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

So WY et al J of Diabetes 2011

CVD Or ESRD CKD or 3 RF No CKD And<3 RF

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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

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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

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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

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Protocol + team = Clinical benefits

Death rate  70% All events  50%

So WY et al Am J Managed Care 2003