Report on Cardiovascular Diseases in China (2011) 中国心血管病报告 2011

REPORT ON CARDIOVASCULAR DISEASES IN CHINA (2011) 中国心血管病报告 2011

National Center for Cardiovascular Diseases,China

Encyclopedia of China Publishing House 图书在版编目（CIP）数据

中国心血管病报告. 2011：英文/卫生部心血管病防治研究中心编著. -北京：中国大百科全书出版社，2014.4 INBN 978-7-5000-9325-1 Ⅰ.①中… Ⅱ.①卫… Ⅲ.①心脏血管疾病－研究报告－中国－2011－英文 Ⅳ .①R54 中国版本图书馆CIP数据核字（2014）第054106号

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INBN 978-7-5000-9325-1 Copyright by Encyclopedia of China Publishing House,Beijing,China,2014.4 Published by Encyclopedia of China Publishing House 17 Fuchengmen Beidajie,Beijing,China 10037 http://www.ecph,com.cn Distributed by Xinhua Bookstore First Edition 2014.4

Printed in the people's Republic of China

EDITORIAL COMMITTEE for Report on Cardiovascular Diseases in China (2011)

Editor-in-Chief: Hu, Shengshou; Kong, Lingzhi

Associate Editor-in-Chief: Gao Runlin; Liu Lisheng; Zhu Manlu; Wang Wen;

Wang Yongjun; Wu Zhaosu; Yang Gonghuan; Rao Keqin Secretaries: Chen Weiwei; Liu Mingbo; Yang Jingang

Editorial Committee

Chen Chunming Chinese Center for Disease Control and Prevention Chen Weiwei National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Chen Yude School of Public Health, Peking University Health Science Center Du Wanliang Beijing Tiantan Hospital Gao Runlin National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Gao Shan Peking Union Medical College Hospital Gu Dongfeng National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Hu Dayi Peking University People's Hospital Hu Shengshou National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Jiang Xiongjing Fuwai Hospital, Chinese Academy of Medical Sciences Jia Weiping Shanghai No.6 People’s Hospital Kong Lingzhi Ministry of Health of the People’s Republic of China Li Guangwei National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Li Wei National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Li Xiaoying China People’s Liberation Army General Hospital Li Xiaomei Peking University First Hospital Li Ying Fuwai Hospital, Chinese Academy of Medical Science Liu Kejun National Health Economy Institute, MOH Liu Lisheng National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Liu Mingbo National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Liu Shuqian Beijing Anzhen Hospital Luo Ren IMS Market Research Consulting (Shanghai) Co. Beijing Branch Luo Xinjin Fuwai Hospital, Chinese Academy of Medical Sciences Mi Jie Capital Institute of Pediatrics Rao Keqin Information center, ministry of health of People’s Republic of China Tang Xinhua Center for CCVDs Control and Research, Zhejiang Province, Zhejiang Hospital Wang Chunning Fuwai Hospital, Chinese Academy of Medical Sciences Wang Haiyan Peking University First Hospital Wang Jinwen Beijing Anzhen Hospital Wang Mei National Health Economy Institute, MOH Wang Wei Beijing Anzhen Hospital Wang Wen National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Wang Wenzhi National Office for CVDs Prevention and Control Wang Yilong Beijing Tiantan Hospital Wang Yongjun Beijing Tiantan Hospital Wang yu Peking University People's Hospital Wang Zengwu Fuwai Hospital, Chinese Academy of Medical Sciences Wu Di Beijing Tiantan Hospital Wu Xigui Fuwai Hospital, Chinese Academy of Medical Sciences Wu Zhaosu Beijing Anzhen Hospital Xu Zhangrong China People’s Liberation Army No.306 Hospital Yang Gonghuan Chinese Center for Disease Control and Prevention Yang Jingang National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Yang Xiaohui Beijing Anzhen Hospital Yao Chonghua Beijing Anzhen Hospital Yu Guoying Institute of Medical Information/medical Library, CAMS and PUMC Zeng Zhechun Beijing Anzhen Hospital Zeng Zhengpei Peking Union Medical College Hospital Zhang Jian Fuwai Hospital, Chinese Academy of Medical Sciences Zhang Shu Fuwai Hospital, Chinese Academy of Medical Sciences Zhang Tong China Rehabilitation Research Center Zhao Dong Beijing Anzhen Hospital Zhao Liancheng Fuwai Hospital, Chinese Academy of Medical Sciences Zhao Wenhua Chinese Center for Disease Control and Prevention Zhou Xin Capital Institute of Pediatrics Zhu Jun Fuwai Hospital, Chinese Academy of Medical Sciences Zhu Manlu National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Zuo Huijuan Beijing Anzhen Hospital

Scientific Committee Chen Chunming Chinese Center for Disease Control and Prevention Chen Haozhu Zhongshan Hospital, Fudan University Chen Jilin Fuwai Hospital, Chinese Academy of Medical Sciences Chen Junshi Chinese Center for Disease Control and Prevention Chen Lanying Fuwai Hospital, Chinese Academy of Medical Sciences Chen Wenxiang Beijing Hospital Chen Xuli Ministry of Health of the People’s Republic of China Chen Yude School of Public Health, Peking University Health Science Center Chen Zaijia Fuwai Hospital, Chinese Academy of Medical Sciences Cheng Xiansheng Fuwai Hospital, Chinese Academy of Medical Sciences Dai Ruizhu Wuhan Union Hospital, Tongji Medical College of Huazhong University of Science and Technology Ding Jinfeng Fuwai Hospital, Chinese Academy of Medical Sciences Fang Qi Peking Union Medical College Hospital Feng Jianzhang Guangdong Provincial Cardiovascular Institute Gao Runlin National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Gao Shan Peking Union Medical College Hospital Ge Junbo Zhongshan Hospital, Fudan University Gong Lansheng Ruijin Hospital, Shanghai Jiao Tong University Gu Dongfeng National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Guan Heng Peking Union Medical College Hospital Guo Jiaqiang Fuwai Hospital, Chinese Academy of Medical Sciences Hong Shaoguang Beijing Anzhen Hospital Hu Dayi Peking University People's Hospital, Hu Jianping Information Center, MOH Hu Shengshou National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Hua Qi Xuanwu Hospital, Capital Medical University Huang Dejia West China Medical School, West China hospital, Sichuan University Huang Jun First Affliated Hospital of Nanjing Medical University Huang Tigang Second Hospital of Tianjin Medical University Hui Rutai Fuwai Hospital, Chinese Academy of Medical Sciences Huo Yong Peking University First Hospital Jia Guoliang Shanxi Xi’an Cardiovascular Hospital Jiang Weijian Beijing Tiantan Hospital Jin Hongyi Center for CVDs Control and Research, Zhengjiang Province, Zhejiang Hospital Jin Shuigao Chinese Center for Disease Control and Prevention Kong Lingzhi, Ministry of Health of the People’s Republic of China Li Guangwei China-Japan Friendship Hospital Li Jianjun Fuwai Hospital, Chinese Academy of Medical Sciences Li Nanfang People's Hospital of Xinjiang Uygur Autonomous Region Li Xiaoying China People’s Liberation Army General Hospital Li Yishi Fuwai Hospital, Chinese Academy of Medical Sciences Li Ying Fuwai Hospital, Chinese Academy of Medical Sciences Li Yong Huashang Hospital, Fudan University Li Yunqian First Hospital of Shanxi Medical University Liang Wannian Beijing Municipal Health Bureau Liao Yuhua Wuhan Union Hospital, Tongji Medical College of Huazhong University of Science and Technology Lin Shanyan Huashang Hospital, Fudan University Lin Shuguang Guangdong Provincial People’s Hospital Liu Guozhang Fuwai Hospital, Chinese Academy of Medical Sciences Liu Lisheng National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences Lu Guoping Ruijin Hospital, Shanghai Jiao Tong University Lu Zaiying Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology Lu Zongliang Fuwai Hospital, Chinese Academy of Medical Sciences Lv Chuanzhen Huashan Hospital, Fudan University Ma Hong The First Affiliated Hospital, Sun Yat-sen University Ma Shuping Institute of Hypertension, Hebei General Hospital Pan Changyu General Hospital of Chinese People’s Liberation Army Qi Wenhang Ruijin Hospital, Shanghai Jiao Tong University Rao Keqin Information center, ministry of health of People’s Republic of China Shen Weifeng Ruijin Hospital, Shanghai Jiao Tong University Sun Ming Xiangya Hospital of Central-south University Sun Ningling Peking University People's Hospital Tang Xinhua Center for CCVDs Control and Research, Zhejiang Province, Zhejiang Hospital Wang Daowen Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology Wang Fangzheng Fuwai Hospital, Chinese Academy of Medical Sciences Wang Haiyan Peking University First Hospital Wang Mei National Health Economy Institute, MOH Wang Wen National Center for Cardiovascular Diseases; Fuwai Hospital, Chinese Academy of Medical Sciences Wang Xiaowan School of Public Health, Central South University Wu Kegui the First Affiliated Hospital of Fujian Medical University Wu Ning Peking Union Medical College Hospital Wu Qinghua Beijing Anzhen Hospital Wu Xigui Fuwai Hospital, Chinese Academy of Medical Sciences Wu Yingsheng the First Affiliated Hospital of Nanchang University Wu Zhaosu Beijing Anzhen Hospital Wu Yangfeng School of Public Health, Peking University Health Science Center Xiang Kunsan Shanghai Sixth People' s Hospital Xu Chengbin Peking University People's Hospital Xu Zhangrong China People’s Liberation Army 306 Hospital Xu Zhimin Fuwai Hospital, Chinese Academy of Medical Sciences Yan Shengkai Peking Union Medical College Hospital Yan Xiaowei Peking Union Medical College Hospital Yang Xiaoguang Chinese Center for Disease Control and Prevention Yang Xinchun Beijing Chao Yang Hospital Yang Yuejin Fuwai Hospital, Chinese Academy of Medical Sciences Yao Chonghua Beijing Anzhen Hospital Ye Ping China People’s Liberation Army General Hospital You Kai Peking Union Medical College Hospital Yu Guoying Institute of Medical Information /Medical Library, CAMS and PUMC Zeng Dingyin First Hospital of China Medical University Zhang Qinyi Sino-American Stroke Group Zhang Shu Fuwai Hospital, Chinese Academy of Medical Sciences Zhang Tingjie Chengdu First Municipal Hospital Zhang Tong Chinese Rehabilitation Research Center Zhang Weiwei General Hospital of Beijing Command Zhang Weizhong Ruijin Hospital, Shanghai Jiao Tong University Zhang Zhuo Beijing Anzhen Hospital Zhao Dong Beijing Anzhen Hospital Zhao Jizong Beijing Tiantan Hospital Zhao Lianyou Fouth Militray Mdical University Tangdu Hospital Zhao Shuiping Second Xiangya Hospital of Central South University Zhao Yuanli Beijing Tiantan Hospital Zhou Jingchun Inner Mongolia Hospital Zhu Dingliang Ruijin Hospital, Shanghai Jiao Tong University Zhu Jun Fuwai Hospital, Chinese Academy of Medical Sciences Zhu Xiaodong Fuwai Hospital, Chinese Academy of Medical Sciences Zhu Junren Zhongshan Hospital, Fudan University Zhu Zhiming Daping Hospital, Third Military Medical University of Chinese P.L.A

Proofreader Ma Liyuan; yang jingang Cardiovascular Diseases in China (2011)

Explanation for the Report Editing

1. The report was edited by the working group composed of young and middle-aged specialists. The contents regarding the cardiovascular risk factors (hypertension, cigarette smoking, blood-lipid disorder, metabolic syndrome, overweight and obesity, diet and nutrition, deficiency of physical activity) and the epidemic situation of cardiovascular disease were edited by the working group. 2. The contents regarding coronary heart disease, stroke, chronic kidney disease, cardiovascular surgery and arrhythmia were edited by the clinical specialists. And the contents regarding the case report of community hypertension prevention and control were edited by the specialists on community prevention and control. The contents regarding the health economics were edited by the specialists from National Health Economics Institute, Ministry of Health. 3. The editing principle and the fi rst draft were reviewed by calling three plenary meetings of the editing specialists. The report was then fi nalized after having been reviewed by the core group for three times. 4. The report was edited by drawing on the experience of the statistical method of reporting of cardiac disease and cerebral stroke in America. 5. The relevant data that were released before December 31, 2011 should have been included in this report. If there is any missing or mistake, please contact and provide the editorial committee with the detailed data. 6. Abbreviations: Cardiovascular Diseases: CVDs Ischemic Heart Diseases: IHD Heart Failure: HF Total cholesterol: TC Triglyceride: TG Low-Density Lipoprotein Cholesterol: LDL-C High-Density Lipoprotein Cholesterol: HDL-C Acute Myocardial Infarction: AMI Chronic Kidney Disease: CKD End-stage Renal Disease: ESRD Glomerular Filtration Rate: GFR Blood Pressure: BP Heart Rate: HR Body Mass Index: BMI Relative Risk: RR Population Attributable Risk Percent: PARP Confi dence Interval: CI Angiotensin Converting Enzyme Inhibitor: ACEI Coronary Artery Bypass Grafting: CABG Percutaneous Coronary Intervention: PCI International Normalized Ratio: INR

8 CONTENTS

Outline of the Report on Cardiovascular Disease in China, 2011……………1

Chapter 1 Cardiovascular Diseases……………………………………………7 1.1 The Number of Existing Patients with Cardiovascular Diseases…………………………7 1.2 Death of Cardiovascular Diseases………………………………………………………7 1.3 Mortality and All-Causes of Death of Cardiovascular Diseases …………………………7 1.4 Prevalence of Cardiovascular Disease and Risk Factors in Chinese……………………12

Chapter 2 Risk Factors of Cardiovascular Diseases…………………………13 2.1 Hypertension………………………………………………………………………………13 2.1.1 Primary Hypertension…………………………………………………………………13 2.1.2 Secondary Hypertension………………………………………………………………27 2.1.3 Hypertension in Children……………………………………………………………28 2.2 Tobacco Use ………………………………………………………………………………31 2.2.1 Prevalence of Cigarette Smoking……………………………………………………31 2.2.2 Smoking Cessation……………………………………………………………………34 2.2.3 Health Consequences of Active Smoking and Passive Smoking……………………34 2.2.4 Disease and Economic Burden of Tobacco Use in China ……………………………38 2.3 Dyslipidemia………………………………………………………………………………39 2.3.1 Lipid Levels and Prevalence of Dyslipidemia in Chinese Adults……………………39 2.3.2 Prevalence of Dyslipidemia in Children and Adolescents ……………………………41 2.3.3 The Relationship of Blood Lipids and Cardiovascular Diseases……………………42 2.3.4 Management and Control of Dyslipidemia …………………………………………44 2.4 Overweight and Obesity…………………………………………………………………45 2.5 Deficiency of Physical Activities…………………………………………………………47

1 2.6 Diet and Nutrition………………………………………………………………………… 50 2.7 Metabolic Syndrome……………………………………………………………………… 51 2.7.1 Prevalence of Metabolic Syndrome………………………………………………… 51 2.7.2 Risk Factors of Metabolic Syndrome………………………………………………… 53 2.7.3 metabolic syndrome and Chronic Kidney Disease………………………………… 54

Chapter 3 Prevention and Control of Cardiovascular Disease……………… 61 3.1 Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris……………… 61 3.1.1 Epidemiological Studies of Coronary Heart Disease………………………………… 61 3.1.2 Coronary Artery Intervention………………………………………………………… 66 3.1.3 Acute Coronary Syndrome…………………………………………………………… 71 3.1.4 Medical Treatment in Coronary Artery Disease……………………………………… 77 3.1.5 Secondary Prevention in Coronary Artery Disease…………………………………… 78 3.2 Stroke…………………………………………………………………………………… 80 3.2.1 Epidemiology of Cerebrovascular Disease: Prevalence, Mortality and Temporal Trends……………………………………………………… 80 3.2.2 Epidemiological Study in Different Areas in China………………………………… 83 3.2.3 Risk Factors in Stroke Patients……………………………………………………… 86 3.2.4 Treatment of Stroke…………………………………………………………………… 86 3.3 Hypertension……………………………………………………………………………… 89 3.4 Cardiovascular Surgery…………………………………………………………………… 89 3.4.1 Cardiac Surgical Volume in China…………………………………………………… 89 3.4.2 Congenital Heart Disease in China…………………………………………………… 91 3.4.3 Surgical Treatment of Coronary Artery Disease……………………………………… 99 3.4.4 Surgical Treatment of Heart Valve Disease …………………………………………102 3.5 Peripheral arterial disease ………………………………………………………………103 3.5.1 Lower Extremity Arteriosclerosis Disease……………………………………………103 3.5.2 Carotid atherosclerotic disease ………………………………………………………105 3.6 Arrhythmia………………………………………………………………………………107 3.6.1 Permanent Pacemaker, Implantable Cardiaoversion defibrillator and Cardiac Resynchronization Therapy………………………………107

2 3.6.2 Catheter Ablation……………………………………………………………………109 3.6.3 Atrial fibrillation……………………………………………………………………111 3.6.4 Sudden Cardiac Death ………………………………………………………………112 3.6.5 Other Arrhythmia ……………………………………………………………………112 3.7 Heart Failure……………………………………………………………………………112 3.7.1 Incidence………………………………………………………………………………112 3.7.2 Prevalence……………………………………………………………………………112 3.7.3 Precipitating Factors…………………………………………………………………113 3.7.4 Risk Factors…………………………………………………………………………113 3.7.5 Mortality………………………………………………………………………………114 3.7.6 Average Time of Hospitalization and Emergency Department Visits…………………114

Chapter 4 Community-based Prevention and Control of Cardiovascular Disease…………………………………………122

4.1 General Introduction of Community-Based Prevention and Control of Cardiovascular Diseases…………………………………………………………………122 4.2 Introduction of a CPCCVDs Case-Comprehensive Prevention and Control of Hypertension in the Community of Yuhuan County…………………………122 4.2.1 The Project is Government-dominated, Health Reform-driven, institutionally Guaranteed and with Effective Measures ……………………………123 4.2.2 Scientific Prevention and Control, 'Sanhua' Management and Strict Quality Control with Effective Results…………………………………………124

Chapter 5 Medical Expenditure of Cardiovascular Diseases ………………126

5.1 Status of Inpatient Service Utilization for Cardiovascular Diseases and CBVD Patients in China………………………………………………………………126 5.1.1 Total Number of Cardiovascular Inpatients Discharged and the Trend in China……………………………………………………………………126 5.2 The Expenditure of Inpatients for Cardiovascular in Chinese Hospital…………………129 5.3 Cardiovascular Medicine Market…………………………………………………………130

3 5.4 Explanation of the Data Analysis…………………………………………………………131 Chapter 6 Prediction of the Cardiovascular Disease in China………………132 6.1 Future Cardiovascular Disease Incidence and Mortality in China………………………132 6.2 The Rising Tide of Non-Communicable Diseases: A Report from the World Bank………135 6.2.1 Explosive Increase in the Number of People with at least One Non-Communicable Disease……………………………………………………………135 6.2.2 Predicted Burden of Major Non-Communicable Diseases in China ……………………135 6.2.3 Cardiovascular Mortality…………………………………………………………………136 6.2.4 The contribution of behavioral and Nutritional Risk Factors to China’s Non-Communicable Diseases burden……………………………………………………137 6.2.5 Economic Impact of the Non-Communicable Diseases Burden…………………………137

4 Outline of The Report on Cardiovascular Disease in China, 2011

The prevalence of risk factors for cardiovascular diseases (CVDs) is continuously increasing in China. CVDs remain the leading cause of death in Chinese population. The burden of CVDs is substantial and has become an important public health issue. Effective strategies should be enforced urgently for the prevention and treatment of CVDs in China.

1. Prevalence of Cardiovascular Diseases In general, the prevalence of CVDs (including heart disease and stroke) in China continues to show an upward tendency. It is estimated that the number of patients with CVDs is 230 million, of whom 200 million have hypertension, more than 7 million suffered a stroke, 2 million had a myocardial infarction (MI), 4.2 million have heart failure, 5 million have pulmonary heart disease, 2.5 million have rheumatic heart disease, and 2 million have congenital heart disease. One in 5 adults is affl icted by CVDs.

2. Mortality of Cardiovascular Diseases The crude death rate of coronary heart disease (CHD) is 94.9 per 100 000 in urban citizens and 71.3 per 100 000 in rural residents. As for stroke, it is 126.3 per 100 000 in urban and 152.1 per 100 000 in rural areas. About 3.5 million Chinese die from CVDs annually, more than half are associated with hypertension. CVDs is the leading cause of death in China, which accounts for 41% of deaths from any cause. The CVDs mortality in rural residents increased more rapidly than that in urban citizens.

3. Continuous Increase in Prevalence of Cardiovascular Risk Factors Diseases 3.1 Hypertension

Hypertension is the major risk factor for CVDs in China. More than half of CVDs is associated with elevated blood pressure (BP). As a cornerstone for the prevention of CVDs, hypertension control is an easy and cost-effective strategy for community doctors to practice. The prevalence of hypertension is increasing steadily. It was 18.8% in adults according to a National Survey in 2002, and rose to approximately 25% in recent years according to reports from various provinces and cities. It is estimated that 200 million Chinese are hypertensives, which means 1 in 5 adults is affl icted by hypertension. The major risk factors of hypertension are high-salt diet, overweight/obesity, excessive consumption of alcohol and chronic stress. Some studies suggested that the prevalence of hypertension is increased by a

1 Report on Cardiovascular Diseases in China (2011)

factor of 3 in patients with obesity [body mass index (BMI)≥ 28 kg/m2] and by a factor of 2 in overweight patients (BMI, 24.0-27.9 kg/m2) in comparison with that in individuals of normal weight (BMI < 24 kg/m2). The prevalence of hypertension increased by 72% among individuals with alcohol consumption≥ 40 g/day. The prevalence of hypertension in Northern China is higher than that in Southern China, which is largely attributed to the difference in salt intake. Prevalence of High Normal Blood Pressure. More individuals with high normal BP was identifi ed in 2002 than in 1991. It is reported that, compared with normotensives, the risk in individuals with high normal BP increased by 56% for stroke, 44% for CHD, and 52% for all CVDs. Close attention should be paid to them in the prevention of hypertension. Health education must be strengthened in high normal BP individuals and BP measurement should be taken at least once half a year. Hypertension Awareness, Treatment and Control. The rates of awareness, treatment and control of hypertension in China were 30.6%, 24.7% and 6.1% respectively, according to a National Survey in 2002. BP control rate could be achieved at 25% by treatment in hypertensive patients. These rates increased with age and were higher in urban areas than those in rural areas. Hypertension in Children. The National Health and Nutrition Survey reported a signifi cant increasing trend in BP levels in Chinese children and adolescents aged 6-17 during 1991-2004. Compared with children whose body weights within normal range, the relative risk (RR) ratios for hypertension among those overweight or obese were 2.23 (95% CI, 1.48-3.35) and 3.71 (95% CI, 2.73-5.06), respectively.

3.2 Smoking

Smoking is a major risk factor for CVDs in China. The rate of smoking in males has reached a plateau, but is slightly increasing in young females. There are 350 million active smokers and 540 million passive smokers in China. Despite non-smoking rate rose slightly in the population older than 15 years in recent years, China still faces signifi cant challenges to quit smoking. Smoking cessation is cost-effective for the prevention of CVDs.

3.3 Dyslipidemia

The prevalence of dyslipidemia in Chinese population has been rising in recent years, and the increase in juveniles is of particular concern. According to a National Survey in 2002, the prevalence of dyslipidemia was 18.6% in adults, of which 2.9% was hypercholesterolemia [total cholesterol (TC) ≥ 5.72 mmol/L], 11.9% was hypertriglyceridemia (triglyceride≥ 1.70 mmol/L), and 7.4% was a low high-density lipoprotein cholesterol level (< 1.04 mmol/L). It is estimated that dyslipidemia affects at least 200 million individuals.

3.4 Overweight / Obesity

Overweight/obesity is a pivotal risk factor for CVDs. According to a survey conducted in the general Chinese population in 2002, the prevalence of overweight was 17.6% and that of obesity was 5.6%. It is

2 Outline of the Report on Cardiovascular Disease in China, 2011 estimated that the number of individuals with overweight and obesity may be as high as 240 million and 70 million, respectively. The prevalence of overweight/obesity in both children and adults is growing steadily, to which great attention should be paid.

3.5 Physical Inactivity

Physical inactivity is a risk factor for CVDs. Lack of activity is known to be associated with overweight /obesity, hypertension, dyslipidemia and hyperglycemia, and with an increased risk of CVDs.

3.6 Diet and Nutrition

In general, the dietary pattern has got markedly improvement in recent years, but some features of diet are still problematic. The intake of grain decreased signifi cantly, whereas the intake of fat increased dramatically. The daily intake of salt (more than 12 g/d) was much greater than recommended by dietary guidelines, i.e., < 6 g/d. The consumption of vegetables and fruits was also insuffi cient.

4. Intervention and Prevention of Cardiovascular Disease 4.1 Coronary Artery Disease

The mortality of coronary heart disease (CHD) in China exhibited an up-ward trend and the growth rate was higher in rural areas than in urban areas. Effect of Glucose Level on Mortality of Acute MI (AMI) The 24 h average blood glucose level of more than 7.1 mmol / L was associated with an increased 7-day and 30-day mortality of ST-segment elevation MI (STEMI). The mortality of non ST-segment elevation acute coronary syndrome (NSTEACS) during hospitalization and 2-year follow-up increased markedly in individuals with diabetes. So did the incidence of chronic heart failure and composite endpoints. Diabetes is an independent risk factor of 2-year mortality for patients with NSTEACS. The control rate of plasma glucose is low in Chinese elderly patients with CHD. This is even worse for the control rate of high blood pressure and lipids, which calls for further improvement. The control rates of high blood pressure and lipids in elderly women are signifi cantly lower than those in elderly men. Standard treatment for hypertension, dyslipidemia and hyperglycemia should be implemented aggressively in elderly patients with CAD, aiming at the factors that determine the target goals of BP, lipids and glucose.

4.2 Stroke

Stroke is a major health problem in China. The prevalence of stroke is very high in the Chinese population. The prevalence of cerebrovascular disease in 2008 was 13.6‰ for urban residents and 8.3‰ for rural residents, and 9.7‰ for the general Chinese population.

3 Report on Cardiovascular Diseases in China (2011)

The crude death rate of cerebrovascular disease in 2009 was 126.3/100 000 for urban residents and 152.1/100 000 for rural residents. It was estimated there were 840 000 urban residents and 850 000 rural residents died from cerebrovascular disease in 2009. In general, rural areas have a higher crude death rate than that of urban areas, and men have a higher crude death rate than women in both rural and urban areas. Some studies presented that hypertension, smoking and alcohol consumption were major risk factors for young subjects aged 35-45 years old.

4.3 Cardiac Surgery

Number of Cardiac Surgery in China The number of cardiac surgeries in mainland China was 170 491 in 2010. Of these surgeries, 136 697 were performed on-pump. Congenital Heart Disease China is a large country with an estimated population of 1.34 billion people in mainland (not including Hong Kong, Macao and Taiwan) according to the Sixth Nationwide Population Census. An investigation conducted in several regions reported that the prevalence of congenital heart disease in perinatal fetus was 6.7‰-14.4‰. If 8‰ was taken for the estimation, there will be about 160 000 newborn babies with congenital heart disease each year in mainland China. Ventricular septal defect, atrial septal defect and patent ductus arteriosus account for the major part of congenital heart disease (50%-60%).

4.4 Heart Failure

According to a survey from 20 towns and rural areas in 10 provinces and cities, the incidence of chronic heart failure in the population aged 35-74 years was 0.9%. There were 4.2 million patients with heart failure in China. The prevalence was higher in females than in males, and was higher in the north than in the south.

4.5 Peripheral Artery Disease

The prevalence of peripheral artery disease (PAD) varies substantially among different samples of the Chinese population. For example, it was 2.1% in Zhoushan fi shermen, 3.0%-6.4% in native populations of multiple domestic regions, 16.4%-27.5% in high risk cardiovascular patients, 6.5% in Xinjiang Uygur and Kazak, and 1.9% in Inner Mongolia area. The prevalence of PAD increases with age in various populations, and is higher in females than in males.

4.6 Arrhythmia

According to the statistics in 2009, 783 hospitals performed permanent cardiac pacemaker implantation in China and 47 915 pacemakers were implanted, with male accounting for 52%. The percentage of patients above 60 years old was 79% and that above 80 was 17%. The number of patients who were treated with radiofrequency ablation was 20 000 in 2006, and

4 Outline of the Report on Cardiovascular Disease in China, 2011 demonstrated an upward trend. The prevalence of atrial fi brillation is 0.77% in the general Chinese population aged over 30 years, which is standardized as 0.61% based on the data of National standard population census 1990. The prevalence is higher in men than in women (0.9% vs 0.7%). The incidence of sudden cardiac death in China is 42 per 100 000 persons. It is estimated that 544 000 sudden cardiac deaths occur annually.

5. Community-Based Prevention and Treatment of Cardiovascular Disease

In the late 1960s, a Hypertension Disease Management Program was initiated in the Capital Steel Corporation. As a result, the incidence of stroke was reduced considerably by 50%. Various studies on the prevention and treatment of CVDs were carried out thereafter. A specifi c integrated management program against hypertension was launched in Yuhuan County, which was regarded as a key task in healthcare fi eld by local health bureau. The data of 132 463 individuals were investigated and documented in one year, of which 37 697 were screened as hypertensives and follow-up. After 1- year intervention, the rate of BP control was greatly increased to 63.2% from 20.6% at baseline.

6. Costs of Cardiovascular Disease 6.1 Number of Patients with Cardiovascular Disease Discharged from Hospital

11.1969 million patients with CVDs (including cerebrovascular disease) were discharged from hospital in 2010, which accounted for 11.81% of the total discharged. Of these, 5.8215 million were heart disease patients, which accounted for 6.14% of the total discharged, and cerebrovascular disease patients were 5.3754 million, which accounted for 5.67%. Most CVDs patients (including patients with cerebrovascular disease) discharged from hospital in 2010 had ischemic heart disease (3.8025 million, including 0.2718 million MI) and cerebral infarction (3.1843 million), accounting for 33.96% and 28.44% of CVDs patients, respectively. The other discharged patients had hypertension (1.8024 million, including 0.13 86 million patients with hypertensive heart disease and renal disease), cerebral hemorrhage (1.1208 million), and rheumatic heart disease (0.2166 million). 1.8 307 million diabetes mellitus patients discharged from hospital in 2010. The average annual increase in the number of CVDs patients discharged (9.54%) during 1980-2010 was more rapid than that of all diseases (6.00%). The average annual increase in discharge rates was highest for diabetes mellitus (14.06%), followed by cerebral infarction (12.12%), ischemic heart disease (11.37%), cerebral hemorrhage (10.58%), AMI (8.92%), hypertension (7.87%), hypertensive heart disease and renal disease (4.95%). There was no signifi cantly change in the discharged number for rheumatic heart disease (1.14%).

5 Report on Cardiovascular Diseases in China (2011)

6.2 Costs of Hospitalization for Cardiovascular Diseases

The average expense for a CVDs hospitalization (including cerebrovascular disease) in 2010 was 15 773.5 RMB for AMI, 11 019.8 RMB for cerebral hemorrhage, and 7 143.3 RMB for cerebral infarction. After adjusted for infl ation, the annual increase in expenses for hospitalization since 2004 was 8.05%, 6.02%, and 2.37% respectively, for each of the above diseases.

6.3 Cost of Treatment for Cardiovascular Diseases

The total cost of drugs in hospitals with≥ 100 beds was 312.796 billion RMB in 2010, of which 38.674 billion was expended on medicines to treat CVDs. The fi rst fi ve classes of medicine were those to treat central as well as peripheral vascular disease and heart disease, calcium antagonists (alone), modulators for cholesterol and triglyceride, and angiotensin receptor blockers (alone).

7. Prediction of Trends in Cardiovascular Diseases

• According to prediction on China CAD policy model, it is projected that from 2010-2030, the number of CVDs events (angina pectoris, MI, stroke and sudden death from CAD) among Chinese population aged 35- 84 years will increase by more than 50% given the increasing age and number of the population. The CVDs events will additionally increase by 23% when the following factors were taken into account, i.e., BP, total cholesterol, diabetes mellitus (The annual increase was 0.17-0.21 mm Hg for SBP, total cholesterol level rose to 5.4 mmol / L, and the prevalence of diabetes mellitus increased by 15%). It is estimated that from 2010 to 2030, the number of CVDs events will increase by 21.3 million and that of CVDs death by 7.7 million. • Prediction of Cardiovascular Disease in China by World Bank Among individuals aged over 40 years, the number of patients with non-communiable chronic diseases (NCDs) is likely to rise by 2- or even 3-fold over the next 20 years, with the peak increase in the next 10 years. The NCDs include CVDs (MI and stroke), chronic obstructive pulmonary disease (COPD), diabetes mellitus and lung cancer. From 2010 to 2030, the burden of MI, stroke, diabetes mellitus and COPD (life loss per year) is estimated to increase by 50%. Of which, the burden of CVDs accounts for more than 50%. Stroke is the most threatening disease for the health and life of people. CVDs mortality is higher in China than that in Japan and developed countries in Europe and America. Stroke mortality in China is 4-6 times as much as that of Japan, America and French. The diabetes mellitus mortality in China is also higher than that in Japan and England. The economic loss caused by CVDs, stroke and diabetes mellitus is estimated to be 550 billion US dollars from 2005 to 2015 if proper strategies are not planned and executed.

6 Chapter 1 Cardiovascular Diseases [1, 2, 3]

1.1 The Number of Existing Patients with Cardiovascular Diseases

It is estimated that the number of existing patients with CVDs (CAD, stroke, heart failure and hypertension, etc.) is about 230 millions in China, which means 2 individuals with CVDs in every 10 adults. In the total CVDs sufferers, 200 million are patients with hypertension, 7 million patients with stroke, 2 millions with MI, 4.2 millions with heart failure, 5 millions with pulmonary heart disease, 2.5 millions with rheumatic heart disease, and 2 millions with congenital heart diseases.

1.2 Death of Cardiovascular Diseases

(1) It is estimated that about 3.5 million patients die of CVDs every year. (2) Two in every 5 deaths is attributed to CVDs. (3) There are 9 590 patients die of CVDs every day; It is estimated that 400 death of CVDs in every hours and 1 death of CVDs in every 10 seconds.

1.3 Mortality and All-Causes of Death of Cardiovascular Diseases

(1) The mortality of CVDs is still at lofty level in recent years in China. The mortality of CVDs ranked fi rst and was still higher than that of tumor and other diseases in 2010 [Figure 1-3 (1), (2), (3), (4), (5), (6)].

7 Report on Cardiovascular Diseases in China (2011)

（1/100 000）

300 CVDs Respiratory Diseases Tumors Injury/Toxication 250 Digestive Diseases

200

150 Mortality

100

0 1990 1995 2000 2005 2006 2007 2008 2009 2010 （Year）

Figure 1-3 (1) Mortality of Major Diseases in Chinese Rural Residents, 1990-2010

（1/100 000）

300

250

Mortality 200

150 1990 1995 2000 2005 2010 ˄ᑈ˅ （Year）

Figure 1-3 (2) Mortality of CVDs in Chinese Rural Residents, 1990-2010

8 （1/100 000）

300

250 Mortality 200

150 2005 2006 2007 2008 ᑈ2009 2010（Year）˄ᑈ˅

Figure 1-3 (3) Mortality of Cardiovascular Diseases in Chinese Residents in Rural Areas, 2005-2010

（1/100 000）

CVDs Respiratory Diseases 300 Tumors Injury/Toxication Digestive Diseases 250

200

Mortality 150

100

0 1990 1995 2000 2005 2006 2007 2008 2009 2010（Year）

Figure 1-3 (4) Mortality of Major Diseases in Chinese Residents in Urban Areas, 1990-2010

9 Report on Cardiovascular Diseases in China (2011)

（1/100 000）

300

250 Mortality 200

150 1990 1995 2000 2005 ˄ᑈ˅2010 （Year）

Figure 1-3 (5) Mortality of CVDs in Chinese Residents in Urban Areas, 1990-2010

（1/100 000）

300

250 Mortality 200

150 2005 2006 2007 2008 2009 2010 （Year） ˄ᑈ˅

Figure 1-3 (6) Mortality of CVDs in Chinese Residents in Urban Areas, 2005-2010

10 (2) In all-cause death of major diseases in Chinese residents, CVDs is the leading cause [Figure 1-3 (7), 1-3 (8)].

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Figure 1-3 (7) Death Constituents of Major Diseases in Chinese Rural Areas (%)

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Figure 1-3 (8) Death Constituents of Major Diseases in Chinese Urban Areas (%)

11 Report on Cardiovascular Diseases in China (2011)

1.4 Prevalence of Cardiovascular Disease and Risk Factors in Chinese [4]

The data gathered from the 2007-2008 China National Diabetes and Metabolic Disorders Study including 46 239 patients over 20 years old. was analyzed. The results showed that the prevalence of CHD, stroke, and CVDs was 0.74%, 1.07%, and 1.78% in males; and 0.51%, 0.60%, and 1.10% in females, respectively. The presence of CVDs increased with age. The prevalence of being overweight or obese, hypertension, dyslipidaemia, or hyperglycaemia was 36.67%, 30.09%, 67.43%, and 26.69% in males; and 29.77%, 24.79%, 63.98%, and 23.62% in females, respectively. In the observed population, the prevalence of one subject having 1, 2, 3, or ≥ 4 of the 5 defi ned risk factors (i.e., smoking, overweight or obese, hypertension, dyslipidaemia, or hyperglycaemia) was 31.17%, 27.38%, 17.76%, and 10.19%, respectively. Following adjustment for gender and age, the odds ratio of CVDs for those who had 1, 2, 3, or ≥ 4 risk factors was 2.36, 4.24, 4.88, and 7.22, respectively, when compared with patients without risk factors.

References

[1] Ministry of Health of the People’s Republic of China. China Health Statistic Yearbook, 2009.Beijing: Chinese Union Medical University Publishers Ltd. 2009. [2] Ministry of Health of the People’s Republic of China. China Health Statistic Yearbook, 2010.Beijing: Chinese Union Medical University Publishers Ltd. 2010. [3] Ministry of Health of the People’s Republic of China. China Health Statistic Yearbook, 2009. Beijing: Chinese Union Medical University Publishers Ltd. 2011. [4] Yang ZJ, Liu J, Ge JP, et al. Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007-2008 China National Diabetes and Metabolic Disorders Study. Eur Heart J. 2012;33: 213-220.

12 Chapter 2 Risk Factors of Cardiovascular Diseases

Chapter 2 Risk Factors of Cardiovascular Diseases

2.1 Hypertension

Hypertension is one of the most important risk factors of CVDs. Since 110/75 mmHg, the risk of CVDs rose with the increase of blood pressure. Overall, 50%-75% of stroke and 40%-50% of MI attributed to the increase of blood pressure. Hypertension also accounted for 6% of physical disability. Hypertension leads to 2 million premature deaths, and 36.6 billion direct medical costs every year. So timely and accurate surveillance of hypertension is of great signifi cance for the prevention and treatment of CVDs.

2.1.1 Primary Hypertension 2.1.1.1 Prevalence of Hypertension

There were four national large-scale sample surveys on prevalence of hypertension since P. R. China has established, which showed a signifi cant upward trend in prevalence of hypertension [Figure 2-1-1 (1)].

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Figure 2-1-1 (1) Comparison of the Prevalence of Hypertension among Populations Aged Over 15 Years in Four National Sampling Surveys in China

13 Report on Cardiovascular Diseases in China (2011)

Note: The diagnostic criteria of hypertension were somewhat different among various surveys. In 1959, it was defi ned as DBP > 90 mmHg and/or SBP > 140 mmHg under the age of 39; and SBP increased 10 mmHg with every 10 year in population aged over 40 years. In 1979-1980, hypertension was defi ned as SBP≥141 mmHg and/or DBP ≥91 mmHg, re gardless of any anti-hypertensive drugs taken within 2 weeks. In 1991, it was SBP ≥140 mmHg and/or DBP ≥ 90 mmHg, or taking anti-hypertensive drugs within 2 weeks; the diagnostic criteria in 2002 was the same as that in 1991. It stands for an estimated national prevalence of hypertension in the same year. It stands for age-adjusted standardized prevalence. All four surveys used the same criteria that referred in 1979-1980. The total population of 1964 was used as a standardized population. Blood pressure unit was mmHg in all 4 surveys.

The data from a survey on the Status of Nutrition and Health of Chinese Residents in 2002[1] showed that the prevalence of high blood pressure in Chinese adults aged over 18 years was 18.8%, with higher in males than that in females. And the prevalence presented an upward trend with age [Table 2-1-1 (1)].

Table 2-1-1 (1) Distribution of Hypertension Prevalence among Different Genders and Age Groups in the Survey on the Status of Nutrition and Health of the Chinese Residents in 2002 (%)

Sex and Age Total Urban Rural

Total 18.8 19.3 18.6

Male 20.2 21.8 19.6

Female 18.0 17.9 18.0

Young People (18-44 Year)

Subtotal 9.1 9.4 9.0

Male 12.7 14.5 12.0

Female 6.7 6.1 6.9

Middle-age People (45-59 Year)

Subtotal 29.3 32.8 28.0

Male 28.6 33.1 26.9

Female 30.0 32.6 29.1

Senior People (≥ 60 Year)

Subtotal 49.1 54.4 47.2

Male 48.1 54.0 46.0

Female 50.2 54.9 48.4

The investigational data in 2002[2] showed that the prevalence of hypertension between urban areas and rural areas still remained difference in China; and also there was signifi cant difference between northern areas and southern areas except for Class 3 and Class 4 rural areas [Figure 2-1-1 (2)].

14 Chapter 2 Risk Factors of Cardiovascular Diseases

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Figure 2-1-1 (2) Prevalence of Hypertension among Chinese Population of Different Regions in 2002

Note: Hypertension was defi ned as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, or taking anti-hypertensive drugs within 2 weeks.

The surveys[3] on prevalence of hypertension in different periods showed that there was signifi cant difference between urban areas and rural areas, or between different regions. The standardized prevalence in urban areas reached 19.3%, and it was 18.6% in rural areas in 2002. But the gap in the prevalence of hypertension between urban areas and rural areas presented a trend of reduction [Figure 2-1-1 (3)].

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Note: the diagnostic criteria of hypertension in 1979: SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, regardless of anti-hypertensive drugs taken within 2 weeks. In 1991 and 2002, it was defi ned as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, or taking anti-hypertensive drugs within 2 weeks. The rates were not standardized except in 2002.

There is no national survey after 2002. But some regional surveys showed that the prevalence of hypertension still remained at a higher level [Table 2-1-1 (2)].

15 Report on Cardiovascular Diseases in China (2011)

Table 2-1-1 (2) Prevalence of Hypertension among Different Regions in China Age-adjusted Time (Year) Region Age (Years) Sample Size Prevalence (%) Prevalence (%) 2004 Tianjin[4] ≥15 2 390 000 31.57 —

2005-2007 Liaoning[5] ≥35 45 925 37.8 —

2007 Shandong[6] ≥25 16 364 43.8 —

2007 Shanghai[7] ≥60 11 220 49.73 —

2007 Yunnan[8] 15-69 5 000 24.8 21.7

2007 Heilongjiang[9] ≥15 10 620 30.48 —

2007-2008 Henan[10] ≥18 20 194 30.77 20.71

2008 Xuzhou[11] 20-75 17 500 20.87 16.39

2008 Chengdu[12] ≥18 3 524 21.78

2007-2009 Hangzhou[13] ≥20 42 998 27.49 —

Comparable data[14] from 'Eighth Five-Year Plan' (1992-1994), 'Ninth Five-Year Plan' (1998) and 'Tenth Five-Year Plan' (2004-2005) of China were analyzed to investigate the dynamic changes of hypertension prevalence among people aged 35-59 years. The results showed that the prevalence of hypertension in three time periods were 21.0%, 22.4% and 24.4%, respectively. The prevalence of hypertension was different in different gender, body mass index, and urban/rural areas [Figure 2-1-1 (4)].

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Figure 2-1-1 (4) The Prevalence of Hypertension in Chinese Middle Aged Population Other surveys[15] were performed in Shandong rural population aged 35-74 years old. The results showed that the prevalence of hypertension presented an upward trend, which was 20.4%, 24.5% and 30.6% in 1991, 2002 and 2007, respectively.

16 Chapter 2 Risk Factors of Cardiovascular Diseases

2.1.1.2 Incidence of Hypertension

One study[16] was performed among 10 525 non-hypertensive adults aged over 40 years. After 8.2 years , 28.9% of men and 26.9% of women developed hypertension [Figure 2-1-1 (5)].

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Figure 2-1-1 (5) Eight-year Cumulative Incidence of Hypertension in Chinese Adults

Another study[17] conducted among 24 052 non-hypertensive adults over 35 years old, after 28 months’ follow-up, 26.5% of participants developed hypertension [Figure 2-1-1 (6)]. New onset of hypertension was age-related and had an association with baseline blood pressure.

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Figure 2-1-1 (6) Incidence of Hypertension in Different Blood Pressure Value Groups

Note: Ideal pressure: SBP < 120 mmHg and DBP < 80 mmHg; normal pressure: SBP 120-129 mmHg and DBP 80-84 mmHg; high-normal pressure: SBP 130-139 mmHg and /or DBP 85-89 mmHg.

17 Report on Cardiovascular Diseases in China (2011)

2.1.1.3 Prevalence of High-normal Blood Pressure

Data on 147 472 individuals aged 18 years and older from the Status of Nutrition and Health of the Chinese Residents in 2002 database were analyzed and showed that the prevalence of high normal blood pressure in Chinese adults aged 18 years and older was 34%.[18] The defi nition of high normal BP was based on Chinese Guidelines for Prevention and Treatment of Hypertension (Edition 2005). The prevalence was higher in males than that in females. On the contrary, compared with women, the proportion of normal BP value was lower in men [Figure 2-1-1 (7)]. Table 2-1-1- (3) shows the prevalence of high-normal BP of adults in different periods.

0DOH )HPDOH 7RWDO Proportion

Normal BP High Normal BP Hypertension Hypertension Hypertension Grade 1 Grade 2 Grade 3 Figure 2-1-1 (7) Proportion of the Hypertension Classiﬁ cation in Chinese Adult, 2002

Table 2-1-1 (3) Distribution of Chinese Adults with High Normal Blood Pressure in Different Age Groups in 1991 and 2002 (%) Male Female Total Age Group (Year) 2002 1991 2002 1991 2002 1991

18- 37.0 34.8 23.4 16.8 28.5 25.4

25- 40.3 36.0 25.1 17.4 30.9 26.0

35- 41.7 36.5 32.8 24.7 36.7 30.2

45- 40.3 35.9 36.1 30.2 38.0 32.9

55- 36.7 33.8 33.2 31.7 34.9 32.7

65- 31.6 32.3 28.9 30.1 30.3 31.2

75- 29.3 30.5 27.0 27.4 28.1 28.7

Total 38.6 35.2 30.4 23.5 34.0 29.0

Other surveys[19] were performed in Shandong rural population aged 35-74 years old. The results showed that the prevalence of high normal hypertension presented an upward trend. It was 33.8%, 61.5% and 54.6% in 1991, 2002 and 2007, respectively.

18 Chapter 2 Risk Factors of Cardiovascular Diseases

It was reported[20] that compared with normotensives, the risk in individuals with high-normal blood pressure increased by 56% for stroke, 44% for coronary heart disease, and 52% for overall CVDs. The attributable risk (AR) of high-normal blood pressure was 12.4%, 15.2% and 14.4% for CHD, stroke and overall CVDs, respectively. Another study[21] conducted among 15 540 Chinese adults aged 35 to 74 years showed that the standardized high-normal BP prevalence was 25.7% in men and 18.0% in women. The prevalence was higher in obesity, and was higher in northern areas than in southern areas [Table 2-1-1 (4)]. Table 2-1-1 (4) Age-Standardized Prevalence of High Normal Blood Pressure in Chinese Population Aged 35 to 74 Years (%) *

Area Male Female Total

Total 25.7 (0.8) 18.0 (0.7) 21.9 (0.5)

Urban 27.2 (1.0) 17.1 (0.8) 22.1 (0.7)

Rural 25.4 (1.0) 18.3 (0.8) 21.9 (0.7)

North 28.3 (1.3) 21.7 (1.2) 24.9 (0.9)

South 24.2 (1.1) 15.5 (0.9) 20.0 (0.7)

* Data was presented as percentage (SD).

2.1.1.4 Isolated Systolic Hypertension

According to the data of a survey[22] in 2002, the standardized prevalence of isolated systolic hypertension (ISH) was 6.0% in Chinese adults, of which, 5.4% in men and 6.9% in women. It was estimated that there were 50 million adults suffered from ISH in China. Generally, the prevalence of ISH presented an upward trend with age, especially in the people over 40 years of age. For people under 40 years old, the prevalence was higher in men than in women; by contrast, for people over 40 years of age, it was higher in women than in men [Figure 2-1-1 (8)].

45 0DOH 40 )HPDOH 35 7RWDO 30 25 20 15 10 ,6+3UHYDOHQFH 5 0 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- ≥80 （Age）

Figure 2-1-1 (8) Age-standardized Prevalence of Isolated Systolic Hypertension (IHS) in Chinese Adults of Different Age Groups

Note: Age-specifi c prevalence estimates were adjusted for region.

19 Report on Cardiovascular Diseases in China (2011)

The prevalence of ISH is also higher in northern areas than that in southern areas. But unlike hypertension, the prevalence of ISH was higher in women than in men, and higher in rural areas than in urban areas in both northern and southern regions [Table 2-1-1 (5)].

Table 2-1-1 (5) Age-standardized Prevalence (%) of ISH in Chinese Adults in Urban and Rural Areas in 2002 Urban Rural Small to Class1 Class 2 Class 3 Class 4 Sex Total Medium Rural Rural Rural Rural North South Subtotal North South Subtotal Cities Areas Areas Areas Areas

Male 5.4 4.5 5.4 4.9 5.1 5.9 5.6 5.4 4.8 6.5 5.8 5.2 3.9

Female 6.9 6.6 6.8 6.7 6.5 7.5 6.9 7.0 6.5 8.2 6.9 77.5 5.0

Total 6.1 5.6 6.0 5.8 5.7 6.7 6.2 6.2 5.6 7.3 6.2 6.3 4.4

2.1.1.5 Blood Pressure Level in Chinese Population

According to a survey [23] on the Status of Nutrition and Health of Chinese Residents in 2002, the mean level of blood pressure in Chinese population rose with age. For the participants under 45 years old, the level of SBP was higher for men than that for women; while for the participants over 45 years old, it was higher for women than for men. Although the level of diastolic blood pressure (DBP) was lower for women at all age groups, the gap was narrowed when they were over 45 years old [Table 2-1-1 (6)].

Table 2-1-1 (6) Mean Blood Pressure in Chinese Population Aged 15-74 Years SBP (mmHg) DBP (mmHg) Age Group (Year) Male Female Male Female

15-24 112.4 107.6 71.9 69.8

25-34 115.7 109.4 75.6 71.5

35-44 118.4 114.8 78.1 74.9

45-54 122.9 123.1 80.0 78.3

55-64 129.3 130.4 80.7 79.1

65-74 135.2 136.8 79.8 78.7

A survey [24] on the Status of Nutrition and Health of the Chinese People was implemented in 2002. The results in different ethnic groups presented that based on the available research documents of 152 683 participants over 15 years old, the average level of SBP was the highest in men and women of Man ethnic, it was 126.2 mmHg and 125.7 mmHg respectively; however, the average level of DBP was the highest in men and women of Tibetan people, which was 85.7 mmHg and 81.6 mmHg respectively [Table 2-1-1 (7)].

20 Chapter 2 Risk Factors of Cardiovascular Diseases

Table 2-1-1 (7) The Average Level of Blood Pressure Among Chinese Populations Aged 15 Years and Older in Different Ethnics SBP (mmHg) DBP (mmHg) Ethnics Male Female Male Female Han 123.3 120.3 78.6 75.9 Mongolian 123.3 123.3 78.2 77.1 Hui 120.4 118.3 78.2 75.3 Tibetan 124.8 117.0 85.7 81.6 Miao 116.2 111.0 73.0 69.7 Zhuang 123.8 116.7 77.4 72.7 Bouyei 119.7 117.3 77.1 73.5 Manchu 126.2 125.7 79.4 77.7 Tujia 122.6 121.0 74.4 73.1 Others 118.2 114.3 76.9 74.6 Total 123.1 120.0 78.5 75.7

A blood pressure survey[25] was conducted among 2.39 millon rural residents aged over 15 years in Tianjin in 2004. The mean SBP was 125.9 ± 18.99 mmHg, 127.17 ± 17.84 mmHg in males and 124.75 ± 19.92 mmHg in females. The mean DBP was 80.44 ± 10.77mmHg, 81. 28 ± 10.4 mmHg in males and 79.65 ± 11.01 mmHg in females. The mean blood pressures of different ages are shown in Figure 2-1-1 (9).

160 DBP SBP

140

120

100

60 Blood Pressure 40

0 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- （Age） Age Age (years) Groups

Figure 2-1-1 (9) Mean Blood Pressure of Different Age Groups among Rural Residents Aged Over 15 Years in Tianjin in 2004

Note: SBP: systolic blood pressure; DBP: diastolic blood pressure

21 Report on Cardiovascular Diseases in China (2011)

2.1.1.6 Awareness, Treatment and Control of Hypertension

A survey[26] in 2002 showed that the rates of hypertension awareness, treatment and control in China were 30.2%, 24.7% and 6.1% respectively. The BP control rate could be reached 25% by treatment in hypertensive patients. These rates increased with age and were higher in urban areas than those in rural areas [Table 2-1-1 (8)].

Table 2-1-1 (8) Rates of Awareness, Treatment and Control among Hypertensives in China (%) Age Group Urban Rural Total

18- 17.8 11.6 13.6 45- 40.8 25.1 31.0 Awareness 60- 48.5 26.8 37.6 Total 41.1 22.5 30.2 18- 11.8 7.9 9.1 45- 34.1 19.4 25.0 Treatment 60- 43.1 21.3 32.2 Total 35.1 17.4 24.7 18- 4.2 2.1 2.7 45- 10.0 3.8 6.2 Control 60- 11.3 3.9 7.6 Total 9.7 3.5 6.1 18- 36.3 26.8 30.7 45- 29.7 20.2 25.2 Control Under Treatment 60- 26.6 19.1 24.1 Total 28.2 20.4 25.0

According to some regional surveys, the awareness, treatment and control rates of hypertension were lower in rural areas than those in urban areas, but also quite different in different areas [Table 2-1-1 (9)].

Table 2-1-1 (9) Awareness, Treatment and Control of Hypertension in Different Areas of China (%) Area Liaoning[27] Henan-Xinan[28] Shandong[29] Xuzhou[30] Year 2005-2007 2007-2008 2007 2008 Sample Size 45 925 20 194 16 364 17 500 Participants Rural Constant Inhabitants Rural Constant Inhabitants Age (Years) ≥35 ≥18 ≥25 20-75 Awareness (%) 29.5 65.0 26.2 42.19 Treatment (%) 20.2 62.2 22.1 34.12 Control (%) 0.9 19.4 3.9 9.27 Control by Treatment (%) 4.5 31.3 - -

22 Chapter 2 Risk Factors of Cardiovascular Diseases

A survey[31] among 5 086 hypertension patients aged 18 years or older treated in the clinic of Cardiology, Nephrology, Endocrinology at 92 fi rst grade hospitals in 2009 showed that hypertension control rate was 30.6%, It was 45.9% in simple hypertension patient, 31.1%, 14.9% and 13.2% in hypertension patients with coronary heart disease, diabetes and renal dysfunction, respectively. Despite improvements for outpatient hypertensives, the control rate remained low. A study [32] on the status of hypertension control among 3 223 patients with acute coronary syndrome (ACS) showed that the prevalence of hypertension was 58.1% for those who had ACS and the treatment rate was 90.0%. Besides, the control for those on treatment was 42.2%. The three rates above were higher than those patients without ACS [Figure2-1-1 (10)].

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˅ 3HUFHQWDJH˄ 3UHYDOHQFH &RQWURO &RQWUROXQGHUWUHDWPHQW Figure 2-1-1 (10) Prevalence, Rates of Control and Control-under-treatment in Hypertensives With and Without ACS A study[33] compared the rates of awareness, treatment and control of hypertension in middle-aged Chinese population in 1992-1994, 1998 and 2004-2005. Awareness, treatment and control rates of hypertension were 48.4%, 38.5% and 9.5% in 2004-2005, respectively, which were signifi cantly higher than those in 1992-1994 and 1998. For treated hypertensive patients, the rate of control increased from 12.2% in 1992-1994 to 19.2% in 1998, and to 24.0% in 2004 [Figure 2-1-1 (11) ].

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Figure 2-1-1(11) Awareness, Treatment and Control Rates of Hypertension in Middle-aged Chinese Population in 1992-1994, 1998 and 2004-2005

23 Report on Cardiovascular Diseases in China (2011)

Another study[34] conducted in rural residents aged 35-74 i n Shandong Province showed that the awareness, treatment and control rates in rural areas had an upward trend [Figure 2-1-1 (12)].

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Figure2-1-1 (12) Awareness, Treatment and Control Rates of Hypertension in Rural Areas of Shandong Province

2.1.1.7 Factors Inﬂ uencing the Prevalence of Hypertension

Age is an unmodifi able risk factor of hypertension, for both men and women, the risk of hypertension rose by times with age. Compared with men aged 15-24, the risk to develop hypertension in men aged 55 -64 increased by 12 times; for women, the risk increased by 34 times [Table 2-1-1 (10)]. [35]

Table 2-1-1 (10) The Relative Risk of Hypertension in Different Age Groups in China Male Female Age Group (Year) Prevalence OR (95% CI) Prevalence OR (95% CI)

15-24 4.76 1 2.13 1

25-34 9.45 2.09 (1.85,2.36) 3.82 1.82 (1.56,2.13)

35-44 17.27 4.18 (3.72,4.68) 11.88 6.19 (5.37,7.14)

45-54 27.24 7.49 (6.69,8.39) 28.42 18.25 (15.89,20.95)

55-64 40.79 13.78 (12.30,15.43) 43.66 35.61 (30.97,40.95)

The prevalence of hypertension was higher for men than women under 45 years old, and higher for women than men when they were over 45 years old [Table 2-1-1 (11)]. [36]

24 Chapter 2 Risk Factors of Cardiovascular Diseases

Table 2-1-1 (11) The Relative Risk of Hypertension among Chinese Population by Gender Age Group Gender Prevalence (%) OR (95% CI) 15-24 Male 4.76 1 Female 2.13 0.44 (0.37,0.52) 25-34 Male 9.45 1 Female 3.82 0.38 (0.35,0.42) 35-44 Male 17.27 1 Female 11.88 0.65 (0.61,0.69) 45-54 Male 27.24 1 Female 28.42 1.06 (1.01,1.11) 55-64 Male 40.79 1 Female 43.66 1.13 (1.07,1.190 65-74 Male 52.46 1 Female 55.7 1.14 (1.07,1.22)

The risk of hypertension in patients with family history was 2 times as patients without family history. The more the alcohol intake, the higher is the risk of hypertension. The risk of hypertension increased in patients with overweight or obesity in comparison with that in people of normal weight. Patients were at a higher risk of hypertension with one of the following abnormality, including triglyceride, cholesterol or high dense lipoprotein cholesterol (HDL-C)[37] [Table 2-1-1 (12)].

Table 2-1-1 (12) Risk of Hypertension for Chinese Population with Different Risk Factors Risk Factor Risk Factor Prevalence (%) OR (95% CI)

yes 18.22 1.0 Hypertension no 30.38 1.96 (1.90,2.20) < 4.8 24.04 1.0 ≥4.8, < 10.51 23.65 0.98 (0.86,1.12) Alcohol Intake (g/d) ≥10.51, < 19.94 26.25 1.13 (0.99,1.28) ≥19.94, < 40.03 30.2 1.37 (1.2,1.55) ≥40.03 35.22 1.72 (1.52,1.94) Thin 13.7 0.8 (0.8,0.9) Normal 16.5 1.0 Overweight / Obesity Overweight 33.3 2.5 (2.5,2.6) Obesity 51.2 5.3 (5.1,5.5) Normal 20.69 1.0 Triglyceride High 37.2 2.27 (2.15,2.4) Normal 21.29 1.0 Cholesterol High 43.26 2.82 (2.56,3.11) Normal 22.68 1.0 HDL-C Low 25.47 1.17 (1.08,1.260)

25 Report on Cardiovascular Diseases in China (2011)

A survey[38] conducted in 4 541 elderly people aged 65 years or older in Fuxin rural district of Liaoning province in 2004-2005 showed that age, sex, overweight, obesity, smoking, family history and unhealthy diet were risk factors of hypertension. For those with pre-hypertension, the prevalence of hypertension increased with BMI [39, 40] [Figure2-1-1 (13), Table 2-1-1 (13)].

45 0DOH )HPDOH 40

3UHYDOHQFH˄˅ 15

0 Normal Weight Overweight 45 0DOH )HPDOH 40

3UHYDOHQFH˄˅ 15

0 Normal Weight Central Obesity Figure 2-1-1 (13) Prevalence of Prehypertension in Chinese Population with Different Gender and Weight

Note: Overweight: BMI≥25 kg/m2, Central obesity: Waist circumference≥90 cm in man and≥80 cm in woman

26 Chapter 2 Risk Factors of Cardiovascular Diseases

Table 2-1-1 (13) Prevalence of Hypertension and Prehypertension (%) in Chinese Population with Different Body Mass Index (kg/m2) BMI < 24 24≤BMI< 28 BMI≥ 28 Total Sex and Age PHT HT PHT HT PHT HT PHT HT Male 50.5 33.3 46.3 43.5 32.0 61.6 48.7 37.0 35-44 61.6 17.1 56.3 30.4 43.7 49.4 59.3 22.2 45-54 53.3 30.6 45.9 43.6 28.0 63.0 50.3 35.5 55-64 43.5 43.2 37.6 55.5 21.4 75.3 41.2 47.5 ≥65 31.7 58.5 26.6 68.9 15.5 79.8 30.4 60.9 Female 40.8 33.6 40.0 42.8 27.7 62.4 39.6 38.6 35-44 46.6 15.7 47.5 26.4 35.4 47.5 46.2 21.4 45-54 43.9 30.1 41.8 42.7 29.9 63.0 42.1 37.1 55-64 36.4 46.8 31.8 57.9 18.0 75.9 33.4 52.9 ≥65 28.8 61.3 24.4 70.1 17.7 79.6 27.2 64.3 Note: BMI: Body mass index; PHT: Prehypertension, HT: Hypertension

2.1.2 Secondary Hypertension

There were no large scale surveys on prevalence of secondary hypertension. It was estimated that the patients with secondary hypertension accounted for 5-10% of total hypertensives. A retrospective study[41] among 2 274 hospitalized hypertensives aged 14-92 found that 14% patients were diagnosed as secondary hypertension (The detail was showed in Figure 2-1-2). For the diagnosed hypertension patients, especially for young patients, the medical history, physical examination and special lab tests must be examined to determine the etiology of the high blood pressure. The patients with refractory to treatment are more likely to have secondary hypertension. The methods for treatment of secondary hypertension and hypertension is different, some secondary hypertension could be cured after removal of causative factors or by surgical treatment.

Primary Aldosteronism Renovascular Hypertension Renal Hypertension Pheochromocytoma Cushing’s Syndrome Others

Figure 2-1-2 Subtype Distribution of Secondary Hypertension in Hospitalized Patients

27 Report on Cardiovascular Diseases in China (2011)

2.1.3 Hypertension in Children 2.1.3.1 Trends in Blood Pressure Changes among Chinese Children and Adolescents

China Disease Prevention & Control Center and North Carolina State University performed the Chinese Health and Nutrition Survey (CHNS) in 1991, 1993, 1997, 2000 and 2004 in seven provinces in China (Jiangsu, Shandong, Henan, Hubei, Hunan, Guangxi and Guizhou). [42] The blood pressure values among 6-17 years old were measured in 1 936, 1 710, 1 888, 1 602 and 1 111 individuals, respectively. Auscultation method was used in all fi ve surveys; the fi fth Korotkoff sound was used to defi ne DBP. The results showed that blood pressure level in Chinese children (6-17 years old) presented a signifi cant upward trend from 1991-2004 [Figure 2-1-3-1 (a) and Figure 2-1-3-1 (b)], in which systolic blood pressure (SBP) rose from 94.9 mmHg (95% CI, 94.4-95.4) to 99.6 mmHg (95% CI, 98.9-100.3), elevated by 4.7 mmHg; diastolic blood pressure (DBP-K5) rose from 61.7 mmHg (95% CI, 61.3-62.2) to 65.7 mmHg (95% CI, 65.2-66.2), elevated by 4.0 mmHg.

Male Femal Total

SBP(mmHg)

ǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂ˄

Figure 2-1-3-1 (a) Trends in Systolic Blood Pressure (SBP) Changes among Chinese Children and Adolescents (6-17 Years Old) from 1991-2004

28 Chapter 2 Risk Factors of Cardiovascular Diseases

Male Female Total

DBP (mmHg)

ǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂ˄

Figure 2-1-3-1 (b) Trends in Diastolic Blood Pressure (DBP-K5) Changes among Chinese Children and Adolescents (6-17 Years Old) from 1991-2004

Note: This report did not cite the DBP-K5 in 1993, because the average DBP-K5 in 1993 declined by more than 10 mm Hg, and is clearly not consistent with the overall trend.

2.1.3.2 Trend in Hypertension Prevalence in Children and Adolescents

Chinese Health and Nutrition Survey[43] (CHNS) reported a signifi cant increasing trend in the prevalence of hypertension for Chinese children aged 6-17 years [Figure 2-1-3 (2)]. The prevalence rose from 7.1%

Male Female Total

Prevalence （%）

ǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂǂ˄\HDU˅

Figure 2-1-3 (2) Trend in Hypertension Prevalence among Chinese Children and Adolescents (6-17 Years Old) during 1991-2004

29 Report on Cardiovascular Diseases in China (2011)

in 1991 to 14. 6% in 2004, increased by 0.58% per year [44] (when prevalence in 1991, 2004 was used. The average annual growth rate was 0.64% by method of logistic regression). Hypertension diagnosis was based on blood pressure reference standards for Chinese children and adolescents.

2.1.3.3 The Incidence of Hypertension in Children and Adolescents by Weight Status

Case-control subgroup individuals (overweight/obese/non-overweight) in the project of 2004 Beijing Children and Adolescents with Metabolic Syndrome (BCAMS) were followed up by Capital Children Institute in 2010. The follow-up rate was 54.1% (1 184/2 189); Age at baseline was 10.5 ± 2.1 years old and at the time-point of follow-up was 15.6 ± 1.8 years old; The prevalence of overweight and obesity at baseline was higher in follow-up population than in the drop out individuals [Table 2-1-3 (1)].

Table 2-1-3 (1) The Baseline Characteristics of Follow-up Individuals and Drop Out Individuals Characteristics Follow-up Drop out t /χ2 P

Sample 1 184 1 005 - -

Age (year) 10.5±2.1 10.5±2.1 0.365 0.716

Male (%) 643(54.3) 561(55.8) 0.503 0.478

BMI*, n (%) 14.618 0.001

Non-overweight 519(43.9) 519(51.9)

Overweight 181(15.3) 143(14.3)

Obesity 484(40.8) 339(33.9)

IFG**, n (%) 399(39.5) 280(38.5) 0.179 0.672

Dyslipidemia***, n (%) 500(48.5) 530(51.5) 0.831 0.362

* Cut-offs standards of overweight/obesity were based on recommendations by the Chinese Working Group on Obesity for Children (WGOC). ** Impaired fasting glucose (IFG): fasting glusoce≥5.6 mmol/L; *** Dyslipidemia was diagnosed if individuals meet one of the following criteria, (1) HDL- C≤1.03 mmol/L; (2) TG≥1.24 mmol/L; (3) LDL-C ≥1.37 mmol/L; (4) TC≥5.2 mmol/L.

BP measurements used auscultation method. Hypertension diagnosis was determined as SBP and/or [45] DBP≥P95 according to Blood pressure reference standards for Chinese children and adolescents. Six- year cumula tive incidence of hypertension for non-overweight, overweight and obese group at baseline were 8.7%, 19.3% and 32.4%, showed a signifi cantly upward trend (trend test,χ 2 = 9. 332, P < 0.001) [Figure 2-1-3 (2)]. Compared with non-overweight group, the relative risk (RR) of hypertension in overweight and obese groups were 2.23 (95% CI, 1.48-3.35) and 3.71 (95% CI, 2.73-5.06). [46] Six-year hypertension cumulative incidence of baseline waist normal group and abdominal obesity group by waist circumference (WC, cm) was showed in Figure 2-1-3 (3).

30 Chapter 2 Risk Factors of Cardiovascular Diseases ˅

˄ ·WUHQG ˈ3= ·WUHQG ˈ3=

&XPXODWLYH,QFOGHQFHRI+\SHUWHQVLRQ 1RQRYHUZHLJKW 2YHUZHLJKW 2EHVLW\ 1RQRYHUZHLJKW $EGRPLQDO2EHVLW\ %0, *URXS :& *URXS

Figure 2-1-3 (3) The Cumulative Prevalence of Hypertension in Chinese Children and Adolescents (6-17 Years Old) during 2004-2010

2.2 Tobacco Use 2.2.1 Prevalence of Cigarette Smoking

(1) Overall Prevalence Since 1984, China has been listed as one of the most prevalent countries of tobacco use in the world. During the period 1996-2002, the smoking rate had dropped by 3.1% in men, but reached a plateau from 2002 to 2010. The prevalence of tobacco use in 2010 was almost the same as that in 2002. In 2010, the Global Adult Tobacco Survey-China was conducted among persons 15 years of age or older (adults) in 28 provinces in China. Results of the survey showed that the total smoking rate was 62.8% in males and 3.1% in females, with an estimated 340 million men and 16.39 million women were cigarette smokers. Compared with 1996 and 2002, there was a modest reduction in total smoking rate in men in 2010, but no signifi cant change occurred in the standardized prevalence rate. In 2010, an estimated 310 million of adults (28.1%) in China [290 million men (52.9%) and 10.46 million women (2.4%)] were current smokers. Although the total smoking rate increased compared with that in 2002, the number of the current smokers had little change. From 1996 to 2002, smoking rates were dropped at different degrees in most age-groups except the young age-group. During the period 2002 to 2010, current smoking rate was increased in men aged 40-59 years. Although the smoking rate maintained at a relative low level in the total female population, the rate among young females was increasing. Among men, the prevalence of smoking was signifi cantly higher in rural residents (56.1%) than that in urban residents (49.2%). On the contrary, among women, the prevalence was signifi cantly higher in urban residents (2.6%) than that in rural areas (2.2%) [Figure 2-2-1 (1) , (2).Table 2-2-1 (1), (2)]. [47, 48, 49, 50, 51]

31 Report on Cardiovascular Diseases in China (2011)

Table 2-2-1 (1) Comparison of Smoking Prevalence among Chinese Aged 15 and Older in 1984, 1996, 2002 and 2010 Survey Year Sample Size Age (Years) Males (%) Females (%) Total (%)

1984 519 600 15- 61.0 7.0 33.9 1996 120 298 15-69 66.9 4.2 37.6 2002 16 056 15-69 66.0 3.08 35.8 2010 13 354 15-69 62.8 3.1 - Note: There was difference at the defi nition of cigarette smoking identifi ed by 3 surveys. • 1996 National Prevalence Survey of Smoking Pattern, “smoker” was defi ned as a person who has smoked daily for at least 6 months by the time of survey. • 2002 National Behavioral Risk Factors Surveillance, “smoker” was defi ned as a person who has smoked at least 100 cigarettes by the time of survey. • Global Adult Tobacco Survey 2010 (GATS 2010-CHINA), smoking rate was referred to current smoking rate.

Table 2-2-1 (2) Estimated Prevalence of Current Smoking among Adults Aged 15 Years or Older (GATS 2010, China) Demographic Characteristics All Adults(%) Men(%) Women(%)

Overall 28.1 52.9 2.4 Age 15-24 17.9 33.6 0.7 25-44 31.0 59.3 1.6 45-64 33.6 63.0 3.2 ≥65 22.7 40.2 6.7

Area

Urban 26.1 49.2 2.6

Rural 29.8 56.1 2.2 Note: Current smoking is defi ned as smoking every day and occasional smoking.

3UHYDOHQFHRI6PRNLQJ˄˅

˄$JH˅

Figure 2-2-1 (1) Age-speciﬁ c Prevalence of Current Smoking among Chinese Male Population of 15 Years Old and Above

Chapter 2 Risk Factors of Cardiovascular Diseases

3UHYDOHQFHRI&XUUHQW6PRNLQJ˄˅ ˄$JH˅

Figure 2-2-1 (2) Age-speciﬁ c Prevalence of Current Smoking among Chinese Female Population of 15 Years Old and Above

• Smoking Rate among Male Physicians and Teachers in China during 2002-2010 The smoking rate among male physicians and teachers was more than 50% during the period 1996 to 2002. [52, 53] GATS-China 2010 showed that the current smoking rate among population aged 15-59 was 40% in male physicians, and 36.5% in male teachers respectively, indicated a signifi cant decline from 2002.[54] But Chinese male physicians still have been regarded as one of the most prevalent subgroups of tobacco use in the world. [55, 56, 57]

• Smoking Prevalence of Chinese Juvenile Results from a survey conducted in 2005 showed that, among the college and middle school students aged 11-23 years old, the attempting rate for smoking was 50.9% in schoolboys and 23.0% in school girls, current smoking rate was 22.4% in schoolboys and 3.9% in schoolgirls. The current smoking rate was increasing rapidly with age among school boys.[58] Meanwhile, the age of start smoking was becoming earlier in China. Among the students ever smoked, the proportion of smoked one cigarette under the age of 13 years was 55.9% and 57.0% for schoolboys and schoolgirls, respectively. [59] According to 2010 GATS survey, 52.7% of the smokers aged 18-34 started smoking before the age of 20. [60]

(2) Passive Smoking Data of epidemiological surveys in 1996, 2002 and 2010 indicated that in the recent decades, rate of exposure to secondhand smoke changed little. The prevalence of passive smoking in non-smokers was 51.9% in 2002, it was estimated that there were 540 million passive smokers in China.

33 Report on Cardiovascular Diseases in China (2011)

5DWHRI([SRVXUHWR6HFRQGKDQG6PRNH˄ 8UEDQ 5XUDO 0HQ :RPHQ

Figure 2-2-1 (3) The Different Year of Rate of Exposure to Second-hand Smoke in 1996 and 2002 by Urban/rural Location and Gender

Note: Defi nition of passive smoking in the 1996 and 2002 survey: in the past 30 days, one has been exposure to tobacco smoke for more than 15 minutes per day, for at least 1 day per week.

2.2.2 Smoking Cessation

Smoking cessation rate increased slightly in the population older than 15 years in recent years, rose from 9.42% in 1996 to 11.5% in 2002.[61, 62] According to the results of GATS in 2010, the cessation rate was 16.9%. Furthermore, 16.1% of the current smokers attempted to stop smoking within 12 months. [63] Since 2002, the proportion of current smokers without intention of attempting to quit was unchanged (44% in 2002 compared with 44.9% in 2010). At the same time, the relapse rate remained high. [64, 65] The ratio of abstainers to total smokers was increased from 9.42% in 1996 to 16.9% in 2010, the number of abstainers increased by 15 million. Meanwhile, the relapse rate has been increasing from 10.5% in 1996 to 32.5% in 2002, rising to 33.1% in 2010.

2.2.3 Health Consequences of Active Smoking and Passive Smoking

Conclusive evidence proves heart diseases, malignant neoplasms, and cerebrovascular disease account for approximately two thirds of the total deaths in the Chinese population aged 40 years and older. Active and passive smoking is one of the leading preventable risk factors of death among men and women in China, the Relative Risk (RR) and population attributable risk (PAR) of death associated with smoking in China was 1.23 (95% CI, 1.18-1.27) and 7.9%, RR was 1.18 (95% CI, 1.13-1.23), PAR was 10.0% for males, and RR 1.27 (95% CI, 1.19-1.34), PAR 3.5% for females. [66] An estimated 673 thousand death in Chinese adults ages 40 and older were attributed to tobacco use (Figure 2-2-3). [67]

34 Chapter 2 Risk Factors of Cardiovascular Diseases

0HQ :RPHQ

'HDWK$WWULEXWDEOHWR6PRNLQJ˄7KRXVDQGV˅ 8UEDQ5XUDO

Figure 2-2-3 Death Attributable to Tobacco Use in China, 2005

2.2.3.1 Impact of Cigarette Smoking on Incidence and Prognosis of CVDs • Smoking was an Independent Risk Factor for CVDs A Multi-Provincial Cohort Study (CMCS) with 10-year follow-up enrolled 30 000 Chinese participants aged 35-64. The study showed that cigarette smoking was one of the independent risk factors for CVDs and acute ischemic stroke. And 19.9% of acute coronary events and 11% of acute ischemic stroke events among the cohort population could be attributed to smoking. Multivariate analysis found that cigarette smoking results in a 1.75 times of acute CHD risk, 1.37 times of ischemic stroke risk, and 1.21 times of haemorrhage stroke risk, respectively. [68] The fi ndings were confi rmed by another large Chinese cohort study, which followed 10 000 people for up to 15 years, that 31.9% of the total ischemic CVDs events (CHD and ischemic stroke) among the cohort population aged 35-59 could be attributed to cigarette smoking. Compared with nonsmokers, there were 100% and 59% increase in ischemic CVDs events in male smokers (RR=2.04), and female smokers (RR=1.59), respectively. [69] • Smoking was a Risk Factor for Stroke [70] A prospective cohort study among 169 871 Chinese men and women aged 40 years and older was conducted in 1991. The study indicated that the relative risk of incidence and mortality of stroke for current male smokers was 1.28 (95% CI, 1.19-1.37) and 1.13 (95% CI, 1.03-1.25) , 1.25 (95% CI, 1.13-1.37) and 1.19 (95% CI, 1.04-1.36) for current female smokers, respectively. • Relationship between Carotid Plaque and Correlative Factors in Patients with Cerebral Infarction [71] A case-control study on relationship between presence or absence of carotid plaque and correlative factors in patients with cerebral infarction was conducted among 546 patients with acute cerebral infarction. Patients were divided into plaque group and non-plaque group according to carotid vascular ultrasonic results. The relationship between the two groups and vascular risk factors, or types of stroke was analyzed.

35 Report on Cardiovascular Diseases in China (2011)

Results showed that patients with cerebral infarction had high incidence of cervical vessel plaque (72.89%). The occurrence of plaque has an association with hypertension, diabetes, smoking, stroke, age, as well as elevated hs-CRP (P < 0.01). Logistic regression analysis demonstrated that cigarette smoking [OR=2.489 (95% CI, 1.448-4.279)], stroke, elevated hs-CRP (≥1.74 mg/L) and hypertension were the independent risk factors for cerebral infarction. • Dose-response Relationship between Smoking and Carotid Atherosclerosis In a study, 959 Chinese men aged 50 or older were randomly selected from Guangzhou Biobank Cohort Study (GBCS) on CVDs. Personal histories were collected and fasting plasma glucose and 1ipids, blood pressure, and common carotid artery intima-median thickness (CCA-IMT) were measured. Results: ① 39.1% were non-smokers. 25.7% were former smokers and 35.2% were current smokers. The mean carotid IMT was 0.78 mm (95% CI, 0.7-70.79). 18.4% of the subjects had carotid IMT≥1.0 mm while 34.1% were found to have carotid plaque. ② After adjusting for age, sex, physical activity, body mass index, fasting glucose, triglyceride, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, current smokers had signifi cantly increased risk for thicker IMT and carotid plaque in comparison with never smokers (OR=1.82, 95% CI, 1.30-2.55 and OR=1.95, 95% CI, 1.38-2.75, respectively, all P < 0.001). The risk for thicker IMT and carotid plaque increased with the increasing amount (cigarettes/day) and duration of smoking (years) as well with cigarette pack years (P for trend all≤0.01). In conclusion, an elevated risk with a clear dose-response relationship was found between smoking and carotid atherosclerosis in this Chinese population group. [Table 2-2-3 (1)]

Table 2-2-3 (1) Adjusted Mean and Odds Ratio of Inﬂ ammatory Marker among Elderly Chinese Men at Different Smoking Status P Value Non-smokers (95% CI) Former Smokers (95% CI) Current Smokers (95% CI) (Trend Test) Numbera 1 253 859 827 – Mean CRP (mg/L) 2.81 (2.66, 2.97) 2.99 (2.80, 3.19) 3.10 (2.90, 3.31) 0.009 OR for Elevated CRP 1.00 1.28 (1.04, 1.57) 1.36 (1.10, 1.68) 0.003 Mean WBC (109 cell/L) 6.16 (6.06, 6.26) 6.39 (6.27, 6.51) 7.07 (6.94, 7.21) <0.001 OR for Elevated WBC 1.00 1.26 (1.02, 1.55) 2.93 (2.37, 3.61) <0.001

Note: Odds ratios adjusted for age, education, physical exercise, alcohol consumption, body mass index, waist circumstance, blood pressure (SBP and DBP), total cholesterol and low-density lipoprotein cholesterol, plasma glucose, and month of hemanalys is performed.

CRP: C-reactive protein, WBC: white blood cell. In the highest tertile (≥4.17 mg/L) of CRP and in the highest tertile (≥7.80×109 ) of WBC was defi ned as elevation of the indicator respectively. a: Indicated participants without missing values.

• Association of Cigarette Smoking with Other Risk Factors for Cardiovascular Disease – Relationship between Cigarette Smoking and Obesity among Middle-Aged and Elderly Shanghai Men [72] From 2002 to 2006, a population-based cohort study of 61 491 Chinese men aged 40-74 years in urban

36 Chapter 2 Risk Factors of Cardiovascular Diseases

Shanghai were conducted by the Shanghai Men’s Health Survey (SMHS). Multiple regression models were used to evaluate the associations of smoking habit with body mass index (BMI), waist-to-hip ratio (WHR) and adult body weight gain after adjusting for potential confounding factors, results found that cigarette smoking may be inversely associated with body weight and weight gain but positively related to central fat deposition which is more detrimental to health than general obesity. The initial gain in weight after smoking cessation is temporary. The current smokers had a lower BMI (23.4 ± 3.1 kg/m2) and body weight gain in adulthood (11.64 ± 9.7 kg) than non-smokers (24.04 ± 2.9 kg/m2 and 12.74 ± 8.9 kg). Adjusted differences between these two groups were 0.60 (95% CI, -0.67– -0.54) for BMI and 1.46 kg (95% CI, -1.65– -1.27) for body weight gain, respectively. Among current smokers, the WHR increased with the early age of starting smoking, cigarettes smoked per day, years of smoking and pack·years of smoking in a dose-response manner (trend test, P< 0.05). Detail was showed in Table 2-2-3 (2).

Table 2-2-3 (2) Association of Cigarette Smoking with BMI, WHR and Body Weight Gain

2 a Weight Gain after 20 Years BMI (kg/m ) WHR Old (kg) Factors Number Mean ± Adjusted Adjusted Mean ± Adjusted Mean ± SD SD Difference Difference SD Difference Non-Smokers 18 697 24.0±2.9 0 0.899±0.06 0 12.7±8.9 0 Former Smokers 6 762 24.4±3.1 0.18 0.909±0.06 3.25 12.8±9.6 0.60 (0.09 – 0.27) (1.80–4.70) (0.32–0.87) Current Smokers 36 031 23.4±3.1 -0.60 0.899±0.06 6.08 11.6±9.7 -1.46 (-0.67– -0.54) (5.08–7.09) (-1.65– -1.27) Age of Starting Smoking 40- 5 517 23.8±3.1 -0.30 0.900±0.06 2.77 12.1±9.6 -0.63 (-0.40– -0.20) (1.27–4.28) (-0.92– -0.35) <40 5 054 23.5±3.1 -0.61 0.900±0.06 7.35 11.6±9.6 -1.37 (-0.71– -0.51) (5.77–8.93) (-1.67– -1.44) <30 15 713 23.4±3.1 -0.68 0.897±0.06 6.20 11.6±9.6 -1.67 (-0.76– -0.60) (5.00–7.40) (-1.90– -1.44) <20 9 747 23.4±3.2 -0.73 0.899±0.06 8.03 11.1±10.1 -1.84 (-0.82– -0.64) (6.66–9.40) (-2.10– -1.58) t=-15.32 t=12.23 t=-13.05 Trend Test P <0.01 P <0.01 P <0.01 Pack·Years of Smokingb <13 9 019 23.5±3.0 -0.47 0.895±0.06 2.44 12.4±9.2 -1.07 (-0.55– -0.38) (1.11–3.76) (-1.33– -0.82) <22 9 246 23.3±3.1 -0.65 0.896±0.06 4.87 11.6±9.5 -1.63 (-0.74– -0.57) (3.54–6.20) (-1.88– -1.38) <31 9 070 23.4±3.2 -0.70 0.899±0.06 7.25 11.3±9.9 -1.67 (-0.79– -0.61) (5.88–8.61) (-1.93– -1.41) ≥31 8 696 23.6±3.2 -0.57 0.905±0.06 9.88 10.9±10.4 -1.36 (-0.66– -0.49) (8.51–15.25) (-1.62– -1.09) t =-11.73 t =16.02 t =-9.19 Trend Test P <0.01 P <0.01 P <0.01 Note: a refers to re-adjusted BMI; b refers to current smokers

37 Report on Cardiovascular Diseases in China (2011)

2.2.3.2 Impact of Passive Smoking on Morbidity and Mortality of CVDs

Passive smoking, i.e., second hand smoking (SHS exposure), was defi ned as exposure to another person’s tobacco smoke at home or in the workplace. Second hand smoke exposure also associated with increase of CVDs incidence and death. Results of a meta-analysis which reviewed 18 epidemiology studies showed that the risk of CVDs increased by 25% (RR=1.25, 95% CI, 1.17-1.32) among passive smokers. [73]

2.2.4 Disease and Economic Burden of Tobacco Use in China

Heavy burden was caused by tobacco use in China, especially the smoking-related non communicable diseases.

2.2.4.1 Disease Burden Attributable to Tobacco Use [74]

Disability-adjusted Life Years (DALYs) Lost of Chinese people due to smoking-related diseases [stroke, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), lung cancer, gastric cancer, esophageal cancer, 5 cancers in other sites, and tuberculosis] was 158.2 years/1 000 in people aged over 40, 118.1 years/1 000 in people aged 40-69, and 445.4/1 000 in people above 70 years old, respectively. And Years Lived with Disability (YLD) contributed 32.3% of total DALY. The younger of age, the larger the years of life lost (YLL). In men, especially those aged 70 years and older, the DALY Lost is the highest. COPD and lung cancer were the major contributors of total DALYs (Figure 2-2-4). '$/< 'HDWK$WWULEXWDEOHWR7REDFFO8VH 'HDWK8QDWWULEXWDEOHWR7REDFFO8VH 3' &2 &+' 6WURNH /XQJ&DQFHU 2WKHU&DQHUV7XEHUFXORVLV *DVWULF&DQFHU (VRSKDJHDO&DQFHU Figure 2-2-4 Disease Burden Attributable to Tobacco Use

2.2.4.2 Economic Burden Attributable to Tobacco Use [75]

An estimation was explored based on epidemiologic and statistic data and the existing literature of smoking related diseases by using data of more than 1 400 thousand death caused by tobacco use in 2005,

38 Chapter 2 Risk Factors of Cardiovascular Diseases which calculated that the direct cost of smoking were ¥166.56 billion, indirect costs were ¥86.111-120.501 billion, total cost was almost ¥300 billion, accounted for 1.5% of GDP of the year of 2005. (Table 2-2-4) Table 2-2-4 Direct Cost of Smoking Related Diseases in China*

Year Cost (10 Billion RMB) GDP%

2000 998.97 1.116 56

2005 1 665.60 0.913 55

* The direct cost of smoking is total cost for diseases caused by smoking.

2.3 Dyslipidemia 2.3.1 Lipid Levels and Prevalence of Dyslipidemia in Chinese Adults

In the 1980s, the data from several international collaborative studies indicated that in comparison with western populations, the level of serum total cholesterol and low density lipoprotein cholesterol (LDL-C) was signifi cantly lower in Chinese populations, while high density lipoprotein cholesterol (HDL-C) was signifi cantly higher in Chinese men. [76, 77] And then, it was found that in several domestic large scale multicenter studies the level of lipids, and the prevalence of dyslipidemia varied among populations in different areas and different economical settings. The prevalence of dyslipidemia increased markedly in the past 20 years. In late 80s and early 90s, the lowest mean serum cholesterol was 137.7 ± 5.9 mg/dl (3.57 ± 0.15 mmol/L) and the highest was 203.1 ± 0.9 mg/dl (5.26 ± 0.02 mmol/L); the age standardized prevalence of high cholesterol (≥200 mg/dl or 5.18 mmol/L) was 4.8%-46.5% among the middle aged populations in different areas. [78, 79] In the late 1990s, the age standardized prevalence of elevated cholesterol was 15% to 53% in 15 groups of middle aged populations from different areas. And an increased secular trends of the age adjusted prevalence for high cholesterol with the survey time (1982-1984, 1992-1994 and 1998) were observed in 9 groups of populations, which participated in all 3 surveys[80] [Figure 2-3-1 (1)].

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39 Report on Cardiovascular Diseases in China (2011)

In 2000-2001, INTERASIA study enrolled 15 540 participants aged 35-74 years from 10 provinces, the mean level of serum TC, HDL-C, LDL-C and TG, was 186.1 mg/dl, 51.7 mg/dl, 109.5 mg/dl and 128.1 mg/dl, respectively; The prevalence of TC borderline high (200-239 mg/dl or 5.186-6.19 mmol/L) and high (≥240 mg/dl or 6.22 mmol/L) was 23.8% (30.7% in urban, 22.4% in rural) and 9.0% (13.4% in urban, 9.3% in rural) respectively; The prevalence of low (HDL-C < 40 mg/dl or 1.04 mmol/L) was 19.2%.[81] The data from National Nutrition and Health Survey in Chinese Residents in 2002 (China NNHS 2002) showed that the prevalence of dyslipidemia (at least one disorder on TC≥5.72 mmol/L, TG≥1.70 mmol/ L, HDL-C < 1.04 mmol/L) was 18.6% in adults (≥18 years of age) the patients number estimated 200 million, of which 2.9% was hypercholesterolemia (TC≥5.72 mmol/L), 3.9% was borderline high cholesterol mmol /L , 11.9% was hypertriglyceridemia (triglyceride≥1.70 mmol/L), and 7.4% was low high-density lipoprotein cholesterol level (< 1.04 mmol/L). It was estimated that dyslipidemia affected at least 200 million individuals.[82, 83] The prevalence for borderline high and high TC was markedly high in urban populations and in elderly people[84] [Figure 2-3-1 (2)].

7&PPRO/ 7&ıPPRO/

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ı ı $JH 8UEDQ5XUDO

Figure 2-3-1 (2) Prevalence of Borderline High TC (5.20-5.71 mmol/L) and High TC (≥ 5.72 mmol/L) by Age, Gender and Setting (Urban/Rural) in Chinese Adults

In recent years, the prevalence of dyslipidemia in different types of populations from several metropolitan area, such as Beijing, Shanghai and Nanjing etc. was relatively high [85, 86, 87, 88] (With different diagnostic criteria, Table 2-3-1).

40 Chapter 2 Risk Factors of Cardiovascular Diseases

Table 2-3-1 Prevalence of Dyslipidemia in Different Types of Populations from Several Metropolitans Sample Survey Year Population Age (Year) Prevalence% Size

Shanghai Urban/Rural 36.9 2002-2003[89] (6 Districts, 12 ≥16 14 385 (At least one abnormal on TC≥6.2 mmol/L, TG≥1.7 Communities) mmol/L, HDL-C<1.0)

59.6 Jiangsu Province, [90] (At least one abnormal on TC≥5.18 mmol/L, 2003-2005 Nanjing City Ofﬁ ce Staff 23-79 2 648 TG≥1.70 mmol/L, HDL-C < 1.04 mmol/L, LDL≥3.37 (7 Institutions ) mmol/L)

54.1*+ [91] Beijing Urban/Rural (7 2006 45-89 3 251 (At least one abnormal on TC≥5.72 mmol/L, Communities) TG≥1.70 mmol/L, HDL-C < 0.91 mmol/L)

Beijing Suburb 35.4* 2007[92] (5 Towns, 30 Villages/ 35-74 16 371 (At least one abnormal on TC≥5.7 mmol/L, TG≥1.7 Streets ) mmol/L, HDL-C<1.0 mmol/L, LDL≥3.4 mmol/L)

*Age standardized; +Sex standardized

2.3.2 Prevalence of Dyslipidemia in Children and Adolescents

China NNHS 2002 showed, the prevalence of hyper cholesteralimia (≥220 mg/dl or 5.72 mmol/L) in children and adolescents (3-17.9 years of age) was 0.8% in total, 1.4% in urban and 0.6% in rural; the prevalence of high TG (≥150mg /dl or 1.70 mmol/L) was 2.8% in total, 2.5% in urban, 2.9% in rural.[93] In 1987-2007, several reports on dyslipidemia in children and adolescents from Beijing and Guangdong area are summarized in Table 2-3-2. [94, 95, 96] Another study in the 6-18 year old children and adolescents in Beijing showed the prevalence of dyslilpidemia (TC≥5.20 mmol/L and/or TG ≥1.70 mmol/L) was about 30% in obese group, markedly higher compared to that in non-obese group[97] (Figure 2-3-2).

Table 2-3-2 The Prevalence of Dyslipidemia in Children and Adolescents in Different Areas and Different Period (%)

Area Publication Year Age (Year) Sample Size High TC High TG

Beijing[98] 1987 7-19 1 201 1.3 4.2

Guangdong Province#[99] 2005 3-14 6 188 2.1 2.2

Beijing#[100] 2007 6-18 19 593 1.2 8.8

High TC: TC≥200 mg/dl (5.17 mmol/L); High TG: TG≥150 mg/dl (1.70 mmol/L) ; # Fasting capillary blood was used for lipid assay

41 Report on Cardiovascular Diseases in China (2011)

˄˅

Prevalence

Obesity (-), Family History (-) Obesity (-), Family History (+) Obesity (+), Family History (-) Obesity (+), Family History (+)

Figure 2-3-2 Prevalence of Dyslipidemia in Children and Adolescents by Obesity and Family History 患病率: 无肥胖，无家族史: 2.3.3 The Relationship无肥胖，有家族史: of Blood Lipids and Cardiovascular Diseases 肥胖，无家族史: 肥胖，有家族史: It is demonstrated in several cohort studies in China that elevated serum TC or LDL-C, or reduced HDL-C increases the risk of ischemic cardiovascular diseases (coronary heart disease, ischemic stroke). However, there wasn’t an obvious correlation between TG elevation and CVDs.

2.3.3.1 TC and LDL - C

The results of two cohort studies, USA-PRC collaborative study on epidemiology of cardiovascular disease (10 222 participants, followed-up for 15.9 years) and the Chinese Multi-Provincial Cohort Study (30 384 participants, followed-up for 10 years) revealed that the risk of ischemic cardiovascular diseases (coronary heart disease and ischemic stroke) increased signifi cantly in people with borderline high and high serum TC or LDL-C than those with the ideal level of the lipids. The relative risk of ischemic cardiovascular disease was similar, about 1.6-1.7 for high TC (≥6.22 mmol/L) and high LDL - C (≥4.14 mmol/L) compared to the idea levels.[101, 102] (Table 2-3-3) The relative risk of ischemic cardiovascular disease was 2.0 (95% CI, 1.5-3.7) in serum cholesterol≥5.7 mmol/L vs < 5.7 mmol/L, and the percentage of population attributable risk was 11.4% in China Multicenter Collaborative Study on epidemiology of Cardiovascular disease in 14 populations with 17 330 participants were followed-up for 6.8 years[103]. The results of 20 year follow-up study in total of more than 5000 male-workers of Capital Steel and Iron Company revealed that the relative risk of myocardial infarction in individuals with serum TC 4.7-5.1 mmol/L, 5.2-5.6 mmol/L, 5.7- 6.1 mmol/L and≥6.2 mmol/L was signifi cantly higher in comparison with those with serum TC below 4.7 mmol/L, it was 1.70 (1.03-2.82), 1.95 (1.14-3.32), 2.76 (1.54-4.95) and 3.69 (2.18-6.24), respectively. [104] The cohort study in 1 211 elderly people in Beijing (follow-up 11.2 years) indicated that serum LDL - C level signifi cantly increased the risk of coronary heart disease, OR was 1.545 (95% CI, 1.321-1.807).[105]

42 Chapter 2 Risk Factors of Cardiovascular Diseases

2.3.3.2 HDL-C

It was also demonstrated that HDL-C was negatively related to the ischemic cardiovascular disease in some of the above cohort studies. The relative risk of ischemic cardiovascular disease was 1.5 (95% CI, 1.2-2.0) in reduced HDL-C (< 1.04 mmol/L) group compared to that in elevated HDL-C (≥1.55 mmol/L) group;[106] (Table 2-3-3) the relative risks was 1.39 (95% CI, 1.00-1.92) for acute coronary heart disease (CHD) events and 1.45 (95% CI, 1.15-1.83) for ischemic stroke; [107] HDL-C level in the elderly people signifi cantly reduced the risk of coronary heart disease, OR was 0.688 (95% CI, 0.574-0.824). [108]

2.3.3.3 Other Lipid Items

Elevated non-high-density lipoprotein cholesterol (non HDL-C) and TC/HDL-C ratio was also predictive for ischemic cardiovascular disease, [109] acute coronary heart disease (CHD) events and ischemic stroke. [110, 111]

Table 2-3-3 Lipid levels and the Incidence, Relative Risk of Cardiovascular Disease

USA-PRC Cohort 11 Province Cohort Lipid Level Incidence/ Incidence/ (mmol/L) N 100 000 RR 95%CI N 100 000 RR 95%CI Per Year Per Year TC

<5.18 7 850 200 1.0 21 800 229 1.0

5.18-5.67 1 163 342 1.2 0.9-1.6 4 353 326 1.3 1.0-1.6

5.70-6.19 635 435 1.7 1.2-2.3 2 530 355 1.3 1.0-1.8

≥6.22 574 502 1.7 1.2-2.3 3 016 475 1.6 1.2-2.1

LDL-C

<3.37 7 898 214 1.0 22 774 233 1.0

3.37-4.12 1 206 352 1.4 1.1-1.8 4 509 369 1.3 1.0-1.6

4.14-4.90 355 460 1.5 0.9-2.3 1 686 421 1.4 1.0-2.0

≥4.92 166 466 1.5 0.8-2.8 1 055 608 2.0 1.4-2.9

HDL-C

≥1.55 2 687 255 1.0 11 268 191 1.0

1.04-1.53 6 161 240 1.1 0.8-1.4 16 200 281 1.2 1.0-1.5

<1.04 1 374 262 1.1 0.8-1.6 4 232 425 1.5 1.2-2.0

<1.70 8 346 226 1.0 23 979 255 1.0

1.70-2.25 755 348 1.0 0.7-1.4 3 467 303 0.9 0.7-1.2

≥2.26 666 425 1.1 0.7-1.5 2 926 352 1.0 0.7-1.3

Note: Relative risk (RR) was estimated by multivariable analyses. In the analyses for TC and LDL-C, adjusted variables included age, sex, smoking, diabetes, obesity, low HDL-C and hypertension; in the analyses for HDL-C, adjusted variables included age, sex, smoking, diabetes, SBP, BMI and TC.

43 Report on Cardiovascular Diseases in China (2011)

2.3.4 Management and Control of Dyslipidemia 2.3.4.1 Community Populations

In 2000-2001, INTERASIA study selected a nationally representative sample of the general population 35-74 years of age from urban and rural of 10 provinces in China. The study reported that the awareness rate of dyslipidemia was 8.8% in men and 7.5% in women among people with serum TC at borderline high level [≥200 mg/dl (5.17 mmol/L)], and was 21.3% in men and 18.1% in women among people with serum TC at high level[≥240 mg/dl (6.22 mmol/L)]. [112] China NNHS 2002 reported that the awareness rate of dyslipidemia in adults (18 year old and older) with at least one disorder on TC≥5.72 mmol/L, or TG≥1.70 mmol/L, or HDL-C < 0.91 mmol/L was 3.2% in total, and was 3.4% in men, 2.7% in women; 7.0% in urban, and 1.5% in rural respectively. The rate of lipid examination by the survey was 6.4% in total. The rate increased markedly with age and was higher in urban areas than that in rural areas (Figure 2-3-4). [113] In 2006, a survey included 3 251 participants aged 45-89 years from 7 urban and rural communities in Beijing, showed that the rate of awareness and treatment in people with dyslipidemia (with at least one disorder on TC≥5.72 mmol/L, TG≥1.70 mmol/L, HDL-C < 0.91 mmol/L) was 50.9% and 23.8%, and the control rate in people under treatment was 39.9%.[114]

5DWHRI/LSLG([DPLQDWLRQ˄˅ Urban Male Urban Female Rural Male Rural Female Figure 2-3-4 Percentage of Lipid Examination in Chinese Adults (%)

2.3.4.2 Inpatients

Two national investigations on clinical control of hypercholesterolemia were conducted in 2000 and 2006. More than 20 provincial hospitals and several county hospitals were selected from more than 10 metropolitans in different provinces. In each of the investigations, 2 136 and 2 237 hypercholesterolemia patients accepted lipid-lowering drug therapy and maintained the treatment for more than 2 months respectively. The overall rate of goal attainment (according to the target value of The Recommendations on Prevention and Control of Dyslipidemia for Chinese Adults, 1997) was 26.5% in 2000; the overall goal attainment rate was 34% and 50% according to the criteria of NCEP ATP Ⅲ , 2004 and The Guidelines on Prevention and Control of Dyslipidemia for Chinese Adults, 2007 respectively in 2006. [115, 116]

44 Chapter 2 Risk Factors of Cardiovascular Diseases

In 2008, the China Cholesterol Education Program (CCEP) investigated 4 778 patients with coronary heart disease from 52 centers located in 6 provinces of China. There was 82.8% of the patients received Therapeutic Lifestyle Change (TLC), 82.2% of them received statin therapy. According to the goal of NCEP ATP Ⅲ , 36.2% of the high-risk patients reached the LDL-C target level (< 2.59 mmo/L), 10.9% and 42.2% of the very high risk patients reached the optimal LDL-C level (< 1.82 mmo/L), and the LDL-C target level (< 2.59 mmo/L) respectively.[117] In 2009, a multicenter (51 hospitals across the country) investigation showed that the rate of receiving statin therapy in patients with acute coronary syndrome was 80.4%, 65.8% and 59.4% at the time of hospital discharge and at 6 months, 12 months after discharge from hospital respectively. [118] Research in the past 3 decades indicated that dyslipidemia was one of the important risk factors of cardiovascular diseases in Chinese population. Lipid levels and dyslipidemia prevalence are getting higher rapidly, especially in those in economic development areas, and also in middle aged and elderly populations. There is a large gap on the management and control of dyslipidemia in China and it is urgent to improve the practice on prevention and control of dyslipidemia with effective measures to reduce the risk of CVDs in the population.

2.4 Overweight and Obesity

During recent three decades, with the development of economy and the change of the life style, the prevalence of overweight and obesity in China has been increasing dramatically. Prevention and control of the obesity has been the most signifi cant public health problem in China. According to National Nutrition and Health Survey of Chinese residents in 2002, there were about 200 million people with overweight (BMI: 24-27.9 kg/m2) and about 60 million with obesity (BMI≥ 28 kg/m2) in China. It was estimated that the number of people who were overweight and obesity reached 240 million and 70 million, respectively, based on the statistics of census in 2006. The trend of overweight and obesity increased signifi cantly[119] [Figure 2-4 (1)].

3UHYDOHQFH˄

2YHUZHLJKW 2EHVLW\ 2YHUZHLJKWRUREHVLW\ Figure 2-4 (1) Prevalence of Overweight and Obesity in China in 1992 and 2002

In the National Nutrition and Health Survey of Chinese residents in 2002, outcome of further analysis of the data for 40 000 population showed, after multi-factors adjustment, the incidence hazard of hypertension,

45 Report on Cardiovascular Diseases in China (2011) hyperglycaemia and lipid-disorder among population would increased signifi cantly following the increase of BMI and waist circumference [120] [Figure 2-4 (2)].

:& :&

25 RI+\SHUWHQVLRQ :& :& %0, %0, %0, %0, A Odds Ratio of Hypertension with Different BMI and WC Subgroups

Notes: BMI subgroups: BMI 1, 18.5-23.9 kg/m2; BMI 2, 24.0-27.9 kg/m2; BMI 3, ≥28.0 kg/m2. WC subgroups: WC1, < 80 cm (female) /85 cm (male); WC2, 80-89 cm (female) /85-95 cm (male); WC3, ≥90 cm (female) / 95 cm (male). Adjusted for areas, age, gender, cigarette, alcohol, :& incomes, education, diet fat, sodium intakes and 25RIOLSLG

+\SHUJO\FDHPLD :& sedentary-lifestyle in logistic analysis.

:& :& %0, %0, %0, %0, B Odds Ratio of Hyperglycaemia with Different BMI and WC Subgroups

GLVRUGHU :&

25RIOLSLG :& :& :& %0, %0, %0, %0, C Odds Ratio of Lipid-disorder with Different BMI and WC Subgroups

Figure 2-4 (2) Odds Ratio of Hypertension, Hyperglycaemia and Lipid-Disorder with Different BMI and WC Subgroups

46 Chapter 2 Risk Factors of Cardiovascular Diseases

One overweight and obesity intervention study, including 10 000 participants (average aged 58 ± 12) with overweight and obesity, which were enrolled from 64 communities in China, was held with 9 months intervention period in average (1-32 months). The intervention included regular physical exercises, diet and nutrition guidance and health education. The outcome showed, there was no difference of body weight between before- and after-intervention for most people (93.3%), and proportion of decreased body weight (4.7%) was higher than that of increased weight (2.1%). [121] Further study should focus on the effective intervention measures for overweight and obesity.

2.5 Deﬁ ciency of Physical Activities

Defi ciency of physical activities had been one of the CVDs risk factors and could cause overweight, obesity, hypertension, lipid-disorder and hyperglycaemia to increase the risk of CVDs. With the Socio-economic development and changes, the intensity of physical activities of Chinese residents decreased signifi cantly. The fi nding of National Nutrition and Health Survey (CHNS) of Chinese residents were carried out in 9 provinces in China showed physical activities in 18-55 years old residents were mainly occupational physical activities and household physical activities. [122] There was an increase trend in spare time activities, while a decrease in other pattern of physical activities. Compared with the data of 1997, the amount of physical activities decreased 27.8% in male and 36.9% in female in 2006 [Table 2-5 (1)].

Table 2-5 (1) The Change of Amount of Physical Activities in Chinese Residents (MET-hour/week) Male Female Activities 1991 1997 2006 1991 1997 2006

Occupational 370.6 334.4 241.5 399.7 340.1 217.1 Household 19.1 11.7 5.6 61.3 46.8 25.3 Spare Time 1.4 3.6 0.6 2.3 Commute 2.6 1.9 2.5 1.3 Totally 350.0 252.7 390.0 246.1

Shanghai Physical Activity Study conducted from 2005 to 2008 measured the amount of physical activities with accelerograph for 576 participants aged 40-74. The result [123] indicated that the amount of physical activities decreased with increase of age of participants. There was no signifi cant difference in time of heavy physical activities between genders, however, time of mild physical activities in female was longer than that of in male. Moreover, the amount of physical activity had a negative correlation with the waist-to- hip ratio [Table 2-5 (2)].

47 Report on Cardiovascular Diseases in China (2011)

Table 2-5 (2) The Average of Amount of Physical Activities in (median) in Population with Different Ages, Genders and Waist-to-hip Ratios, (Shanghai Physical Activity Study) Totally Heavy and Moderate Mild Items (Min/Day) (Min/Day) (Min/Day)

Age (Year) 40-49 286 86 242 50-59 267 84 242 ≥60 221 64 215 P value < 0.001 < 0.001 < 0.001

Gender

Male 260 78 227 Female 270 81 244 P value 0.6 0.5 < 0.001

Waist to Hip Ratio

< 0.80 292 86 250 0.80-0.85 261 78 244 ≥0.85-0.90 255 78 232 ≥0.90 256 76 216 P value 0.001 0.004 < 0.001

The fi ndings of baseline data analysis from Guangzhou Biobank Cohort Study, conducted from 2003 to 2008 in 29 000 participants aged ≥50 years old, showed that there was a signifi cant negative correlation between intensity of physical activity and prevalence of diabetes [124] [Table 2-5 (3)].

Table 2-5 (3) Logistic Analysis between Physical Activity Intensity and Diabets Prevalence, (Guangzhou Biobank Cohort Study) Total Physical Activity+ Prevalence OR (95% CI) ‡ Active 30.1 1.00 Sufﬁ cient 36.8 1.16 (1.06-1.27) Deﬁ cient 33.0 1.18 (1.07-1.31)

P value (trends test) 0.001 Notes†: Active, ≥63 MET-hour/week; Suffi cient: 31-62 MET-hour/week; Defi cient:≤ 31 MET-hour/week; ‡: Adjusted the factors of age, gender, occupation, educations, incomes, cigarette, alcohol, BMI and waist-to-hip ratio in analysis.

A cross-sectional study for 9 000 teenagers, aged 11-18, in Hong Kong indicated prevalence of hypertension in teenagers who often do some physical exercise was remarkably lower than that of no- exercise teenagers [125] (Figure 2-5).

48 Chapter 2 Risk Factors of Cardiovascular Diseases

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QRQH ZHHN ZHHN ! ZHHN Figure 2-5 Hypertension Prevalence and Physical Exercise Frequency, Teenagers Study in Hong Kong

One case-control study, [126] conducted during 2007-2008 in Guangdong Foshan, included 374 ischemic stroke in-patients cases and 464 participants in control. The results showed the more common physical activities, including high intensity physical exercise, heavy and moderate physical activities, and total amount physical activities, the lower risk of ischemic stroke[Table 2-5 (4)].

Table 2-5 (4) Logistic Analysis of Ischemic Stroke Incidence Hazard and Totally Physical Exercise

Totally Physical Exercise Cases Control OR (95% CI) * (MET, Hour/Week) n % n % < 10 91 31.9 56 14.6 1.0 10-13 55 19.3 58 15.1 0.44 (0.24-0.81) 14-21 90 31.6 159 41.5 0.35 (0.21-0.59) ≥22 49 17.2 110 28.7 0.25 (0.14-0.45) Trends test for P value < 0.0001

* Adjusted the factors of age, gender, BMI, education, cigarette, amount of smoke per year, alcohol, hypertension, hyperlipemia, diabetes, intakes of meat, fi sh, fowl, fruit and vegetable in analysis.

A total of more than 70 000 women aged 40-70 in Shanghai Women’s Health Study, with 9 years follow- up year in average. The results showed the risk of deaths of cardiovascular diseases decreased following the increase of total amount of physical activities [Table 2-5 (5)]. [127]

Table 2-5 (5) CVDs Death Hazard and Physical Activities (Shanghai Women’s Health Investigation)

Physical Activities (MET, CVDs Death Subjects Hour/Day) n HR (95% CI) * None 46 093 417 1.00

> 0-1.99 17 284 232 0.92 (0.78-1.08) ≥2.00 7 866 126 0.79 (0.65-0.97)

* Note: Adjusted the factors of occupation, education, income, BMI, waist-to-hip ratio, cigarette in spouse, fruit and vegetable intakes in Cox analysis.

49 Report on Cardiovascular Diseases in China (2011)

2.6 Diet and Nutrition

According to National Nutrition and Health Survey of Chinese residents in 2002, there was a huge change in diet structure in Chinese residents, including the amount of grain food intakes, but increased amount of fat intake, and greatly decreased the proportion of carbohydrate for energy content , but increased in that of fat, which had been exceeded the range recommended in the diet guideline. [128] Furthermore, amount of vegetable and fruit intakes in Chinese residents were still low and amount of salt intakes extremely exceeded the recommended standard, that of < 6 g/day (estimated the dietary sodium intake, equal to 15.9 g/day of salt in National Nutrition and Health Survey of Chinese residents in 2002). Recently there were investigations and data indicated that this situation still existed in some area in China. Results from a long term observation (Figure 2-6) [129] in Shanghai Huangpu District showed that the proportion of carbohydrate for energy content decreased from 54.7% to 48.3% from 1992 to 2007, while the proportion of fat for energy content increased from 30.2% to 35.1%. Another study from Beijing [130] indicated the proportion of fat for energy content of resident in 2009 was 32.8%, decreased 2% from that of in 2002. The study also found that although the dietary sodium intake decreased 18%, the daily sodium intake still was as high as 6 280 mg/day (equal to 16.1 g/day of salt). So, to promote resident diet guideline in order to improve the diet structure will be still main measures to prevent cardiovascular diseases.

3URSRUWLRQRI'LHWIRU(QHUJ\˄ &DUERQK\GUDWH )DW 3URWDLQ Figure 2-6 The Changes of the Proportion of Diet for Energy Content of Residents in Shanghai Huangpu District (%) The Lifestyle and Mortality (LIMOR) study was a population based case-control study of 23 608 Chinese deaths aged over 30 in Hong Kong during Dec. 1997 to Jan. 1999, including 81% of all eligible deaths. The survey was conducted for family member of the dead to investigate the lifestyle habits 10 years ago of the case (including diet and nutrition). 12 395 subject were enrolled by the same method to match in age and gender. It found that fi sh intake was associated with a signifi cant benefi cial reduction in all-cause and cardiovas cular mortality from all-cause, all-CVDs in this Hong Kong Chinese population. [131](Table 2-6)

50 Chapter 2 Risk Factors of Cardiovascular Diseases

Table 2-6 OR Values of Deaths in Different Frequency of Fish Intakes (Logistic Analysis, LIMOR) Frequency of Fish Intakes

Outcome ≤3/Month 1-3/Week ≥ 4/Week Trends Test for P Value

OR OR (95% CI) OR (95% CI) Total Death 1.00 0.75 (0.62-0.89) 0.80 (0.68-0.94) < 0.01 Ischemia Heart Diseases 1.00 0.66 (0.48-0.92) 0.63 (0.47-0.85) < 0.01 Stroke 1.00 0.70 (0.50-0.98) 0.82 (0.61-1.11) 0.03 Note: Adjusted the factors of age, gender, occupation style, education, physical activities, cigarette, alcohol, meat, fruit and tea intakes in each model.

Recently, through a salt-control spoon providing for common people, some health promotion activities was held to prevent and control hypertension in many cities in China. The awareness of residents for harmful over-intake salt was signifi cantly enhanced by the using of spoon, according to the small scale assessment indicated,[132] however, the change of intake of salt in Chinese needed to be assessed.

2.7 Metabolic Syndrome 2.7.1 Prevalence of Metabolic Syndrome

A survey on the Status of Nutrition and Health of the Chinese Residents in 2002 showed that the prevalence of metabolic syndrome was 6.6% for Chinese people aged over 18 according to the diagnostic criteria of MS based on Chinese Association of Diabetes (CDS) 2004, and 13.8% if the MS diagnosis was based on the ATPIII criteria of adult hypercholesterolemia of NCEP in USA. Behavior surveillance in Beijing 2005 included 16 442 subjects aged over 18 years. [133] It was showed that the prevalence of MS was 27.9% according to the diagnostic criteria of MS based on International Diabetes federation (IDF), and 19.5% based on the ATPIII criteria of adult hypercholesterolemia of NCEP in USA. A study conducted among 19 003 subjects aged from 18 to 76 in Beijing suburbs showed that the prevalence of MS was 11.6% according to the diagnostic criteria of MS based on Chinese Association of Diabetes (CDS) 2004.[134] Another study [135] among 3 785 subjects aged from 18 to 72 in North-East China suggested that the prevalence was 22.4% according to the diagnostic criteria of MS based on International Diabetes federation (IDF) (Table 2-7-1).

Table 2-7-1 Prevalence of Metabolic Syndrome in Different Regions (%)

Sampling (IDF) (ATPIII) (CDS) Region Age Size Male Female Total Male Female Total Male Female Total

Beijing[136] ≥18 16 442 27.8 28.0 27.9 18.2 20.4 19.5

Beijing Suburbs[137] 18-76 19 003 12.2 11.7 11.6

North-East[138] 18-72 3 785 20.8 23.9 22.4

A total of 1 379 Uygur and 1 123 Kazak individuals aged 30-70 years were recruited from Xinjiang

51 Report on Cardiovascular Diseases in China (2011)

areas. The age-adjusted prevalence of MS was 10.3% and 3.3% respectively based on the ATPIII criteria [139] [Figure 2-7-1 (1)].

㓈਒ᇨᮣUygur ˅ ˅ જ㧼ܟᮣKazak ˄ ˄

3UHYDOHQFH 3UHYDOHQFH ̚30- ̚40- ̚ 50- ̚60- (Age) ᑈ啘˄ቕ˅ Figure 2-7-1 (1) Crude Prevalence of Metabolic Syndrome in Different Age Groups

A total of 1 535 Yi farmers, 1 306 Yi migrants and 2 130 Han people aged over 20 years were recruited from Sichuan province. The prevalence of MS was 2.7%, 29.5% and 18.4% in male and 2.0%, 18.0% and 11.8% in female among the three populations according to the diagnostic criteria of MS based on International Diabetes federation (IDF).[140] The detail was showed in Figure 2-7-1 (2).

MS Prevalence（%) 10

10 MS Prevalence（%) 5 5 0 0 20- 30- 40- 50- (Age) 20- 30- 40- 50- (Age) Male Female

Figure 2-7-1 (2) MS Prevalence by Gender

52 Chapter 2 Risk Factors of Cardiovascular Diseases

2.7.2 Risk Factors of Metabolic Syndrome

The following factors have been reported as being associated with incident of metabolic syndrome: smoking, lack of physical activity, heavy alcohol consumption, high-fat diet, high-salt diet, low birth weight and family history. Smoking and Metabolic Syndrome. Multivariate regression analysis on one study conducted in North-eastern China[141] showed that in comparison with non-smokers, smokers were at increased risk for metabolic syndrome, with an adjusted OR of 1.222 (95% CI, 1.024-1.459). Analysis of data from the Status of Nutrition and Health of the Chinese Residents in 2002 found that among male population aged 18 to 45 years, those reported having smoked > 600 cigarettes/year had higher metabolic syndrome risk than those smoked < 300 cigarettes/year. [142] Compared with individuals smoked < 300 cigarettes/year, the OR for those smoked 60-899 cigarettes/year was 1.433 (95% CI, 1.044-1.993), and 1.765 for those smoked > 900 cigarettes/year (95% CI, 1.050-2.708).

Alcohol and Metabolic Syndrome. Multivariate regression analysis on one study conducted in Sichuan province [143] demonstrated that in comparison with non-drinkers, individuals with alcohol consumption had increased risk for metabolic syndrome (OR 1.36, 95% CI, 1.06-1.75 ). Analysis of data from the Status of Nutrition and Health of the Chinese Residents in 2002[144] found that among male population aged 18 to 45 years, compared with individuals with no alcohol intake, the OR was 1.525 for individuals with alcohol intake 1-2 times/week (95% CI, 1.135-2.048), and 2.322 for individuals with alcohol intake 3-4 times/week (95% CI, 1.671-3.255), and 2.033 for those with alcohol intake > 5 times/week (95% CI, 1.478-2.796).

Diet patterns and Metabolic Syndrome. The results of a cross-sectional survey in Beijing suburb suggested[145] that in comparison with low-salt individuals, those with high-salt diet had increased risk of MS, the adjusted odds ratios of MS for participants with a high intake of salt was 1.48 (95% CI, 1.16- 1.77). In addition, participants who consumed a high-fat diet had higher risk for metabolic syndrome (OR 1.57, 95% CI, 1.20-1.48), whereas vegetarians had lower risk of metabolic syndrome compared with non-vegetarians (OR 0.83, 95% CI, 0.74-0.92).

Physical activity and Metabolic Syndrome. A population-based cross-sectional study in Sichuan province of China[146] indicated that lifestyle had an important infl uence on the development of MS. Compared with those engaged in light-intensity physical activity, individuals engaged in moderate-intensity physical activity (OR 0.58, 95% CI, 0.43-0.80) and those engaged in vigorous physical activity (OR 0.66, 95% CI, 0.40-0.95) had signifi cantly lower risk for metabolic syndrome. A cross-sectional survey in suburban area of Beijing[147] showed that the incident of MS was lower in those with higher physical activity levels than that in those with lower physical activity levels, the adjusted OR was 0.74 (95% CI, 0.62-0.89). Analysis of data from the Status of Nutrition and Health of the Chinese Residents in 2002[148] found that compared with those engaged in 90-150 min/week of physical activity, those engaged in 301-420 min/week of physical activity had a lower risk of metabolic syndrome (OR = 0.844, 95% CI, 0.675-0.968).

53 Report on Cardiovascular Diseases in China (2011)

Low Birth Weight and Metabolic Syndrome. An urban Chinese cohort study[149] presented that in comparison with those with birth weights of 3 000 to 3 500g, the risk of adult MS increased 66% for those with low birth weights of < 2 500 g (95% CI, 1.18-2.34), whereas the risk increased 33% for those with birth weights between 2 500 and 3 000g (95% CI, 1.09-1.63).

Family History and Metabolic Syndrome. In a population-based cross-sectional study in Sichuan province of China,[150] individuals with a family history of hypertension or DM had higher metabolic syndrome risk than those without family history (OR 1.46, 95% CI, 1.15-1.87). Data from the Status of Nutrition and Health of the Chinese Residents in 2002[151] revealed that both diabetes and hypertension family history increased the risk of MS, the OR was 1.859 (95% CI, 1.519-2.276) and 1.462 (95% CI, 1.295-1.650), respectively.

2.7.3 Metabolic Syndrome and Chronic Kidney Disease

The relationship between metabolic syndrome and chronic kidney disease was analyzed in 3 465 participants with CAD from the China Heart Survey. [152] The result suggested that patients with metabolic syndrome had a higher prevalence of CKD than those without metabolic syndrome. The multivariate- adjusted odds ratio (OR) of CKD was 1.27 (95% CI, 1.07-1.51).

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[59] Same as [49] [60] Same as [49] [61] Same as[47] [62] Same as [48] [63] Same as [49] [64[Same as [47] [65] Same as [49] [66] Jiang H, Dongfeng G, Xigui W, et al. Major causes of death among men and women in China. N Eng J Med 2005;353: 1124-1134. [67] Gu D, Kelly TN, Wu X, etc. Mortality attributable to smoking in China. N Engl J Med. 2009 Jan 8, 360 (2): 150-159. [68] Wang W, Zhao D, Sun JY, et al. Risk factors comparison in Chinese patients developing acute coronary syndrome, ischemic or hemorrhagic stroke: a multi-provincial cohort study. Zhonghua Xin Xue Guan Bing Za Zhi. 2006, 34 (12): 1133-1137. [69] Beifan ZHOU. An prospective study on characteristics of risk factors for cardiovarscular diseases in Chinese population. Zhonghua Xin Xue Guan Bing Za Zhi. 2005, 26 (1): 58-61. [70] Kelly TN, Gu D, Chen J, etc. Cigarette smoking and risk of stroke in the Chinese adult population. Stroke. 2008;39 (6): 1688-93. [71] Cao M, Ke K, Zhou R, et al. Analysis of carotic plaque and correlative factors in patients with cerebral infarction. Chinese Journal of Geriatria Heart Brain and Vessel Disease, 2011 (31): 62-64. [72] Xu W, Shu X, Xiang Y, et al.Association of cigarette smoking with obesity among middle-aged and elderly Chinese men. Chinese Journa of Preventive Medicine, 2008. (42) supplement: 110-117. [73] Peter H Whincup, Julie A Gilg, Jonathan R Emberson, et al. Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement. BMJ 2004, 329: 200-205. [74] Hong Xia. Epidemiology and risk factors of stroke. Chinese Journal of Stroke, 2006 (8): 559-563. [75] Li L, Chen Q, Jia R, et al. The Smoking pattern and disease burden of tobacco use in China. Chinese Health Economic, 2008, 27. 299 (1): 26-30. [76] Tao SC, Li YH, Xiao ZK et al. Serum lipids and their correlates in Chinese urban and rural populations of Beijing and Guangzhou. Inter J Epidemiol, 1992, 21 (5): 893-903. [77] The WHO MONICA Project. Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years. World Health Statistics, 1988, 41 (3/4): 115-140. [78] Wu Z, Yao C, Zhao D, et al. Multiprovincial monitoring of trends and determinants in cardiovascular diseases (Sino- Monica project), Result of risk factor monitoring. Chinese Journal of Cardiology, 1997, 25 (4): 255-259. [79] Zhou B.et al. Ecological Analysis of the association between incidence and risk factors of coronary heart disease and stroke in Chinese populations..CVDs Prevention, 1998, 1 (3): 207-216. [80] The Collaborative study group on trends of cardiovascular diseases in China and preventive strategy. Current status of major cardiovascular risk in Chinese populations and their trends in the past two decades. Chinese Journal of Cardiology, 2001, 29 (2): 74-79. [81] He J, Gu D, Reynolds K et al. Serum total and lipoprotein cholesterol levels and awareness, treatment, and control of hypercholesterolemia in China. Circulation 2004 July 27, 110 (4): 405-411. [82] Same as [79] [83] Same as [80] [84] Zhao W; Zhang J; You Y et al. Epidemiologic characteristics of dyslipidemia in people aged 18 years and over in China. Chinese Journal of Preventive Medicine 2005, 39 (5) 306-310. [85] Wu JY, Duan XY, Li L, et al. Dyslipidemia in Shanghai, China. Prev Med, 2010, 51 (5): 412-415.

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[86] Ouyang X, Lou Q, Gu L, et al. Cardiovascular disease risk factors are highly prevalent in the offi ce-working population of Nanjing. Int J Cardiol, 2010.[Epub ahead of print] [87] Wang S, Xu L, Jonas JB, et al. Prevalence and associated factors of dyslipidemia in the adult Chinese population. PLoS One, 2011, 6 (3): e17326. [88] Zhang L, Qin LQ, Cui HY, et al. Prevalence of cardiovascular risk factors clustering among suburban residents in Beijing. Int J Cardiol, 2011, 151 (1): 46-49. [89] Same as [85] [90] Same as [86] [91] Same as [87] [92] Same as [88] [93] Zhao WH, Zhang J, Li Y. Report on national nutrition and heath survey of China residents in 2002, Part.7: Blood Lipids. People’s Health Publishing House, 2008.7. [94] Li J, Niu Q, Li P, et al. Serum lipid and lipoprotein levels from birth to maturity. Beijing Medical Journal, 1987, 9 (6): 346-349. [95] Ma W, Xu Y, Fu C, et al. A Cross Sectional survey on serum lipid level and its infl uencing factors in 6188 Children aged 3-14 years in Guangdong province. Chinese Journal of Cardiology, 2005, 33 (10): 950-955. [96] Liu Y, Mi J, Du J, et al. A survey on dyslipidemia of 6-18 Years Old Children in Beijing. Chinese Journal of Practical Pediatrics, 2007, 22 (2): 101-102. [97] Yan H, Mi J, Liu Y et al. The effect of Family history and BMI on screening of dyslipidemia in children. Journal of Peking University (Health Scineces), 2007; 39 (6): 591-594 [98] Same as [93] [99] Same as [94] [100] Same as [95] [101] Wu YF, Zhao D, Zhou BF, et al. Cut offs and risk stratifi cation of dyslipidemia in Chinese adults. Chin J Cardiol, 2007, 35 (5): 428-433. [102] Li Y, Chen ZH, Zhou BF et al. The predictive effects of lipids and lipoproteins on the incidence of ischemic cardiovascular disease in middle aged Chinese population. Chin J Cardiol, 2004, 32 (7): 643-647. [103] Zhou BF organized the manuscript. The prospective studies on the effects of cardiovascular disease risk factors in Chinese populations. Chin J Epidemiol, 2005, 26 (1): 58-61. [104] Yue H, Gu DF, Wu XG et al. A 20 year prospective study on risk factors for myocardial infarction of 5 137 men in Capital Steel and Iron Company. Chin J Prev Med, 2004, 38 (1): 43-46. [105] Li JZ, Chen ML, Wang Set al.Long term prospective study on lipids and coronary heart disease in elderly people. Chin J Cardiol, 2002, 30 (11): 647-650. [106] Same as [101] [107] Wang W, Zhao D, Sun JY. Risk factors comparison in Chinese patients developing acute coronary syndrome, ischemic or hemorrhagic stroke: a multi-provincial cohort stuay. Chin J Cardiol, 2006, 34 (12): 1133-1137. [108] Same as [105] [109] Same as [102] [110 Ren J, Zhao D, Liu J et al. Relationship between serum non-high-density lipoprotein cholesterol and incidence of cardiovascular disease. Chin J Cardiol, 2010, 38(10): 934-938. [111] Li Y, Chen ZH, Zhou BF, etal.Serum TC/HDL-C ratio and the risk of ischemic and hemorrhagic stroke incidence in middle aged Chinese population.Chin J Neurol, 2005, 38 (5): 305-308. [112] Same as [81] [113] Same as [84]

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[114] Same as [87] [115] The current status in cinical control of hypercholesterolemia in China collaborative research group. A multi-center study on current status of clinical control of hypercholesterolemia in China: success rate and related factors. Chin J Cardiol, 2002, 30 (2): 109-104. [116] The Collaborative research group for the second multi-center survey of clinical management of dyslipidemia in China. The second multi-center survey of dyslipidemia management in China: goal attainment rate and related factors. Chinese J Cardiol, 2007, 35 (5): 420-427. [117] Hu D, Li J, Li X for CCEP. Investigation of blood lipid levels and Statin Interventions in outpatients with coronary heart disease in China—The China Cholesterol Education Program (CCEP). Circ J 2008, 72: 2040-2045. [118] Bi YF, Gao RL, Patel A et al. Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization: results from the clinical pathways for acute coronary syndromes in China (CPACS) study. Am Heart J 2009, 157: 509-516. [119] Ma G, Li Y, Wu Y, et al. The prevalence of body overweight and obesity and its changes among Chinese people during 1992 to 2002. 2005;39 (5): 311-315. [120] Du SM, Ma GS, Li YP, et al. Relationship of body mass index, waist circumference and cardiovascular risk factors in Chinese adult. Biomed Environ Sci. 2010;23 (2): 92-101. [121] Yang Z, Wang H, Feng Y, et al. Effect of body weight management on community residents with over-weight or obesity. Chinese Journal of Health Management. 2010;4 (3): 149-152. [122] Ng S, Norton E, Popkin B. Why have physical activity levels declined among Chinese adults? Findings from the 1991-2006 China health and nutrition surveys, Social Science & Medicine. 2009, 68 (7): 1305-1314. [123] Peters TM, Moore SC, Xiang YB, et al. Accelerometer-Measured Physical Activity in Chinese Adults. Am J Prev Med. 2010, 38 (6): 583-591. [124] Qin L, Corpeleijn E, Jiang C, et al. Physical Activity, Adiposity, and Diabetes Risk in Middle-Aged and Older Chinese Population -The Guangzhou Biobank Cohort Study. Diabetes Care. 2010, 33 (11): 2342-2348. [125] So HK, Sung RYT, Li AM, et al. Higher exercise frequency associated with lower blood pressure in Hong Kong adolescents: a population-based study. J Hum Hypertens. 2010, 24: 646-651. [126] Liang W, Lee A, Binns C, et al. Habitual Physical Activity Reduces the Risk of Ischemic Stroke: A Case-Control Study in Southern China. Cerebrovasc Dis. 2009, 28: 454-459. [127] Nechuta SJ, Shu XO, Li HL, et al. Combined impact of lifestyle-related factors on total and cause-specifi c mortality among Chinese women: prospective cohort study. PLoS Med. 2010, 7 (9): e1000339. [128] Zhai FY,Yang XG. China Health and Nutrition Survey 2002-Report. Ⅱ .Diet and intake of nutrients. Beijing: People' s Medical Publishing House,2006.(in Chinese) [129] Ma L, Xu J, Zhou W, et al. A Study on Nutritional Status and Trend of Residents in Huangpu District of Shanghai between 1992 and 2007. Journal of Environmental & Occupational Medicine, 2010;27 (11): 664-666. [130] Zhao Y, Sha Y, Yu Y, et al. A preliminary study on nutritional status of Beijing residents in 2009 and its changing trend. Chinese Journal of Public Health, 2010;26 (12): 1596-1596. [131] Wang MP, Thomas GN, Ho SY, et al. Fish consumption and mortality in Hong Kong Chinese-the LIMOR study. Ann Epidemiol, 2011;21 (3): 164-169. [132] Mei K, Yu M, Wang J. Effect assessment of salt intake reduction intervention among residents in Baoshan District, Shanghai, Chinese Journal of Health Education. 2010;26 (9): 655-657. [133] Li G, Maximilian de Courten, Jiao SF, et al. Prevalence and characteristics of the metabolic syndrome among adult in Beijing, China. Asia Pac Clin Nutr, 2010, 19: 98-102. [134] Zhang L, Qin LQ, Liu AP, et al. Prevalence of risk factors for Cardiovascular Disease and their associations with diet and physical activity in suburban Beijing, China. J Epidemiol 2010, 20: 237-243.

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[135] Wand W, Kong J, Sun J, et al. Epidemiological investigation of metabolic syndrome and analysis of relevant factors in north-eastern China. J of International Medical Research, 2010, 38: 150-159. [136] Same as [133] [137] Same as [134] [138] Same as [135] [139] Wang LF, Tao YC, Xie ZJ, et al. Prevalence of metabolic syndrome, insulin resistance, impaired fasting blood glucose and dyslipidemia in uygur and kazak populations. The Journal of Clinical Hypertension, 2010, 12: 741- 745. [140] Wang CX, Wei DY, Wang B, et al. Effect of lifestyle on the prevalence of the metabolic syndrome among farmers, migrants with Yi ethnicity and the Han population in Sichuan province of China. Asia Pac J Nutr, 2010, 19: 266-273. [141] Same as [135] [142] Zuo H, Yao C, Hu Y, et al. Relationship between duration of low to moderate intensity physical activity and the prevalence of metabolic syndrome. Chin J Prev Med, 2010, 44: 908-912. [143] Same as [140] [144] Same as [142] [145] Same as [134] [146] Same as [140] [147] Same as [134] [148] Zuo H, Yao C, Hu Y, et al. Relations between smoking, alcohol intake, physical activity, sleeping hours and the metabolic syndrome in Chinese male aged 18-45 years old. Chin J Epidemiol, 2011, 32: 235-238. [149] Xiao XH, Zhang Z, Li WH, et al. Low birth weight is associated with components of the metabolic syndrome. Metabolism clinical and experimental, 2010, 59: 1282-1286. [150] Same as [140] [151] Same a s[148] [152] Liu H, Yu JM, Chen F, et al. Does obesity attenuate the effect of metabolic syndrome on chronic kinney disease in patients with coronary artery disease? Report from China heart survey. Circulation Journal, 74: 462-467.

60 Chapter 3 Prevention and Control of Cardiovascular Disease

Chapter 3 Prevention and Control of Cardiovascular Disease

3.1 Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris 3.1.1 Epidemiological Studies of Coronary Heart Disease 3.1.1.1 Mortality and Epidemic Trend of Coronary Heart Disease in Chinese Population [1]

(1) Crude Death Rate of CHD in 2009 According to the data from Health Statistic Yearbook of Ministry of Health of China in 2009, the crude CHD death rate was 94.96/100 000 in urban residents and 71.27/100 000 in rural residents, higher than that in 2008 (urban 91.41/100 000; rural 51.89/100 000). Generally, the crude CHD death rate was higher in urban areas than in rural areas, and higher in men than in women [Figure 3-1-1 (1) , Table 3-1-1 (1)].

ϛ1/100 000 Men⬋ᗻ Womenཇᗻ Totalড়䅵

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Crude CHD Death Rate

ජᏖUrban Ruralݰᴥ

Figure 3-1-1 (1). Urban–rural Comparison of Crude CHD Death Rate between Men and Women.

61 Report on Cardiovascular Diseases in China (2011)

Table 3-1-1(1) Crude CAD Dath Rate in 2009 (1/100 000) Urban Big Cities Small- or Middle-city Rural Subtotal Men Women Subtotal Men Women Subtotal Men Women Subtotal Men Women

AMI 43.14 47.79 38.37 48.03 53.07 42.91 25.57 29.10 21.89 44.95 49.43 40.33

Other CHDs 51.82 50.02 53.67 56.71 54.30 59.17 34.27 34.83 33.69 26.32 26.34 26.29

Total 94.96 97.81 92.04 104.74 107.37 102.08 59.84 63.93 55.58 71.27 75.77 66.62 AMI: Acute myocardial Infarction; CHD: Coronary Heart Disease.

(2) Age-specifi c CHD Death Rate in Urban Population in 2009 (1/100 000) The mortality of CHD in urban areas increased with age. It was higher for men than for women in < 80 years groups and higher for women than for men in > 80 years groups. A similar indexation of the mortality to age was presented in the trend of increase[Figure 3-1-1 (2), Table 3-1-1 (2)].

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Figure 3-1-1 (2) Comparison of Age-speciﬁ c Death Rates of Acute Myocardial Infarction and Coronary Heart Disease among Individuals between Men and Women in Urban Areas Table 3-1-1 (2) Age-specifi c Death Rates of CHD in Urban Population of China in 2009 (1/100 000)

Sex Events 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85-

AMI 1.07 1.62 2.70 7.05 14.50 21.44 32.92 49.46 76.08 126.69 221.07 389.20 667.72 1 252.04 Other Types Men 0.30 0.49 0.88 1.99 4.57 11.13 19.89 30.33 54.85 100.26 221.58 467.51 918.28 2 029.65 of CHD Total 1.37 2.11 3.58 9.04 19.07 32.57 52.81 79.79 130.92 226.95 442.65 856.71 1 585.99 3 281.69

AMI 0.29 0.52 1.39 1.94 3.91 5.35 9.54 18.30 36.73 81.78 160.67 282.34 521.55 1 067.43 Other Types Women 0.16 0.18 0.17 0.68 1.70 2.85 5.99 11.99 26.81 64.82 179.10 385.84 838.96 2 106.08 of CHD Total 0.45 0.71 1.56 2.62 5.60 8.20 15.53 30.29 63.54 146.60 339.77 668.18 1 360.51 3 173.51 CHD: Coronary Heart Disease.

62 Chapter 3 Prevention and Control of Cardiovascular Disease

(3) Age Specifi c Death Rates of CHD in Chinese Rural Population in 2009 (1/100 000) Age-specifi c death rates in rural areas presented a similar index relation to age [Figure 3-1-1 (3)], but generally remained a lower level compared with those in urban areas [Table 3-1- (3)].

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Figure 3-1-1 (3) Comparison of Age-speciﬁ c Death Rates of Acute Myocardial Infarction and Coronary Heart Disease among Individuals between Men and Women in Rural Areas

Table 3-1-1(3) Age-specifi c Death Rates of CHD in Rural Population of China in 2009 (1/100 000)

Sex Events 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85-

AMI 1.53 1.93 3.15 8.23 18.45 20.40 36.73 61.87 99.08 149.38 277.06 502.22 1 018.09 2 389.50 Other Types of Men 0.48 0.41 0.42 1.88 2.82 4.65 11.80 21.65 41.03 70.28 166.81 313.58 681.55 1 562.94 CHD Total 2.01 2.34 3.57 10.11 21.27 25.05 48.54 83.52 140.11 219.66 443.87 815.80 1 699.64 3 952.44

AMI 1.07 1.27 1.42 2.52 6.08 8.90 15.44 30.14 56.88 87.28 169.99 327.91 699.06 1 791.62 Other Types of Women 0.16 0.28 0.37 0.76 1.88 1.92 7.35 11.52 26.88 43.55 114.25 220.18 503.26 1 363.90 CHD Total 1.23 1.55 1.79 3.28 7.96 10.81 22.79 41.66 83.76 130.83 284.25 548.09 1 202.32 3 155.52

(4) Trend of Crude CHD Mortality in 2002-2009 A steady increase in CHD mortality for the Chinese population has been observed in both urban and rural areas during 2002-2009. Generally, the crude CHD mortality in urban areas was higher than that in rural areas. However, rural areas had a higher increase of CHD mortality than did urban areas [Figure 3-1-1 (4) ]. Of note, individuals in rural areas suffered a higher increase of crude mortality of AMI than their counter- parts in urban areas since 2005. In 2009, AMI mortality rate of rural residents surpass urban residents [Figure 3-1-1 (5) ].

63 Report on Cardiovascular Diseases in China (2011)

Cities Big Cities Middle and Small Cities Rural &UXGH'HDWK5DWH

Figure 3-1-1 (4) Trend of Crude CHD Mortality among Urban and Rural Residents during 2002-2009

Cities Big Cities Middle and Small Cities Rural

&UXGH'HDWK5DWH

Figure 3-1-1 (5) Trend of Crude AMI Mortality among Urban and Rural Residents during 2002-2009

64 Chapter 3 Prevention and Control of Cardiovascular Disease

3.1.1.2 Prevalence of Coronary Heart Diseases[2]

The fourth national survey on healthcare service in China in 2008 showed that the prevalence of CHD was 7.7 per 1 000 residences in total, 15.9 per 1 000 residences in urban, 4.8 per 1 000 residences in rural, which was higher than the fi ndings in third national survey on healthcare service in China in 2003 (4.6 per 1 000 residences in total, 12.4 per 1 000 residences in urban, 2.0 per 1 000 residences in rural).

3.1.1.3 Risk Factors Associated with Coronary Heart Diseases

(1) Relationship between Birth Size and Coronary Heart Disease in China[3] Peking Union Medical College Hospital investigated a total of 2 033 subjects who were born between 1921 and 1954 and examine the association between various birth characteristics and CHD occurrence. All participants were followed up between May 2002 and April 2004 for the occurrence of CHD. As a result, CHD was identifi ed in 135 patients. The occurrence of CHD was inversely related to birth sizes, such as birth-weight, head circumference, placental weight, but was not signifi cantly related to birth length or ponderal index (birth-weight head circumference). After multivariable logistic regression, the ratio of birth-weight to birth length was an independent predictor of CHD along with two other variables: obesity and age.

(2) The Effect of Total Cholesterol on Myocardial Infarction in Chinese Male Hypertension Population[4] A cohort of 5 298 male employees aged 18-74 years recruited from Capital Steel and Iron Company in Beijing of China in 1974-1980 was followed up for an average of 20.84 years. A total of 122 incident MI cases were identifi ed during the period of follow-up. The incidence of MI among participants with elevated TC and those with desirable TC in male non-hypertension population was 137.20 and 63.81 per 100 000 person-years, respectively; and the corresponding incidence in male hypertension population was 279.80 and 130.96 per 100 000 person-years, respectively. After adjustment for important covariables, 10.38%, 16.71%, and 23.80% of MI cases were attributable to hypertension, elevated TC, and hypertension plus elevated TC, respectively. In male hypertension population, the multivariate adjusted hazard ratios of MI were 1.21, 2.39, 3.38, and 3.95 for participants with TC level of 5.17-5.68, 5.69-6.20, 6.21-6.71, and ≥6.72 mmol/L, compared with those with TC < 5.17 mmol/L. The corresponding population attributable risks were 2.92%, 9.20%, 8.87%, and 9.84%, respectively. Elevated TC is an important independent risk factor of MI both in male non-hypertension and hypertension populations. There is a linear association between TC level and MI incidence in Chinese male hypertension population.

(3) Heart Rate Infl uence on Incidence of Cardiovascular Disease among Adult in China[5] A prospective study was conducted for 169 871 Chinese adults≥40 years in 1991 and followed during 1999-2000 with a response rate of 93.4%. Hazard ratios (HRs) were estimated by Cox proportional hazard regression model. CVDs was defi ned as diagnosis of acute myocardial infarction or stroke or death due to CVDs (International Classifi cation of Diseases, Ninth Revision: 390.0-398.9, 401.0-429.9 and 430.0- 438.9). After an average of 8.3 years' follow-up (836 811 person-years), 6 837 participants (3 932 men, 2 905 women) developed CVDs. Compared with the participants with heart rate 60-74 beats per minute

65 Report on Cardiovascular Diseases in China (2011)

(bpm), heart rate 75-89 and≥90 bpm in men increased the risk of CVDs after multivariate adjustment, with corresponding HRs [95% confi dence intervals (CIs)] 1.12 (1.04-1.20) and 1.32 (1.18-1.47). Heart rate≥90 bpm increased women's risk of CVDs with HR (95% CI,) 1.23 (1.09-1.38). Heart rate≥75 bpm in men increased the risk of heart disease. Heart rate≥90 bpm increased the risks of coronary heart disease (CHD) and stroke in men, and the risks of heart disease and CHD in women. Elevated heart rate was associated with high CVDs incidence in Chinese adults. This suggests that higher heart rate might be a risk marker for CVDs in Chinese adults.

3.1.2 Coronary Artery Intervention 3.1.2.1 Effi cacy and Safety of Firebird Sirolimus-eluting Stent in Treatment of Complex Coronary Lesions in Chinese Patients: One-year Clinical and Eight-month Angiographic Outcomes from the FIREMAN Registry.

The FIREMAN registry was a prospective multi-center registry, which included 1 029 consecutive patients undergoing PCI with Firebird SES implantation between September 2006 and July 2007 in 45 centers in China. The clinical follow-up was designed to be performed at 1, 6, 12, 18, 24, 30 and 36 months post index procedure, and non-mandatory angiographic follow-up at 8 months was planned. One hundred percent site monitoring was conducted. Long lesions (59.2%), multi-vessel disease (50.4%), and small vessel disease (31.6%) were mostly found in angiography. Major adverse cardiac events (MACE) occurred in 51 (5.1%) patients at 1 year clinical follow-up, including cardiac mortality in 6 (0.6%), non-fatal myocardial infarction in 11 (1.1%), and target lesion revascularization in 36 (3.5%) of the patients. Defi nite and probable stent thrombosis (ST) by Academic Research Consortium (ARC) defi nition occurred in 12 (1.36%) patients at one-year clinical follow-up [Table 3-1-2 (1) ]. The 8-month binary restenosis rate was 5.7% in-segment and 4.3% in-stent, respectively. Late lumen loss was (0.21 ± 0.40) mm in-segment and (0.23 ± 0.36) mm in- stent, respectively [Table 3-1-2 (2)]. Table 3-1-2 (1) Major Adverse Cardiac Events in 1-year Follow-up [n( %) ] Events 12 Months (n=1 021) Major Adverse Cardiac Events 52 (5.1) Cardiac Death 6 (0.6) Non-fatal Myocardial Infarction 11 (1.1) Target Lesion Revascularization 36 (3.5) Stent Thrombosis 12 (1.36) All Cause Death 20 (2.0) Table 3-1-2 (2) QCA Results of 8-month Angiographic Follow-up (n=517) Variables In-segment In-stent Late Lumen Loss (mm) 0.21±0.40 0.23±0.36 Restenosis [% (n)] 5.7 (50) 4.3 (38) Cox regression analysis revealed that diabetes, small vessel diameter, and chronic total occlusion were independent predictors of ST.

66 Chapter 3 Prevention and Control of Cardiovascular Disease

The results showed that the Firebird SES was effective and safe in treating Chinese patients with complex coronary lesions and occurrence of ST rate at one-year clinical follow-up was acceptable, however further long-term follow-up was still necessary. [6]

3.1.2.2 Six-month Clinical Outcomes of Firebird 2TM Sirolimus-eluting Stent Implantation in Real- world Patients with Coronary Artery Diseases

The FOCUS registry is a prospective, non-randomized, international multi-center, single-arm clinical registry. Between March 2009 and February 2010, 5 084 patients receiving at least 1 Firebird 2 stent during daily clinical practice at 83 medical centers were enrolled. Of the 5 084 patients enrolled in the registry, 5 077 and 5 058 were respectively available for 30 days and 6 months follow-up. The 30-day rate of major adverse cardiac events (MACE) was 1.20%, including 13 cardiac deaths, 46 non-fatal MI, and 6 target vessel revascularization (TVR). At 6 months follow-up, the rate of MACE was 1.80%. There were 32 cardiac deaths, 48 non-fatal MI, and 15 TVR. According to the Academic Research Consortium defi nition, defi nite/ probable stent thrombosis (ST) occurred in 0.43% (22/5 058) of patients, including 8 cases of acute ST, 11 subacute ST, and 3 late ST.

Table 3-1-2 (3) Clinical Outcomes In-hospital, At 30 Days and at 6 Months Follow-up of Patients

In-hospital 30-day Follow-up 6-month Follow-up Outcomes (n,%) (n=5 084) (n=5 077) (n=5 058)

Major Adverse Cardiac Events 52(1.02) 61(1.20) 91(1.80)

Cardiac Death 5(0.10) 13(0.37) 32(0.63)

Non-fatal Myocardial Infarction 46(0.91) 46(0.91) 48(0.95)

Targe Vessel Revascularization 5(0.10) 6(0.12) 15(0.30)

Stent Thrombosis 16(0.31) 19(0.37) 22(0.43)

The Firebird 2 stent showed the promising effi cacy and safety at 30 days and 6 months in a real-world population of patients with coronary artery diseases. [7]

3.1.2.3 A prospective Multicenter Parallel-controlled Trial of TIVOLI Biodegradable-polymer-based Sirolimus-eluting Stent Compared to ENDEAVOR Zotarolimus-eluting Stent for the Treatment of Coronary Artery Disease: 8-month Angiographic and 2-year Clinical Follow-up Results.

A prospective, multicenter clinical trial comparing TIVOLI biodegradable coated sirolimus-eluting stent with ENDEAVOR zotarolimus-eluting stent was conducted in 324 patients (TIVOLI group: 168 patients; ENDEAVOR group: 156 patients) at 12 centers in China to demonstrate the non-inferiority of in-stent late loss with TIVOLI stent compared to ENDEAVOR stent in subjects with a maximum of two de novo native coronary artery lesions. Angiographic late lumen loss at 8 months in the TIVOLI group was superior to the ENDEAVOR group [in-stent (0.25 ± 0.33) mm vs. (0.57 ± 0.55) mm, 95% CI -0.23 (-0.32, -0.14), P

67 Report on Cardiovascular Diseases in China (2011)

< 0.0001; in-segment (0.25 ± 0.33) mm vs. (0.42 ± 0.55) mm, 95% CI -0.13 (-0.23, -0.02), P = 0.0083] showed in Table 3-1-2-3 (1).The rate of in-stent binary restenosis at 8 months was reduced from 8.6% in the ENDEAVOR group to 2.9% in the TIVOLI group (P=0.0229). Compared to ENDEAVOR stent, TIVOLI stent resulted in a signifi cant reduction in target-lesion revascularization (4.2% vs. 9.6%, P = 0.0495) at 2 years. The two-year major adverse cardiac events (MACE) rate was lower for the TIVOLI group, but not signifi cantly different (6.6% vs. 10.9%, P = 0.1630) showed in Table 3-1-2-3 (2) .

Table 3-1-2 (4) 8-Month Angiographic Follow-up Results

Variables TIVOLI (n=175) ENDEAVOR (n=128) P value RVD (mm) 3.09 ±0.43 3.20 ±0.44 0.0361 DS (%) In-stent 21.14 ±10.38 29.33 ±16.38 <0.0001 In-segment 30.13 ±11.37 36.70 ±16.26 0.0001 LL (mm) In-stent 0.25 ±0.33 0.57 ±0.55 <0.0001 In-segment 0.25 ±0.33 0.42 ± 0.55 0.0083 Re-stenosis (%) In-stent 2.9 8.6 0.0229 In-segment 5.7 11.7 0.0594

RVD: refenrence vessel diamenter; DS: diameter stenosis; MLD: minimal lumen diameter; LL: late loss

Table 3-1-2 (5) 2-Year Clinical Follow-up Results [n (%)]

Variables TIVOLI ENDEAVOR P value

(n=168) (n=156)

Major Adverse Cardiac Events 11(6.6) 17(10.9) 0.1630

Death 1(0.6) 0(0) 1.0000

Myocardial Infaction 4(2.4) 2(1.3) 0.6859

Target Vessel Revascularization 7(4.2) 15(9.6) 0.0495 In conclusion, TIVOLI was superior to ENDEAVOR stent with respect to late lumen loss at 8 months, and it yielded both lower rates of angiographic binary restenosis at 8 months and target lesion revascularization (TLR) at 2 years. The MACE rate at 2 years was comparable in both groups.[8]

3.1.2.4 Clinical Outcomes and Cost-utility after Sirolimus-eluting Versus Bare Metal Stent Implantation

In a prospective, nonrandomized, multi-center registry study, 1 241 patients undergoing percutaneous coronary revascularization (PCI) with either SES (n=632) or BMS (n=609) were enrolled continuously. Follow-up was completed in 1 205 (97.1%) patients at 12 months. Rates of MI, all causes of death were similar between the two groups. Signifi cant differences were found at rate of cardiovascular re-hospitalization

68 Chapter 3 Prevention and Control of Cardiovascular Disease

[136 (22.4%) in BMS group vs. 68 (10.8%) in SES group, P = 0.001] and recurrent angina (149 (24.5%) vs. 71 (11.3%), P = 0.001) showed in Table 3-1-2 (6). Dramatic difference was observed when compared the baseline and 9-month HRQOL scores intra- group (P < 0.001). However no signifi cant difference was found inter-group either in baseline or follow-up HRQOL. Compared with SES, the total cost in BMS was signifi cantly lower on discharge (62 546.0 vs. 78 245.0 Yuan, P=0.001). And follow-up expenditure was remarkably higher in the BMS group than that in the SES group [(13 412.0 vs. 8 812.0 Yuan, P = 0.0001). Table 3-1-2 (7)].

Table 3-1-2 (6) Incidences of Death, Myocardial Infarction, Stent Shrombosis and Cardiac Rehospitalization after 365 Days of Follow-up

Endpoints BMS SES P Value

(n=609) (n=632)

Death 7(1.15) 6(0.95) 0.07

Cardiac Death 10(3.12) 20(3.16) 0.183

Angiographic Conﬁ rmed Stent Thrombosis 3(0.48) 5(0.79) 0.09

Cardiovascular Rehospitalization 136(22.4) 68(10.76) 0.001

Recurrent Angina 149(24.5) 71(11.3) 0.001

Table 3-1-2 (7) Discharge and Follow-up Cumulative Cost in Two Groups

Variables BMS SES P Value

Total Hospital Cost (Yuan, Median) 62 546 78 245 0.001

Total Follow-up Cost 13 412 8 812 0.000

There were no signifi cant differences on death, in-stent thrombosis, MI irrespective of stent type. SES was superior to BMS on improvement of life quality. SES was with higher cost-utility compared to BMS. [9]

3.1.2.5 Use of Tailored Loading-dose Clopidogrel in Patients Undergoing Selected Percutaneous Coronary Intervention (PCI) Based on Adenosine Diphosphate-mediated Platelet Aggregation

A total of 205 patients with acute coronary syndrome and stable angina pectoris coming from 11 clinical research centers of Beijing undergoing selected percutaneous coronary intervention were enrolled in this multicenter, prospective, randomized study. Patients receiving domestic clopidogrel (n=104) served as the Talcom (Taijia) group; others (n=101) received Plavix, the Plavix group. Patients received up to 3 additional 300 mg loading doses of clopidogrel to decrease the adenosine phosphate-mediated platelet aggregation index by more than 50% (the primary endpoint) compared with the baseline. The secondary endpoint was major adverse cardiovascular events at 12 months.The ADP-mediated platelet aggregation rate decreased both 2 hours and 3 days post-treatment, showing that both the Talcom and Plavix groups had obvious inhibitions on the ADP-mediated platelet aggregation rate [Table 3-1-2 (8)]. There was no signifi cant difference in the eligible index between the Talcom and Plavix groups (47% vs.

69 Report on Cardiovascular Diseases in China (2011)

49% at 300 mg; 62% vs. 59% at 600 mg; 74% vs. 72% at 900 mg; P > 0.05) based on a standard adenosine diphosphate-mediated platelet aggregation decrease of > 50%. even when the cumulative loading doses of clopidogrel reached 900 mg, there were still nearly 27% of patients with poor responses [Table 3-1-2 (9)].

Table 3-1-2 (8) Platelet Aggregation and Aggregation Inhibition Rates at Baseline, 2 Hours, and 3 Days Post-administration

Variables Talcum Plavix P Value

Baseline of Platelet Aggregation Rate (%) 42.85±12.76 39.36±15.28 0.0780

2-hour Baseline of Platelet Aggregation Rate (%) 32.35±11.45 28.55±11.87

2-hour Baseline of Platelet Aggregation ate Difference (%) 10.50±11.35 10.49±12.75 0.9952

3-day Platelet Aggregation Rate (%) 24.30±10.56 24.88±9.37

3-day Platelet Aggregation Rate Difference (%) 18.46±14.49 16.29±14.73 0.0605

Table 3-1-2 (9) The Standard-reaching Rate of Platelet Aggregation Decrease Using Different Loading dose of Clopidogrel and Talcom

Group 300mg 600mg 900mg

Talcom 47 62 74

Plavix 49 59 72

P value >0.05 >0.05 >0.05

After 12 months of follow-up, there were no signifi cant differences in major adverse cardiac events (2.5% vs. 2.9%, P=5.43). No acute or subacute stent thrombosis events occurred.

In conclusion, an adjusted loading dose of clopidogrel could have signifi cant effects on antiplatelet aggregation compared with a rational dose, decreasing 1-year major adverse cardiac events in patients undergoing percutaneous coronary interventions based on adenosine phosphate-mediated platelet aggregation with no increase in bleeding. [10]

3.1.2.6 Comparison between the NERS (New Risk Stratifi cation) Score and the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) Score in Outcome Prediction for Unprotected Left Main Stenting

The NERS (New Risk Stratifi cation) prospective registry involved UPLMS PCI from 4 centers in China from January 21, 1999, through March 1, 2009. This study aimed to compare the NERS and SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) scores for prognostication after stenting of unprotected left main stenosis in a 'real-world' setting. The NERS score was derived from 260 patients with unprotected left main stenosis who underwent percutaneous coronary intervention and tested in 337 patients in a consecutive left main registry (66.55 +/- 10.49 years, 78.9% men) undergoing percutaneous coronary intervention. The NERS scoring system consisted of 54 variables,

70 Chapter 3 Prevention and Control of Cardiovascular Disease including 33 angiographic variables, 4 procedural Variables and 17 clinical variables. Six-month clinical and angiographic follow-up was obtained in 100% and 88.9% of patients, respectively. The primary end point was major adverse cardiac events (MACE), encompassing myocardial infarction, all-cause death, and target vessel revascularization. Receiver-operator characteristic (ROC) curve was generated for the comparison of NERS versus SYNTAX scores. As table 3-1-2 (10) showed, the AUC was 0.89 for NERS score (95% CI, 0.86-0.93, P < 0.001) and 0.69 for SYNTAX score (95% CI, 0.63-0.76, P < 0.001), when cumulative MACE was considered as “state variable.” Per ROC curve, a value of 25 stratifi ed scores as NERS-lower (0 to 24) and NERS-higher (≥25). The NERS-higher scores demonstrated enhanced MACE sensitivity and specifi city of 92.0% and 74.1%, respectively [Table 3-1-2 (11)].

Table 3-1-2 (10) ROC Analysis for NERS and SYNTAX Scores When Cumulative MACE was Considered as 'State Variable' Variables Area 95%CI P Value

NERS 0.89 0.86-0.94 <0.001

SYNTAX 0.69 0.63-0.76 <0.001

Table 3-1-2 (11) Comparison of Diagnostic Values Between NERS and SYNTAX Scoring System

SYNTAX Score NERS Score Items P Value ≥33 23-32 ≥23 ≥25

Sensitivity(%) 70.5 20.5 90.9 92.0 <0.001

Speciﬁ city(%) 35.4 25.4 32.4 74.1 <0.001

A NERS Score≥25 (hazard ratio: 1.13; 95% CI: 1.11-1.16; P < 0.001) was the only independent predictor of cumulative MACE and stent thrombosis at follow-up. In conclusion, the NERS score was more predictive of MACE than SYNTAX score. [11]

3.1.3 Acute Coronary Syndrome 3.1.3.1 Outcome of Patients with Non-ST Segment Elevation Acute Oronary Syndrome Undergoing Early or Delayed Intervention

Twenty four hospitals participated in this multicenter randomized trial from April, 2007, through Jun, 2008. Patients diagnosed as non-ST segment elevation acute coronary syndrome were randomly signed to undergo early intervention (coronary angiography≤24 hours after randomization, n= 446, age 67 ± 10) or delayed intervention (coronary angiography > 36 hours after randomization, n=369, age 66 ± 10) . (1) The Effect and Safety of Early Intervention and Delayed Intervention in Patients with non-ST segment Elevation Acute Coronary Syndrome. Primary outcome was a composite of death, myocardial infarction or stroke at 180 days. The secondary

71 Report on Cardiovascular Diseases in China (2011)

outcome was death, myocardial infarction, refractory ischemia, stroke or revascularization at 180 days. Baseline clinical characteristics were comparable between the two groups. Table 3-1-3 (1) showed the primary and secondary outcome.

Table 3-1-3 (1) Comparison of the Outcome of Patients with Non-ST Segment Elevation Acute Coronary Syndrome Undergoing Early or Delayed Intervention at 180 Days Early Delayed Outcomes Intervention Intervention P Value (n=446) (n=369) Death, Myocardial Infarction or Stroke 40(9.0) 54(14.6) 0.01

Death, Myocardial Infarction or Refractory Ischemia 65(14.6) 81(22.0) 0.01 Death, Myocardial Infarction, Stroke, Refractory Ischemia or 119(26.7) 112(30.4) 0.25 Revascularization Death 16(3.6) 12(3.3) 0.79

Myocardial Infarction 23(5.2) 40(10.8) 0.00

Refractory Ischemia 26(5.8) 29(7.9) 0.25

Stroke 1(0.2) 2(0.5) 0.87

Revascularization 53(11.9) 29(7.9) 0.05

Bleeding 3(0.7) 2(0.5) 1.00

In conclusion, compared to delayed intervention group, early intervention reduced incidence of myocardial infarction. [12] (2) An Analysis of Intervention Outcome in Non-ST Segment Eevation Acute Coronary Syndrome in Elderly Patients A totaI of 815 patients were enrolled, including 198 elderly patients aged 75 years above, 617 younger patients aged below 75 years. The primary endpoint was a composite endpoint of death, myocardial infarction and stroke during 180 days follow-up. The 1st secondary endpoint was death, myocardial infarction and refractory ischemia. The 2nd secondary endpoint was death, myocardial infarction, refractory ischemia or revascularization. Results were showed in Table 3-1-3 (2) and (3).

Table 3-1-3 (2) Comparison of the Outcome of Patients among Elderly and Younger Patients with Non-ST Segment Elevation Acute Coronary Syndrome Patients Aged Patients Aged below Outcomes P Value OR 95%CI above 75 Years 75 Years Primary Endpoint 37(18.7) 57(9.2) 0.00 0.44 0.28-0.69

The 1st Secondary Endpoint 54(27.3) 92(14.9) 0.00 0.47 0.32-0.69

The 2nd Secondary Endpoint 73(36.9) 158(25.6) 0.00 0.59 0.42-0.83

Myocardial Infarction 23(11.6) 40(6.5) 0.02 0.53 0.31-0.91

72 Chapter 3 Prevention and Control of Cardiovascular Disease

Table 3-1-3 (3) Comparison of the Outcome of Patients among Ederly and Younger Patients Presenting with Non-ST Segment Elevation Acute Coronary Syndrome and Undergoing Early or Delayed Intervention at 180 Days Delayed Outcomes Early Intervention P Value OR 95%CI Intervention Patients Aged above 75 Years (n=198) 109 89

Primary Endpoint 18(16.5) 19(21.3) 0.39 0.73 0.36-1.49

The 1st Secondary Endpoint 29(26.6) 25(28.1) 0.82 0.93 0.50-1.74

The 2nd Secondary endpoint 41(37.6) 32(36.0) 0.81 1.07 0.60-1.92

Myocardial Infarction 11(10.1) 12(13.5) 0.46 0.72 0.30-1.72

Patients Aged below 75 Years (n=617) 337 280

Primary Endpoint 22(6.5) 35(12.5) 0.01 0.49 0.28-0.86

The 1st Secondary Endpoint 36(10.7) 56(20.0) 0.00 0.48 0.30-0.75

The 2nd Secondary Endpoint 78(23.1) 80(28.6) 0.12 0.75 0.52-1.08

Myocardial Infarction 12(3.6) 28(10.0) 0.00 0.33 0.17-0.67

In conclusion, elderly patients with non-ST segment elevation acute myocardial infarction who underwent intervention had higher incidence death and myocardial infarction. Early intervention reduced the rate of myocardial infarction in younger patients.[13] (3) Gender Difference of Intervention Outcome in Non-ST Segment Elevation Acute Coronary Syndrome Among 815 patients diagnosed as non-ST segment elevation acute coronary syndrome, 545 were males, 270 were females. The primary outcome was a composite of death, myocardial infarction or stroke at 180 days. The 1st secondary endpoint was death, myocardial infarction and refractory ischemia. The 2nd secondary endpoint was death, myocardial infarction, refractory ischemia or revascularization. Results were showed in table 3-1-3 (4) and (5).

Table 3-1-3 (4) Patients with Non-ST Segment Elevation Acute Coronary Syndrome with OR for Men vs Women Male Female Outcomes P Value OR 95%CI (n=545) (n=270)

Primary Endpoint 58(10.6) 36(13.3) 0.26 0.77 0.50-1.21 The 1st Secondary 90(17.1) 56(20.7) 0.22 0.79 0.55-1.15 Endpoint The 2nd Secondary 156(28.6) 75(27.8) 0.80 1.04 0.75-1.44 Endpoint Myocardial Infarction 40(7.3) 23(8.5) 0.55 0.85 0.50-1.45 Revascularization 64(11.7) 18(6.7) 0.02 1.86 1.08-3.21

73 Report on Cardiovascular Diseases in China (2011)

Table 3-1-3 (5) Comparison of the Outcome of Patients among Male vs Female Presenting with Non-ST Segment Elevation Acute Coronary Syndrome and Undergoing Early or Delayed Intervention at 180 Days Delayed Outcomes Early Intervention P Value OR 95%CI Intervention Male (n=545) 295 250

Primary Endpoint 21(7.1) 37(14.8) 0.00 2.27 1.29-3.99

The 1st Secondary Endpoint 37(12.5) 53(21.2) 0.01 1.88 1.19-2.97

The 2nd Secondary Endpoint 77(26.8) 79(32.4) 0.15 1.31 0.91-1.90

Myocardial Infarction 14(4.7) 26(10.4) 0.01 2.33 1.19-4.57

Female(n=270) 151 119

Primary Endpoint 19(12.6) 17(14.3) 0.68 1.16 0.57-2.34 st The 1 Secondary Endpoint 28(18.5) 28(23.5) 0.32 1.35 0.75-2.44 nd The 2 Secondary Endpoint 42(28.5) 33(27.7) 0.89 0.96 0.57-1.65

Myocardial Infarction 9(6.0) 14(9.2) 0.09 2.10 0.88-5.04 In conclusion, Patients with non-ST segment elevation acute coronary syndrome undergoing intervention demonstrate no signifi cant gender differences in effi cacy and safety. Early intervention reduces the rate of myocardial infarction for males, but it is not superior to delayed intervention for females.[14] (4) Impact of Timing of Intervention on Prognosis of Non-ST Segment Elevation Acute Coronary Syndrome Patients with Renal Dysfunction Serum creatinine was determined in 781 patients at admission and glomerular fi ltration rate (eGFR) calculated by the abbreviated MDRD formula. The subjects were stratifi ed according to eGFR≥90 ml/ min/1.73 m2 (207 cases, 25.4%), 60-90 ml/min/1.73 m2 (464 cases, 56.9%) and eGFR< 60 ml/min/1.73 m2 (110 cases, 13.5%) and followed up for 180 days. Death, myocardial infarction or stroke was regarded as the primary end point. The result was showed in fi gure 3-1-3 (1).

3ULPDU\(QGSRLQW 0RUWDOLW\ ˄˅ Event Rates H*)5ıPOPLQP H*)5POPLQP H*)5 POPLQP

5HQDO)XQFWLRQ

Figure 3-1-3 (1) Primary Endpoint and Mortality in Patients with Different Glomerular Filtration Rate

74 Chapter 3 Prevention and Control of Cardiovascular Disease

In a logistic regression analysis, adjusting for other important covariables, the delayed intervention remained independently associated with the risk of primary end point in 60≤eGFR< 90 ml/min/1.73 m2 group (odds ratio, 2.106; 95% CI, 1.102-4.024). In conclusion, the strategy of early intervention reduces the risk of death/MI or stroke at 180 days in NSTEACS patients with mild renal dysfunction.[15]

3.1.3.2 Impact of First 24 Hours Mean Blood Glucose Level on the Prognosis of Hospitalized Patients with ST-segment Elevation Myocardial Infarction

In a subgroup analysis of China Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment Evaluation (CREATE) Investigation, a total of 7 446 Chinese STEMI patients hospitalized within 12 hours of symptom onset were included. Plasma glucose was measured at admission, 6 and 24 hours after admission, respectively. The 24 hours mean blood glucose (MBG) level through the fi rst 24 hours for each patient was calculated. Patients were stratifi ed into six groups according to their MBG levels: < 4.5, 4.5-5.5, 5.6- 7.0, 7.1 - 8.5, 8.6-11.0 and > 11.0 mmol/L. The incidence of all-cause mortality and combined end point of death, re-infarction, cardiogenic shock, recurrence ischemia, and stroke at 7 days and 30 days post hospitalization were analyzed.Compared with the MBG of 4.5-5.5 mmol/L group, 7 days and 30 days mortality and combined end point events increased in proportion to plasma MBG level increase. Figure 3-1-3 (2) and Figure 3-1-3 (3).

'HDWK &RPELQHG(QG3RLQW

˄˅ Event Rate ! 3ODVPD0%*/HYHO

Figure 3-1-3 (2) 7-day Mortality and Combined End Point Events

'HDWK &RPELQHG(QG3RLQW (YHQW5DWH˄˅ ! 3ODVPD0%*/HYHO

Figure 3-1-3 (3) 30-day Mortality and Combined End Point Events

75 Report on Cardiovascular Diseases in China (2011)

Multivariate logistic regression analysis showed that elevated MBG (equal or greater than 7.1-8.5 mmol/L) level is an independent predictor of 7 days and 30-day mortality and combined end point events. Nested models analysis showed that the prognostic impact of MBG is superior to AG (P < 0.001) on predicting 7days and 30 days mortality and combined end point events in this patient cohort. In conclusion, elevated MBG (≥ 7.1 mmol/L) level is an independent predictor of 7 days and 30 days mortality and combined end point events. MBG is superior to AG on predicting short-term prognosis in this patient cohort.[16]

3.1.3.3 Clinical Characteristics, Treatments and Outcome of Diabetic Patients with Non-ST Elevation Acute Coronary Syndromes in China

In a subgroup analysis OASIS study, 2 294 consecutive patients admitted with NSTEACS from March 1999 to December 2000 in 38 centers in north China were enrolled. Follow-up was made at 6, 12, and 24 months after their initial hospital admission. As in Table 3-1-3 (6), there were 420 diabetic patients out of 2 294 NSTEACS patients (18.3%). Diabetic patients were older [(64.9 ± 6.7) years vs. (62.3 ± 8.6) years, P < 0.01], more often women and were associated with higher baseline comorbidities such as previous hypertension, myocardial infarction, congestive heart failure and stroke than non-diabetic patients. Table 3-1-3 (7) showed the treatment in diabetic patients vs non-diabetic patients.

Table 3-1-3 (6) Baseline Characteristics of the Patient Cohort Diabetic Patients Non-diabetic Patients Variables P Value (n=420) (n=1 874) Age (Years) 64.9±6.7 62.3±8.6 <0.01 Female (%) 202(48.1) 662(35.3) <0.05 History Hypertension 290(69.0) 1 027(54.8) <0.01 Myocardial Infarction 132(31.4) 444(23.7) <0.01 Heart Failure 66(15.7) 103(5.5) <0.01 Stroke 40(9.5) 124(6.6) <0.05

Table 3-1-3 (7) Treatment in Diabetic Patients vs Non-diabetic Patients Diabetic Patients Non-diabetic Patients Variables P Value (n=420) (n=1874) Coronary Angiography 126(30.0) 680(36.3) <0.05

Two or More Vessels Disease 96(76.2) 436(64.1) <0.01

Three-Vessel Disease 59(46.8) 241(35.4) <0.05

Antiplatelet Therapy 387(92.1) 1 780(95.0) <0.05

Percutaneous Coronary Intervention 51(12.1) 352(18.8) <0.05

Coronary artery Bypass Graft 15(3.6) 82(4.4)

76 Chapter 3 Prevention and Control of Cardiovascular Disease

In hospital and 2-year mortality as well as the incidence of congestive heart failure and composite outcomes of myocardial infarction, stroke, congestive heart failure and death were substantially higher in diabetic patients compared with non-diabetic patients. Multivariate Cox regression analysis revealed that age≥70 years, diabetes, previous myocardial infarction, previous congestive heart failure, systolic blood pressure less than 90 mmHg and heart rate more than 100 bpm at admission were risk factors for 2 years death. In conclusion, diabetes is associated with higher rate of in-hospital and 2-year death, congestive heart failure and composite outcomes of myocardial infarction, stroke, congestive heart failure and death in NSTEACS patients. Diabetes mellitus is a major independent predictor of 2 years mortality post NSTEACS. Status of antiplatelet therapy, coronary angiography and revascularization should be improved for diabetic patients with NSTEACS during hospitalization.[17]

3.1.4 Medical Treatment in Coronary Artery Disease

In a multicenter cross-sectional survey from Dec. 2007 to March 2008, physicians in 29 hospitals in 17 cities consecutively enrolled 1 089 outpatients with stable angina who were diagnosed and treated for at least one month. A standardized questionnaire including information on patients characteristics, risk factors, complicating diseases and current medication was fi lled out by investigator for each individual patient. The result was showed in Table 3-1-4.

Table 3-1-4 Current Status of Medical Therapy of Chronic Stable Angina Pectoris in Mainland of China

Medication Cases (n=1 809) Percent %

Aspirin 1 651 91.3

Clopidogrel 677 37.4

β-blockers 1 169 64.6

Angiotensin-converting enzyme inhibitors 910 50.3

Angiotensin Receptor Blockers 363 20.1

Satins 1 181 65.3

Calcium Channel Blockers 629 34.8

Nitrates 1 589 87.8

In general, guidelines were followed in the medical treatments of stable angina in the mainland of China; however, there are still gaps between current clinical practice and guidelines, the insuffi cient use of β-blocker and statin for stable angina patients is especially signifi cant.[18]

77 Report on Cardiovascular Diseases in China (2011)

3.1.5 Secondary Prevention in Coronary Artery Disease 3.1.5.1 A Cross-sectional Study on the Treatment Goals of Blood Pressure, Serum Lipids and Blood Glucose in Elderly Patients with Coronary Heart Disease

In a cross-sectional survey, the CHD subjects aged > 65 years old were recruited from 66 hospitals in Beijing, Shanghai, Tianjin, Guangdong, Zhejiang and Xinjiang from June 2006 to January 2007. A total of 2 420 participants were enrolled, including 1 441 males and 979 females. The targeted blood pressure was systolic blood pressure < 130 mmHg and diastolic blood pressure < 80 mmHg. The serum lipids goal of achievement was LDL-C (low density lipoprotein-cholesterol) < 2.6 mmol/L for the high-risk patients and LDL-C < 2.07 mmol/L especially for the very high risk patients. The blood glucose goal of achievement was FPG (fasting plasma glucose) > 4.4-6.1 mmol/L, non-fasting plasma glucose 4.4-8.0 mmol/L, or HBA1c < 6.5%. The results were shown in table 3-1-5 (1).

3-1-5 (1) The Reaching Standard Rate of Blood Pressure, Level of Serum Glucose and Lipid in Elderly Patients with Coronary Artery Diseasea

Reaching Standard Reaching Standard Reaching Standard Variables P Value Rate (%) Rate (Male) (%) Rate (Female) (%)

Blood Pressure 24.8(599/2 420) 386(26.8) 213(21.8) <0.01

Serum Glucose 36.5(884/2 420) 603(41.8) 281(28.7) <0.01

Serum Lipid 61.0(1 476/2 420)

In the present survey, the achievement rates of blood pressure, serum lipids and blood glucose are low in the elderly CHD patients, especially in females. There has been a huge gap between the treatment guidelines and clinical practices in China. We should carry out different strategies according to different conditions to enhance the health and life quality for the elderly CHD patients. [19]

3.1.5.2 Statin Use among Patients with Coronary Heart Disease in China

In the context of an international multi-center clinical trial (HPS THRIVE) being undertaken in China, 8 161 patients (male 6 189 cases; female 1 927 cases) with coronary heart disease were screened in 39 hospitals in 10 cities from June to December in 2007. All patients had indications for statins. However, up to 45.9% patients were not using statins when screened. Even in those with statins, duration of statin therapy was shorter than their CHD history in 877 (19.9%). Table 3-1-5 (2) showed the predicting factors of statin usage.

78 Chapter 3 Prevention and Control of Cardiovascular Disease

Table 3-1-5 (2) Factors Inﬂ uencing Statin Usage

Proportion of Proportion of Statin Variables OR (95% CI) Population (%) Usage (%)

Age

50-59 33.2 (2 708) 57.3 (1 553/2 708) 1

60-69 39.5 (3 223) 53.7 (1 731/3 223)* 0.863(0.778-0.956)

70-80 27.3 (2 230) 50.8 (1 132/2 230)* 0.767(0.685-0.858)

Sex

Male 75.8 (6 189) 55.4 (3 432/6 189) 1

Female 24.2 (1 972) 49.9 (984/1 972)* 0.800(0.723-0.886)

History of Disease

3 Months–1 Year 29.0 (2 365) 65.5 (1 549/2 365) 1

>1-2 Years 35.2 (2 871) 58.3 (1 674/2 871)* 0.738(0.660-0.826)

>2-5 Years 17.3 (1 412) 49.9 (704/1412)* 0.525(0.459-0.600)

>5 Years 9.5 (778) 43.4 (338/778)* 0.405(0.344-0.478)

History of Myocardial Infarction

No 19.9 (1 627) 43.1 (701/1 627) 1

Yes 80.1 (6 534) 56.8 (3 715/6 534)* 1.741(1.560-1.934)

History of CABG

No 87.3 (7 121) 53.3 (3 799/7 121) 1

Yes 12.7 (1 040) 59.3 (617/1 040)* 1.275(1.118-1.456)

History of PCI

No 50.6 (4 133) 38.1 (1 575/4 133) 1

Yes 49.4 (4 028) 70.5 (2 841/4 028)* 3.887(3.544-4.263)

History of Ischemic Stroke

No 75.9 (6 198) 59.2 (3 668/6 198) 1

Yes 24.1 (1 963) 38.1 (748/1 963)* 0.425(0.383-0.471)

History of PCI

No 59.0 (4 816) 54.0 (2 603/4 816) 1

Yes 41.0 (3 345) 54.2 (1 813/3 345) 1.006(0.921-1.099)

History of Ischemic Stroke

No 35.6 (2 909) 54.7 (1 592/2 909) 1

Yes 64.4 (5 252) 53.8 (2 824/5 252) 0.962(0.897-1.054)

In conclusion, statins were greatly underused in secondary prevention among CHD patients in China. There was a huge gap between evidence and practice.[20]

79 Report on Cardiovascular Diseases in China (2011)

3.2 Stroke 3.2.1 Epidemiology of Cerebrovascular Disease: Prevalence, Mortality and Temporal Trends[21] 3.2.1.1 Prevalence of Cerebrovascular Disease in 2008

In 2008, the Fourth National Health Services Survey enrolled 177 501 individuals from 94 districts in 31 provinces to explore the cerebrovascular disease (CVDs) status in China. Among the population surveyed, males and females accounted for 50% each. People under 14 years old accounted for 17.7% and people aged 65 and older 11.5%. The prevalence of cerebrovascular disease among the surveyed population was 9.7‰, 13.6‰ for urban residents and 8.3‰ for rural residents in 2008.[22]

3.2.1.2 Crude Death Rate of Cerebrovascular Disease in 2009

According to data from the China Public Health Statistical Yearbook (2010 volume), the crude death rate of cerebrovascular disease in 2009 was 126.27/100 000 for urban citizens and 152.09/100 000 for rural residents. It was estimated there were 840 000 urban citizens and 851 000 rural residents died from cerebrovascular disease in 2009. In general, rural areas have a higher crude death rate than that of urban areas, and men have a higher crude death rate than women in both rural and urban areas showed in Figure 3-2-1 (1), Table 3-2-1 (1). 0DOH )HPDOH 7RWDO

0RUWDOLW\嘅5DWH

8UEDQ5XUDO Table 3-2-1 (1) Cerebrovascular Disease Mortality for Urban or Rural Males and Females (China, 2009)

Table 3-2-1 (1) Cerebrovascular Disease Mortality in 2009(1/100 000) Small and Mid-sized Urban Total Metropolis Rural CVDs Cities Total Male Female Total Male Female Total Male Female Total Male Female 126.27 135.41 116.93 135.74 144.27 126.90 92.30 103.41 80.73 152.09 164.41 139.40

80 Chapter 3 Prevention and Control of Cardiovascular Disease

3.2.1.3 Age-adjusted Stroke Mortality in China Urban Population (1/100 000)

According to data from the China Public Health Statistical Yearbook 2010, men had a higher age-adjusted stroke mortality than women in urban areas. Mortality rate increased with age in both men and women. The detail was showed in Table 3-2-1 (2), Figure 3-2-1 (2).

Table 3-2-1 (2) Age, Sex-specifi c Mortality Rate in Urban Area (China, 2009)

Age 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85-

Male 1.31 1.54 3.84 10.02 24.39 43.26 77.10 121.76 192.10 327.07 671.33 1 273.04 2 224.17 3 610.17

Female 0.74 0.71 1.39 3.80 8.74 16.29 30.45 54.78 106.68 205.87 450.69 921.83 1 781.96 3 178.26

8UEDQ0DOH 8UEDQ)HPDOH

0RUWDOLW\嘅

(Age)

Figure 3-2-1 (2) Age, Sex-speciﬁ c Mortality Rate in Urban Areas

3.2.1.4 Age-adjusted Stroke Mortality in China Rural Population (1/100 000)

According to data from the China Public Health Statistical Yearbook 2010, the crude death rate of cerebrovascular disease also increased with age in China rural areas. Men had a higher age-adjusted stroke mortality than women at each age group. In general, rural areas have a higher crude death rate than that of urban areas. Detail was showed in Table 3-2-1 (3), Figure3-2-1 (3).

Table 3-2-1 (2) Age, Sex-specifi c Mortality Rate in Urban Area in China, 2009 (1/100 000)

Age 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85-

Male 2.41 2.55 5.09 13.00 33.36 42.23 97.60 189.69 319.74 512.53 1 057.68 2 019.22 3 744.29 7 041.60

Female 1.23 1.63 2.03 5.35 15.84 26.00 54.58 110.56 197.08 308.76 650.71 1 301.28 2 606.35 5 299.28

81 Report on Cardiovascular Diseases in China (2011)

8UEDQ0DOH 8UEDQ)HPDOH

0RUWDOLW\

˄$JH˅

Figure 3-2-1 (3) Age, Sex-speciﬁ c Stroke Mortality Rate in Rural Area

3.2.1.5 Temporal Trends of Stroke Mortality in 2003-2009

An analysis of data (China Public Health Statistical Yearbook) from 2003 to 2009 showed that overall crude death rate of cerebrovascular disease was higher among rural population than urban population. Data from 2003 to 2006 showed that the crude death rate decreased slightly, but presented an upward trend after 2006. In comparison with the rate in 2006, the crude death rate in 2009 was increased by a factor of 1.41 in urban areas and by a factor of 1.44 in rural areas, respectively.

ජᏖড়䅵 ЁᇣජᏖ 8UEDQ7RWDO 6PDOODQG0LGVL]HG&LWLHV ໻ජᏖ ݰᴥ 0HWURSROLV 5XUDO

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ǂǂǂǂǂǂǂǂǂǂ˄

82 Chapter 3 Prevention and Control of Cardiovascular Disease

3.2.2 Epidemiological Study in Different Areas in China 3.2.2.1 Epidemiological Survey of Stroke in Lhasa, Tibet [23]

A City Staff Medical Insurance Registry was made in Lhasa, which covered 13.21% of the permanent residents there, between October 2006 and October 2008. This comprised 81 298 people, who were all > 18 years old and of which 52 199 were men (63.50%). Stroke patients (165) were included in the study, with 133 being fi rst-ever patients. The age-standardized incidence rate was 88.725/100 000 per year (95% CI, 72.228- 105.221), and mortality rate was 25.941/100 000 per year (95% CI, 16.416-35.466). The case fatality rate was 21.82%. Seventeen of the 133 patients (12.8%) were < 45 years of age. Stroke incidence rate was higher in ethnic Han patients than ethnic Tibetan patients [Table 3-2-2 (1)], stroke remains the primary fatal disease for the elderly. The most common subtype was cerebral infarction [Table 3-2-2 (2)], and the most important risk factor was hypertension. The occurrence of stroke at younger ages is higher in Lhasa than in other areas of China [Table 3-2-2 (3)].

Table 3-2-2 (1) Stroke Incidence Rate by Sex and Ethnicity Stroke Interviewed Average IR per 100 000/Year Standardized IR by 2000 World Characteristic Cases (of 81 298) (95% CI) Population per 100 000/Year (95% CI) (of 133) Male 109 52 199 104.408 (76.698-132.113) 103.468 (82.927-125.486)

Female 24 29 099 41.239 (17.911-64.567) 52.409 (28.500-76.319)

Tibetan 71 46 079 77.042 (51.708-102.376) 79.798 (59.544-100.052)

Han 61 32 124 94.945 (61.266-128.62) 108.888 (79.038-138.737)

Table 3-2-2 (2) Stoke Subtypes and Average Incidence Rate Constituent Stroke Subtype Male Female Tibetan, n(%) Han, n(%) Ratio(%) Cerebral infarction 61 15 34(47.89%) 41(67.21%) 57.14

Intracerebral Hemorrhage 44 8 34(47.89%) 18(29.51%) 39.10 Subarachnoid 4 1 3(4.22%) 2(3.28%) 3.76 Hemorrhage Total 109 24 71 61

Table 3-2-2 (3) Average Incidence Rate by Age Crude Average Incidence Rate Age (Years) Stroke Cases (of 133) Interviewed (of 81 298) per 100 000/Year (95% CI) 10-19 0 99 0.0000

20-29 1 11 908 4.199(3.376-5.022)

30-39 6 21 305 14.081(12.488-15.674)

40-49 17 20 731 41.001(13.44-68.558)

50-59 34 14 644 116.088(100.138-232.041)

83 Report on Cardiovascular Diseases in China (2011)

Continued Table Table 3-2-2 (3) Average Incidence Rate by Age Crude Average Incidence Rate 100 000/ Age (Years) Stroke Cases (of 133) Interviewed (of 81 298) Year (95% CI) 60-69 43 9 012 238.57(137.85-339.294)

70-79 28 3 030 462.046(220.57-703.52)

80 and older 4 569 487.80(186.6-1162.2)

3.2.2.2 Trends in Stroke Incidence in Hong Kong Differ by Stroke Subtype[24]

Data from the Clinical Management System database of the Hong Kong Hospital Authority for 1999-2007 were used to examine incidence rates of stroke by subtypes among the Hong Kong population aged 35 and above. While the age-adjusted incidence of ischemic stroke has decreased, that of hemorrhagic stroke has remained fairly stable [Figure 3-2-2 (1)]. In the younger age group (35-44 years), the incidence of ischemic stroke remained stable, whereas that of hemorrhagic stroke has increased [Table 3-2-2 (4)]. Furthermore, the incidence of all stroke among Hong Kong Chinese is much higher than in many other developed countries [Table 3-2-2 (5)].

˄˅

,QFLGHQFHUDWHV

0DOH )HPDOH 0DOH )HPDOH +HPRUUKDJLF ,VFKHPLF Figure 3-2-2 (1) Stroke Incidence Rates among the Population Aged 35 and above in Hong Kong Standardized to WHO Standard World Population, by Gender and Subtype, 1999-2007.

Table 3-2-2 (4) Fitted Incidence Rates of Stroke in Hong Kong by Age Group, Sex and Subtype, and IRRs for Different Periods Estimated from Poisson Regression Fitted Incidence Rates (per 100 000) Episode / Subtype Age Group 1999-2001 2002-2004 2005-2007 35-44 11.6 14.7 16.3 45-54 36.1 44.0 44.9

Hemorrhagic stroke 55-64 107.4 112.9 104.1 Male 65-74 215.2 234.7 226.7 75-84 408.8 451.5 442.7 85+ 622.2 686.3 676.7

84 Chapter 3 Prevention and Control of Cardiovascular Disease

Table 3-2-2 (4) Fitted Incidence Rates of Stroke in Hong Kong by Age Group, Sex and Subtype, and IRRs for Different Periods Estimated from Poisson Regression Continued Table Fitted Incidence Rates (per 100 000) Episode / Subtype Age Group 1999-2001 2002-2004 2005-2007 35-44 5.2 6.2 6.9 45-54 18.0 21.0 21.3 Hemorrhagic Stroke 55-64 47.3 47.6 43.7 Female 65-74 116.9 122.0 117.2 75-84 266.4 281.6 274.6 85+ 479.0 505.7 495.9 35-44 22.1 22.7 23.5 45-54 92.1 91.1 87.0 55-64 425.5 363.6 314.0 Ischemic Stroke 65-74 1 053.7 933.9 844.6 Male 75-84 1 908.2 1 713.0 1 572.4 85+ 2 471.2 2 215.4 2 045.1 35-44 13.2 13.0 13.4 45-54 61.7 58.5 55.5 Ischemic Stroke 55-64 252.6 206.6 177.4 Female 65-74 770.4 653.6 587.8 75-84 1 673.7 1 438.3 1 313.0 85+ 2 560.8 2 197.5 2 017.6

Table 3-2-2 (5) International Comparison of First-ever Stroke Subtypes and Age-standardized Rates among Population Aged 35 and Above

Ischemic: Hemorrhagic Age-standardized Rates (per 100 000) City Year Ratio Ischemic Hemorrhagic Male Female Male Female Male Female

Hong Kong, China 1999-2007 3.4 4.6 270.7 204.5 80.5 44.5

Beijing, China 1991-2000 2.2 2.6 97.2 85.0 44.6 32.6

Shanghai, China 1991-2000 1.5 1.6 47.0 36.3 32.3 23.1

Changsha, China 1991-2000 0.8 0.9 77.7 50.5 102.3 58.8

Shiga, Japan 1989-1993 3.3 2.0 182.8 90.1 56.1 45.7

Melbourne, Australia 1997-1999 4.7 4.4 189.6 129.4 40.4 29.2

Valley of Aosta, Italy 2004-2005 7.1 9.5 223.6 131.3 31.6 13.8

Joinville, Brazil 2005-2006 6.1 7.7 319.4 204.1 52.2 26.5

Mashhad, Iran 2006-2007 5.9 7.8 461.5 460.8 78.0 58.7

85 Report on Cardiovascular Diseases in China (2011)

3.2.3 Risk Factors in Stroke Patients

A study collected data from Jan. 1996 to Dec. 2000 in-hospital stroke patients aged 35–45 years old from 36 hospitals in mainland China and compared it to 12 260 health controls with the same age.[25] Information about stroke risk factors was obtained through a questionnaire. Of the stroke patients, 94.3% had an ischemic stroke and 73.0% were male. The major risk factors were hypertension, smoking and alcohol drinking [Table 3-2-3 (1), (2)].

Table 3-2-3 (1) Comparison of Risk Factors between Case Group and Control Group Case Group (n=1 988) Control Group (n=12 260) Risk Factors N % N % Hypertension 816 41.0 1 163 9.0

Diabetes 104 5.2 221 1.7

Hyperlipidemia 84 4.2 367 2.9

Heart Disease 143 7.2 210 1.6

Stroke 296 14.9 166 1.3

Smoking 771 38.8 4 312 33.3

Alcohol Drinking 760 38.0 3 208 24.9

Table 3-2-3 (2) Comparison of Risk Factors between Male and Female Female (n=537) Male (n=1 451) Risk Factors N % N %

Hypertension 211 39.3 605 41.7

Diabetes 34 6.3 71 4.9

Hyperlipidemia 17 3.2 69 4.8

Heart Disease 58 10.8 85 5.9

Stroke 84 15.6 212 14.6

Smoking 35 6.5 738 50.9

Alcohol Drinking 31 5.8 731 50.4

3.2.4 Treatment of Stroke 3.2.4.1 Age and Gender Variations in the Management of Ischaemic Stroke

Using a multicentre prospective hospital register across all eight major economic (geographic) regions in China,[26] a study described the baseline, management and outcome of 6 500 patients admitted to 62 hospitals in China with acute ischaemic stroke. Traditional Chinese medicine and neuroprotectant use were remarkably high, with nearly 80% of patients receiving the former and > 70% receiving the latter in hospital. Length of hospital stay was also long (median duration 16-days). Multivariate analyses revealed no clinically important

86 Chapter 3 Prevention and Control of Cardiovascular Disease differences in management between the genders [Table 3-2-4 (1)]. For the age-specifi c analyses, there were signifi cant trends of decreasing use of thrombolysis, warfarin, corticosteroids, and lipid-lowering therapy; however, more assisted feeding and rising rates of disability and in-hospital complications occurred with increasing age [Table 3-2-4 (2), Figure 3-2-4].

Table 3-2-4 (1) Management of Ischaemic Stroke Patients by Gender N (%) Odds Ratio (95% CI) Investigations/Treatment/Outcome Crude Age-adjusted Multi at Discharge Male* Female n=4 782 n=4 782 n=4 718 Investigations Computerised Tomography 2 625(88) 1 642(91) 1.20(0.97,1.49) 1.18(0.95,1.46) 1.10(0.84,1.44) Magnetic Resonance Imaging 1 447(49) 775(43) 0.80(0.69,0.93) 0.84(0.72,0.97) 1.02(0.85,1.23) Carotid Doppler 1 060(36) 608(34) 0.77(0.66,0.91) 0.80(0.68,0.94) 0.97(0.79,1.18) Transcranial Doppler 991(33) 545(30) 0.67(0.56,0.81) 0.69(0.57,0.83) 0.96(0.76,1.21) Transthoracic or Transoesophageal 372(13) 227(13) 1.08(0.87,1.33) 1.10(0.89,1.36) 1.07(0.82,1.40) Echocardiogram Supportive Care Allied health Therapist 801(27) 530(29) 1.12(0.96,1.31) 1.13(0.97,1.31) 1.21(0.99,1.46) Traditional Chinese Medicine 361(12) 226(12) 0.93(0.73,1.18) 0.94(0.74,1.19) 0.93(0.69,1.25) Therapist Assisted Feeding 212(7) 155(9) 1.26(1.01,1.57) 1.17(0.94,1.47) 1.07(0.79,1.45) Treatment Antiplatelet Therapy 2 365(80) 1 413(78) 0.82(0.70,0.96) 0.84(0.71,0.98) 0.98(0.80,1.20) Intravenous Traditional Chinese 2 341(79) 1 443(80) 1.24(1.03,1.48) 1.21(1.01,1.45) 1.24(0.99,1.55) Medicine Intravenous Neuroprotectant 2 245(76) 1 397(77) 1.23(1.04,1.45) 1.22(1.03,1.44) 1.29(1.05,1.58) Antihypertensive Therapy 1 821(61) 1 124(62) 1.04(0.92,1.18) 1.03(0.91,1.17) 0.99(0.84,1.16) Intravenous Diuretic 1 072(36) 666(37) 1.14(0.99,1.32) 1.13(0.98,1.30) 1.05(0.87,1.27) Lipid-lowering Therapy 868(29) 566(31) 1.09(0.95,1.25) 1.14(0.99,1.31) 1.27(1.07,1.51) In Neurology Ward with Stroke Unit 883(30) 566(31) 0.89(0.72,1.10) 0.89(0.72,1.11) 0.82(0.63,1.07) Subcutaneous Low-dose Heparin 452(15) 238(13) 0.86(0.71,1.04) 0.84(0.69,1.02) 0.76(0.60,0.96) Intravenous Thrombolysis 307(10) 178(10) 0.96(0.77,1.18) 1.00(0.81,1.24) 1.11(0.85,1.44) Intravenous Corticosteroids 101(3) 51(3) 0.82(0.58,1.16) 0.85(0.60,1.20) 0.73(0.48,1.11) Intravenous Therapeutic Heparin 84(3) 36(2) 0.59(0.38,0.92) 0.62(0.40,0.96) 0.60(0.35,1.05) Warfarin 41(1) 47(3) 1.89(1.23,2.91) 1.95(1.27,3.01) 1.33(0.75,2.36) Outcome at Discharge Length of Hospital Stay ≥ 16 Days 1 592(54) 935(52) 0.95(0.84,1.07) 0.95(0.84,1.08) 1.05(0.89,1.23) Vital Status Independence 1 976(66) 1 055(58) 0.68(0.60,0.78) 0.72(0.64,0.82) 0.89(0.75,1.05) Disability/Dependency 913(31) 693(38) 1.45(1.28,1.65) 1.38(1.22,1.57) 1.17(0.99,1.38) Death 85(3) 66(4) 1.25(0.90,1.74) 1.13(0.81,1.58) 0.69(0.44,1.08) Discharge Destination Home 2 599(87) 1 550(86) 0.88(0.74,1.05) 0.90(0.76,1.08) 1.01(0.80,1.26) Alternate hospital 163(5) 106(6) 1.03(0.79,1.33) 1.01(0.77,1.31) 0.93(0.67,1.29) * Reference group

87 Report on Cardiovascular Diseases in China (2011)

Table 3-2-4 (2) Management of Ischaemic Stroke Patients by Age

N (%) Odds Ratio (95% CI) Investigations/treatment/Outcome Sex Multi >55 y 55–64 y 65–74 y ≥75 y Crude at Discharge Adjusted Adjusted *n=994 n=1 191 n=1 584 n=1 013 n=4 782 n=4 782 n=4 718 Investigations Computerised Tomography 897(90) 1 031(87) 1 413(89) 926(91) 0.03 0.04 0.12 Magnetic Resonance Imaging 475(48) 564(47) 742(47) 441(44) <0.001 <0.001 0.36 Carotid Doppler 338(34) 412(35) 552(35) 366(36) <0.001 <0.001 0.47 Transcranial Doppler 304(31) 370(31) 524(33) 338(33) 0.003 0.01 0.26 Transthoracic or Transoesophageal 128(13) 135(11) 198(13) 138(14) 0.23 0.20 0.46 Echocardiogram Supportive Care Allied health Therapist 275(28) 340(29) 447(28) 269(27) 0.98 0.86 0.70 Traditional Chinese Medicine 114(11) 146(12) 181(11) 146(14) 0.93 0.97 0.99 Therapist Assisted Feeding 37(4) 78(7) 133(8) 119(12) <0.001 <0.001 0.004 Treatment Antiplatelet Therapy 775(78) 979(82) 1 255(79) 769(76) 0.01 0.02 0.73 Intravenous Traditional Chinese 767(77) 904(76) 1 292(82) 821(81) 0.005 0.01 0.09 Medicine Intravenous Neuroprotectant 757(76) 894(75) 1 223(77) 768(76) 0.18 0.29 0.45 Antihypertensive Therapy 594(60) 735(62) 983(62) 633(62) 0.24 0.27 0.68 Intravenous Diuretic 368(37) 406(34) 555(35) 409(40) 0.03 0.05 0.93 Lipid-lowering Therapy 342(34) 377(32) 470(30) 245(24) <0.001 <0.001 0.001 In Neurology Ward with Stroke 292(29) 373(31) 481(30) 303(30) 0.88 0.97 0.56 Unit Subcutaneous Low-dose 136(14) 176(15) 236(15) 142(14) 0.10 0.07 0.61 Heparin Intravenous Thrombolysis 140(14) 117(10) 162(10) 66(7) <0.001 <0.001 0.04 Intravenous Corticosteroids 44(4) 31(3) 28(2) 17(2) 0.001 0.002 0.09 Intravenous Therapeutic Heparin 36(4) 36(3) 60(4) 20(2) 0.12 0.15 0.03 Warfarin 27(3) 16(1) 18(1) 27(3) 0.50 0.32 0.01 Outcome at Discharge Length of hospital Stay≥16 Days 499(50) 631(53) 866(55) 531(52) 0.73 0.67 0.58 Vital Status Independence 719(72) 813(68) 991(63) 508(50) <0.001 <0.001 <0.001 Disability/Dependency 255(26) 359(30) 549(35) 443(44) <0.001 <0.001 0.001 Death 20(2) 22(2) 47(3) 62(6) <0.001 <0.001 0.56 Discharge Destination Home 868(87) 1 073(90) 1 382(87) 826(82) 0.003 0.004 0.25 Alternate Hospital 57(6) 53(4) 80(5) 79(8) 0.23 0.23 0.35 * Reference group

88 Chapter 3 Prevention and Control of Cardiovascular Disease

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3.3 Hypertension (See the Chapter 2, Risk Factors of Cardiovascular Diseases)

3.4 Cardiovascular Surgery 3.4.1 Cardiac Surgical Volume in China

In 2010, the cardiac surgical volume reached 170 491 cases in mainland China, including 136 697 cases performed under Cardiopulmonary Bypass (CPB) support.

Table 3-4-1 Cardiac Surgical Volume in Mainland China

Province 2009 2010 Area and City Total CPB HTx Total CPB HTx Beijing 20 608 13 797 54 22 818 15 145 81 Tianjin 3 611 2 189 7 3 563 2 541 3 North Hebei 5 540 4 352 5 189 4 046 Shanxi 1 760 1 376 2 077 1 474 Inner Mongolia 1 062 840 1 257 906

89 Report on Cardiovascular Diseases in China (2011)

Table 3-4-1 Cardiac Surgical Volume in Mainland China

Province 2009 2010 Area and Region Total CPB HTx Total CPB HTx North East Heiongjiang 3 100 2 364 3 047 2 129

Jilin 2 185 1 750 1 929 1 549

Liaonin 4 015 2 946 3 918 2 799 2

East Shanghai 13 375 11 382 21 14 879 12 588 22

Shandong 10 554 8 251 10 998 8 177

Jiangsu 8 330 7 446 7 935 6 550

Zhejiang 4 743 4 015 4 800 4 157

Middle Hubei 8 756 7 893 9 767 9 009 11

Hunan 5 855 5 327 6 740 5 843

Jiangxi 2 470 2 230 2 753 2 527

Henan 11 143 9 546 13 263 11 431

Anhui 3 065 2 834 3 828 3 738

South Guangdong 11 757 10 368 4 13 101 11 288 1

Guangxi 3 302 2 892 7 3 407 3 054

Fujian 4 912 3 726 17 5 364 3 875 9

Hainan 630 560 680 625

North West Shanxi 7 224 5 458 2 7 674 5 343 9

Gansu 2 321 1 804 2 436 1 846

Qinghai 604 458 627 443

Ninxia 698 394 739 434

Xinjiang 2 947 2 207 3 361 2 341

South West Chongqing 3 825 3 550 4 388 4 103

Sichuan 5 343 4 838 5 839 5 048

Yunnan 2 673 2 484 1 2 860 2 482

Guizhou 1 036 1 036 1 254 1 206

Tibet

China Total 157 444 128 358 113 170 491 136 697 138 Note: Data from Extracorporeal circulation branch of Chinese Society of biomedical engineering. HTx: heart transplantation, CPB: cardiopulmonary bypass support

The cardiac surgical volume has been increasing in the recent 8 years in mainland China.

90 Chapter 3 Prevention and Control of Cardiovascular Disease

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Figure 3-4-1 Cardiac Surgical Volume in Mainland China from 2003 to 2010

3.4.2 Congenital Heart Disease in China

Correction operation of congenital heart diseases accounts for 50% to 60% of total cardiovascular surgery and ranks the fi rst place in cardiac surgery of mainland China.

3.4.2.1 Epidemiology of Age-cross-section Survey on Prevalence of Congenital Heart Disease in China

Since 1980s, epidemiological age-cross-section survey has been conducted in part regions of China, including provinces, municipality and autonomous. Some important results can be introduced from survey. [27] (1) The Prevalence of Congenital Heart Diseases is to Some Extent Associated with the Altitude Level Prevalence of congenital heart disease in highland areas, such as Qinghai and Yunan provinces was much higher than that in low-altitude areas, such as Guangdong, Fujian and Sichuan provinces. For example, the prevalence of congenital heart diseases in Yushu of Qinghai province (4 068–5 188 meters of altitudes) reached 13.8‰, while, 1.3‰ of prevalence existed in Panyu of Guandong province (44–45 meters of altitudes). The effect of high altitude on the prevalence of congenital heart disease was tested by examining adolescent aged < 17 years at the same period in Qinghai study on congenital heart disease. [28] Prevalence of CHD has been shown to increase along with increase in altitude with 7.1‰ at Xi Ning, an altitude of 2 261 m, 8.1‰ at Hai Xi, 3 050 m and 13.8‰ at Yu Shu, the highest altitude site. The above phenomena may possibly be related to hypoxia in high altitudes, cold and intensive ultraviolet radiation. Even in the same province, the prevalence of congenital heart diseases is also infl uenced by altitude level.[29] A survey in Gansu province indicated that the prevalence of Jiuquan, Zhangye and Jinchang, which all located in high-land area of the Gansu Western Corridor, were much higher than that of the cities located in the Yellow River Valley, such as Lanzhou and Dinxi prefecture (7.31‰: 4.84‰).

91 Report on Cardiovascular Diseases in China (2011)

In an epidemiological survey in children aged from 4 to 18 years in Qinghai province during 2006– 2008, [30] the prevalence of congenital heart diseases increased when altitude rose. The prevalence was 4.89‰ at the altitude of 2 535 m, 5.71‰ at 3 600m, and 8.74‰ at 4 200 m respectively. Furthermore, with rise of altitude, the prevalence of congenital heart diseases in females increases much more obviously. There was no statistical difference between males and females at the altitude of 2 000 m. However, there were signifi cant differences between males and females at the altitude of 3 000 m (4.10‰:7.57‰) and 4 000 m (6.51‰:11.25‰). (2) The Prevalence of Congenital Heart Diseases is to Some Extent Associated with the Environmental Factors The outcomes of survey in Shanxi province showed that prevalence of congenital heart diseases in Gaoyang mineral management bureau of Fenxi was 6.14‰, and 6.73‰ of prevalence existed in coal mines of six counties around Jingcheng, the prevalence in both cities above was obviously higher than that in Taiyuan (2.9‰) and Changzhi (3.37‰) of the same province. Gejiu, a city in Yunnan province, is famous in China for its tin mine. However, the epidemiological survey in Gejiu indicated that the prevalence of congenital heart diseases at Datun concentrator and Laochang Ore Deposit were 11.20‰ and 9.10‰ respectively, which was much higher than that of urban district of Gejiu (3.25‰). It is well known that environmental pollution is more serious at tin mine area. (3) There are Many Ethnic Groups in China, and Much Different Revalence of Congenital Heart Diseases Exists among Various Ethnic Groups [Table3-2-4 (2) ]. In Chabuchar County of Xinjiang autonomous region, the prevalence of congenital heart diseases in Sibo nationality was 5.68‰, obviously higher than that in Kazak nationality (2.23‰). This attributed partly to distinctive customs of Sibo nationality, living in a compact community, intermarry within narrow limits, increasing the probability of marriages in proximity of blood.[31] In an epidemiological survey in Lasa of Tibet, [32] the prevalence of congenital heart diseases in Tibetan was 6.12‰, lower than that in Han nationality (7.09‰) living in the same area. It was due to that generations of Qingzang Gaoyuan living reinforced Tibetan’s adapting ability under hypoxic environment at high altitude. In many areas of China, such as Guangxi Guilin, many races are mixed together for a long time. Various nationalities intermarried to each other, with habits and customs becoming convergence. Furthermore, infl uenced by the same geographical environments, the prevalence of congenital heart diseases gets no statistical difference in different ethnic groups. (4) Constitution of Congenital Heart Disease Presents Some Regularity in Epidemiological Age-cross- section Survey in Different Areas In most part of China, ventricular septal defect ranked the fi rst place of congenital heart diseases (30.4%– 59.68%), then followed by atrial septal defect (18%-39.8%) and patent arterial duct (5%–14.9%). While, among cyanotic congenital heart diseases, Fallot tetrad (3.8%) ranked the fi rst, and followed by pulmonary stenosis.

92 Chapter 3 Prevention and Control of Cardiovascular Disease

But in high land area, the constitution of congenital heart diseases was different from that in low-altitude area. The survey in Tibet autonomous region showed that the patent arterial duct ranked the fi rst place (32.5%), whereas the survey in Dali of Yunnan province showed that atrial septal defect was at the fi rst place (54.5%). The survey in Qinghai province during 2006–2008 also confi rmed that the constitution rate of congenital heart diseases varied at different altitudes. [33] For example, atrial septal defect constituted 37% of congenital heart diseases at the altitude of 2 000 m and 3 000 m, ranked the fi rst place. With the altitude rose to 4 200 m, the fi rst place was taken by patent arterial duct, constituted 46.4% of congenital heart diseases at that altitude.

Table 3-4-2 (1) Epidemiology of Age-cross-section Survey on Prevalence of Congenital Heart Disease in China

Prevalence Constitution (%) Publishing Area Subject Population Altitude (m) (‰) VSD ASD PDA Year Shanghai Yangpu < 2 year 11 420 6.7 5 1989

13 Cities of Zhejiang < 2 year 115 836 3.72 59.40 8.82 10.67 5 1999

Zhejiang Ningbo < 2 year 50 020 4.02 53.7 9.4 10.4 5 1999

Zhejiang Ningbo 0-24 year 5 897 5.76 5 1999

Zhejiang Zhoushan < 2 year 6 605 4.09 51.85 11.11 25.93 1999

Jiangsu Suzhou 0-24 day 10 281 2.52 2-6 1999

Jiangsu Wuxi 0-24 year 13 133 1.98 5-8 1999

Guangdong Panyu 7-15 year 7 168 1.30 50 1983 Primary and Middle Fujian Xiamen 14 774 4.00 30.50 15.25 5.00 139 School Students Fujian Fuzhou 15-20 year 53 560 1.97 30.19 30.19 22.64 1999

Fujian Quanzhou < 14 year 36 570 2.98 200 1988

Guangxi Guilin 0-18 year 10 498 1.52 43.8 18.8 6.3 167 1999

5 Cities of Hainan < 19 year 81 921 2.70 43.3 31.3 14.9 500 1992

Henan Zhengzhou Preschool Children 32 860 4.70 45.8 12.9 < 100 1997 Primary and Middle Henan Fengqiu 5 327 2.40 38.46 23.07 100 1995 School Students Hebei Shijiazhuang 0-24 day 17 715 2.48 45.2 17.5 9.4 100 1999

Shandong Zhaoyuan 0-7 year 10 804 1.94 2001

9 Cities of Shandong 0-7 year 183 249 1.33 2003

Shandong Zaozhuang 0-7 year 27 105 2.80 2004 Primary and Middle Yimeng Mountain 12 468 3.05 44.7 26.3 10.5 1993 School Students Primary and Middle Harbin 17 577 3.13 150 1984 School Students Hunan Changsha 3-14 year 21 588 2.93 < 500 1985

93 Report on Cardiovascular Diseases in China (2011)

Table 3-4-2 (1) Epidemiology of Age-cross-section Survey on Prevalence of Congenital Heart Continued Table Disease in China Prevalence Constitution (%) Publishing Area Subject Population Altitude (m) (‰) VSD ASD PDA Year Sichuan Chengdu < 6 year 11 230 3.10 600 1984

Beijing 0–2 year 19 432 4.63 45.55 15.55 8.88 900 2001 Middle School Beijing Dongcheng 41 234 2.52 Students Primary and Middle Shanxi Changzhi 92 593 3.37 55.4 30.4 7.1 750 1994 School Students Primary and Middle Shanxi Jincheng 16 5929 6.73 44.00 42.83 7.70 1 000 1994 School Students 6 cities of Gansu 2–19 year 115 535 5.71 52.72 31.82 5.30 2000 Innermongolia Primary and Middle 20 093 2.04 1 000 1983 Huhehaote School Students

Innermongolia [34] 6–14 year 5 700 4.04 34.8 34.8 2009 Balinyouqi Ningxia Yinchuan All Population 26 117 3.19 45.7 39.8 6.0 1 000 1992

South of Ningxia 0–14 year 10 041 4.58 56.52 21.74 8.69 1 900 2009[35]

Yunnan Kunming 0–17 year 76 959 2.73 55.44 17.62 11.40 1 800 2000

Dali Bai ethical area 5–15 year 13 821 7.96 34.5 54.5 8.2 2 029 1991

Yunnan Dali 3–18 year 12 614 7.85 34.5 54.5 8.2 2 029 2005

Yunnan Baoshanlongling 3–18 year 3 334 7.50 54.45 27.27 0 2005

Yunnan Xishuangbanna 3–18 year 19 307 2.75 43.75 18.75 18.75 2005

Yunnan Gejiu 3–18 year 12 912 4.80 41.10 32.57 21.05 2005

Yunnan Luxi 3–18 year 471 16.99 0 25.00 0 2005

9 Counties of Qinghai 4–18 year 288 066 5.66 26.01 37.42 28.47 2009[36]

Qinghai Xi ning < 17 year 56 58 7.10 19.69 27.27 50.76 2 261 1982

Qinghai Haidong 4–18 year 97 718 5.08 35.69 37.30 22.18 2 535 2009[37]

Ping An County 4–18 year 20 851 3.64 43.43 28.95 21.05 2 183 2009[38]

Le Du County 4–18 year 27 094 5.46 40.54 29.73 18.90 2 400 2009[39]

Hu Zhu County 4–18 year 49 773 5.45 30.88 43.75 24.26 2 700 2009[40]

Qinghai Huangzhong 1–14 year 10 262 13.70 21.3 26.9 42.6 2 631 1984

Xinjiang Chabuchar < 25 year 7 042 5.68 3 000 1992

Qinghai Haixi < 17 year 51 76 8.10 3 050 1982

Qinghai Hainan 4–17 year 53 827 5.68 29.36 32.35 23.56 3 200 2009[41]

Qinghai Haixi district 4–17 year 67 663 5.22 21.25 39.94 29.46 3 468 2008[42] Primaryear Shool Tibet Lasa 6 500 6.15 27.5 27.5 32.5 3 658 2002 Students Qinghai Huangnan 4–17 year 33 235 6.67 22.07 41.44 30.63 3 700 2008[43]

Qinghai Yushu < 17 year 2 612 13.80 4 628 1982 Note: VSD ventricular septal defect, ASD atrial septal defect, PDA patent arterial duct

94 Chapter 3 Prevention and Control of Cardiovascular Disease

Table 3-4-2 (2) Epidemiological Survey on Prevalence of Congenital Heart Disease in Different Ethnic Groups in China Compare Area Goup Population Prevalence (‰) with Han Publishing Year Ethnic Qinghai Han 7 655 8.10 1982 Hui 2 730 6.30 Tibetan 2 384 14.70 p < 0.01 Mongolia 887 7.90 Hazak 578 17.30 Qinghai Han 1 42 019 5.32 2009[44] Tibetan 91 249 6.40 p < 0.005 Mongolia 10 728 7.55 p < 0.005 Tu 14 704 5.23 Hui 27 281 4.89 Shala 1 354 2.22 Huhehaote Han 14 371 1.90 1983 Mongolia 42 35 1.10 Hui 904 1.10 Man 490 4.00 p < 0.05 Yunnan Dali Han 3 506 6.90 1991 Bai 9 108 8.40 p < 0.05 Ningxia Yinchuan Han 3.25 1992 Hui 2.82 5 Cities in Hainan Han 62 373 3.04 1992 Li 14 330 1.79 Xinjiang Chabuchar Sibo 7 042 5.68 1992 Hazak 3 589 2.23 Guangxi Guilin Han 9 507 1.58 1999 Yao 783 1.28 Tibet Lasa Han 1 270 7.09 2002 Tibetan 5 066 6.12 5 Cities in Yunnan Han 33 040 4.18 2005 Dai 4 080 5.39 Jinuo 1 172 6.83 Hani 1 020 0 Bai 9 108 8.12 Jinpo 141 14.18

95 Report on Cardiovascular Diseases in China (2011)

3.4.2.2 The Incidence of Congenital Heart Disease in Surveilliance of Perinates with Birth Defects in China

Since the beginning of this century, birth defect surveillance programs on perinates have been carried out in many areas of China. Among the frequently seen birth defects, the rate of congenital heart diseases increased in many cities and provinces. [45] Table 3-4-2 (3) Incidence of Congenital Heart Disease in Surveilliance of Perinates with Birth Defects in China The Position Incidence Area Population Investigation Period Subject Ranked in Local (‰) Birth Defects

Perinates (Fetal Death and Stillbirth Hunan Anren 43 931 1991.1.1-1999.12.31 0.98 No. 5 not Included)

Chongqing Beipei 20 136 1998.10-2001.9 All Infants Born during This Period 0.695 No. 1

Shenzhen Baoan Perinates (Fetal Death and Stillbirth 17 763 2000.10.1-2005.9.30 1.13 No. 5 Shajing Street Included)

Perinates (Fetal Death and sillbirth Hunan Changsha 65 298 2001.1.1-2005.12.31 2.79 No. 1 Included)

Shanxi Perinates (Fetal Death and Stillbirth Zhongyang and 6 420 2002.1.1-2004.12.31 7.32 No. 2 Included) Jiaokou

Guangdong Perinates (Fetal Death and Stillbirth 245 615 2003.1.1-2005.12.31 3.3 No. 1 Shenzhen Included)

Zhejiang Perinates (Fetal Death and Stillbirth [46] 41 396 2000.1.1-2006.12.31 3.36 No. 1 Zhoushan Included)

Beijing Perinates (Fetal Death and Stillbirth [47] 6 699 2001.1.1-2005.12.31 2.23 No. 2 Chongwen Included)

[48] Allinfants Born during This Period Anhui Bengbu 16 698 2001.7.1-2006.6.30 5.15 No. 2 (fetal Death and Stillbirth Included)

Guangdong 21 [49] 150 357 2007 Perinates 5.89 No. 1 Cities

Beijing Shangdi Perinates (Fetal Death and Stillbirth [50] 10 956 2006-2007 5.84 No. 1 Hospital Iincluded)

Fujian Perinates (Fetal Death and Stillbirth [51] 199 563 2003.1.1-2008.9.30 0.76 No. 3 Zhangzhou included)

In the survey of Changsha, [52] the congenital heart disease has ranked to No.1 in 2005 on the list of local birth defects, climbing up from No.4 in 2001. In Shenzhen,[53] Zhejiang zhoushan[54] and Guangdong province[55] the incidence of congenital heart diseases in local birth defects also rose year by year.

96 Chapter 3 Prevention and Control of Cardiovascular Disease

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The surveillance programs indicated that the incidence of congenital heart diseases increased in recent years in many cities and provinces in China. This increasing trend was coincident with the result of the foreign similar surveillance. The Metropolitan Atlanta Congenital Defects Program (MACDP) of U.S.A. has also been documenting long-term trends of increasing rates of heart defects in recent 35 years. [56] However, the increasing trend of surveillance rate of congenital heart disease in China seemed to be comprehensively affected by the factors as method being adopted, target and extension of birth defects surveillance, technology used for diagnosis (such as the popularization and application of echocardiography for diagnosis), and quality control on surveillance programs. Otherwise, high maternal age, drug use, and exposure to environment harmful factors in early pregnancy stage, mother’s illness were also the reasons.

3.4.2.3 Epidemiological Survey on Incidence of Perinatal Congenital Heart Disease in China

Since 1970s, many surveys in other countries showed that the incidence of congenital heart disease in live birth ranged from 4.05‰ to 12.3‰. Beginning from 1990s, the special epidemiological survey on perinatal congenital heart diseases was conducted in a few cities of China.[57, 58, 59] These valuable surveys afforded us the more accurate incidence and the distribution of types of congenital heart disease in mainland China. Table 3-4-2 (4) Incidence of Perinatal Congenital Heart Disease in Mainland China Affected Areas Subjects Population Incidence (‰) Publishing Year Fetuses Shanghai Yangpu and Xuhui District Live Birth 20 082 138 6.87 1995 Zhejiang Jiaxing Live Birth 20 436 294 14.39 1997 Liaoning Dalian Total Birth 35 068 487 13.9 2005 Beijing Total Birth 84 062 686 8.2 2009[60] Beijing Live Birth 83 292 556 6.7 2009[61] Urban District of Tongling Live Birth 5 410 65 12.01 2010[62]

97 Report on Cardiovascular Diseases in China (2011)

(1) The incidence of perinatal congenital heart disease had great differences between different regions of mainland China. It ranged from 6.7‰-14.39‰. (2) The survey in Shanghai indicated that the death of congenital heart diseases occurred mostly in a short period after birth, and mainly was attributed to cyanotic congenital heart diseases. Main cause of deaths include: interrupted aortic arch, joint truncus arteriousus, single ventricle, hypoplasia left heart syndrome, complete transposition of great arteries, total anomaly pulmonary venous drainage and complete atrioventricular canal. The outcomes of urban district of Tongling showed that congenital heart diseases had a mortality of 15.38% in the fi rst year after born, accounted 30.3% of infant death during that period. (3) In mainland China, congenital heart diseases were mainly consisted of ventricular septal defect, atrial septal defect and patent arterial duct. The sum of the three could account 50%-60% or more of the total congenital heart diseases. In cyanotic congenital heart diseases, Fallot tetrad, pulmonary stenosis and complete transposition of great arteries ranked the front of all. The high incidence of TOF and low incidence of aortic stenosis and coarctation of the aorta were more notable in Chinese survey than those reported by Mitchell et al. [63] In Beijing’s survey, the incidences of TOF, aortic stenosis and coarctation of the aorta were 52.3, 11.9 and 14.3 per 100 000 births, respectively, whereas in the study of Mitchell et al, they were 28.5, 28.5, and 53.5 per 100 000 births, respectively.

Table 3-4-2 (5) Distribution of Types of Congenital Heart Disease in Perinates (%) Cardiac Beijing Shanghai Jiaxing Dalian Cardiac Malformation Beijing Shanghai Jiaxing Dalian Malformation VSD 34.0 56.5 19.4 20.95 Aortic Stenosis 1.6 1.5

ASD 10.8 8.0 29.6 18.07 Truncus Arteriosus 1.4 1.5 0.3 0.21

PDA 23.7 7.2 10.9 13.14 ECD 1.3 1.5 0.6 0.42

ASD+PDA 11.9 11.5 Single Ventricle 0.7 0.7 0.7 0.21

ASD+VSD 10.9 12.73 Pulmonary atresia 0.7 0.7

PS+ASD 0.7 5.95 TAPVC 0.4 0.7 0.21 Hnterruption of aortic PS 9.2 4.3 5.1 5.13 0.2 2.2 0.7 0.21 arch TOF 4.7 5.1 2.0 3.08 Ebstein’s Anomal 0.4 0.3

TGA 3.6 5.1 0.7 2.05 Tricuspid Atresia 0.2 0.7 0.3 0.63

VSD+PDA 0.7 1.03 HLHS 0 0 0.6 0.63

CoA 1.8 0.7 1.0 1.03 HRHS 0.3 0.42

Note: VSD: ventricular septal defect, ASD: atrial septal defect, PDA: patent arterial duct, PS: pulmonary stenosis, TOF: tetralogy of Fallot, TGA: complete transposition of the great arteries, CoA: coarctation of the arota, ECD: atrioventricular septal defect, TAPVC: total anomalous pulmonary veinous connection, HLHS: hypoplastic left heart syndrome, HRHS: hypoplastic right heart syndrome.

(4) About 20.5%-52.9% ventricular septal defects would spontaneously close within 1 year after born, the

98 Chapter 3 Prevention and Control of Cardiovascular Disease occlusion rate of defect at ventricular muscles was higher, as well as 80% of occlusion rate occurred in atrial septal defect and 21% in patent arterial duct. There were a high incidence and a high 1 year occlusion rate among preterm infants with patent arterial duct. (5) In the survey of Beijing, 22.0% (151/686) of the affected fetuses with congenital heart disease were diagnosed prenatally by fetal echocardiography during routine obstetric examinations. Among them, 84.8% (128 cases) had the pregnancy terminated, a rate quite higher than the average (43%) reported (P< 0.001). [64] The incidence of congenital heart disease in stillborn was reported to be 27.5‰ in the westen countries.[65] This refl ected the natural fetal loss because there were no prenatal diagnoses such as fetal echocardiography then. However, in the survey of Beijing, the incidence of congenital heart disease in stillbirth rose to 168.8‰. The difference was highly signifi cant (P< 0.001). An important reason for this difference in Beijing’s survey should be due to the termination of pregnancy because of the negative result of fetal echocardiography. It also caused the signifi cantly difference of the incidence of congenital heart disease between the total birth and live birth in Beijing’s survey (8.2‰ vs 6.7‰, P< 0.001). Fetal echocardiography signifi cantly reduced the incidence of congenital heart disease in live birth in mainland China. In summary, according to the sixth national census of 2010, the population in mainland China had reached 1 339 724 852. On the other hand, since the current family planning policy has been kept for many years, China has entered a new period of low birthrate. The proportion of births to the population stabilized at about 1.5%. The incidence of perinatal congenital heart disease ranged from 6.7‰-14.39‰ in different regions of mainland China. If counted by 8‰ incidence of congenital heart disease, there are about 0.16 million newborns with congenital heart diseases every year in mainland China.

3.4.3 Surgical Treatment of Coronary Artery Disease 3.4.3.1 Chinese CABG Registered Research

From 2007-2008, complete clinical information of 9 564 consecutive CABG patients was collected from Chinese coronary artery bypass grafting registry which recruited patients from 43 Chinese centers. The fi nal data of these patients were reported in 2010[Table 3-4-3(1)].[66]

Table 3-4-3 (1) Outcomes of Chinese CABG Registered Research

Group Period Cases Male Age (Y) Hypertension

CABG Group A[67] 2007-2008 9 564 77.3% 62.1±9.2 37%

Group Diabetes Mellitus Isolated CABG Selective Operation In-hospital Mortality

CABG Group A[68] 29.8% 87.7% 97.1% 2.54%

(1) A scoring system was constructed based on a risk mode which was developed by using logistic regression. [69] Thresholds were defi ned for each model to distinguish different risk groups for the prediction

99 Report on Cardiovascular Diseases in China (2011)

of in-hospital mortality in Chinese patients undergoing CABG.

Table3-4-3 (2) 11 Risk Factors in Chinese CABG Patients

Risk Factors Deﬁ nition Weights

Relative Factors of Patient

65-69 Year 3

70-74 Year According to last birthday 5

≥75 Year 6

BMI≥24 kg/m2 -2

BMI< 18 kg/m2 5

Chronic Renal Failure History of renal failure, or history of Scr > 176 μmol/L 6

Angina, or carotid artery occlusion or stenosis > 50%, or operative 5 Extracardiac Arteriopathy history on artery of extremity, abdominal aorta, or carotid artery Long-term use of bronchodilators or cortical hormone because of Chronic Obstructive 4 pneumonopathy, forced expiratory volume in one second/forced vital Pulmonary Disease capacity < 0.7 NHYA III 3

NHYA IV NHYA Stage 7 Relative Factors of Heart

Preoperative AF/Af Within 2 weeks 2

LVEF< 50% Depending on echocardiography 4

Preoperative cardiogenic shock, or ventricular ﬁ brillation / ﬂ utter, or 4 Critical Preoperative State preoperative IABP support

Non-selective Operation

Combined Non time selecting operation 5

Valve Procedure CABG combined valve procedure 4 Note: Weights = regression coeffi cient×5

(2) According to the total weights of the risk factors a patient would suffer, the mortality risk of CABG procedure can be estimated.

Table 3-4-3 (3) Prediction Model for In-hospital Mortality in Chinese CABG Patients (%) The Prediction of In-hospital Mortality Group Weights (95% CI) Low Risk ≤1 0.52-0.89

Moderate Risk 2-5 1.29-1.94

High Risk ≤6 6.36-6.63

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3.4.3.2 Comparison of Off-pump and On-pump CABG

Despite its widespread use and short-term effi cacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB). A retrospective review of prospectively collected data was conducted of 6 665 consecutive patients undergoing isolated CABG at Fu Wai Hospital during 1999 to 2006.[70] All patients were followed up until September 30, 2008. Short- and long-term outcomes were compared between OPCAB and conventional CABG. The overall mean baseline age was 60.3 ± 8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fi brillation (P =0.003) and requirement for blood transfusion (P =0.003) and ventilation time > 24 hours (P < 0.001). After an average of 4.5 years of follow-up, the rates of repeated revascularization (adjusted hazard ratio, 1.40; 95% CI, 1.03- 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% CI, 1.09-1.39) were signifi cantly higher in OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate. Compared with conventional on-pump CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeated revascularization and major vascular events, especially among high- risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run.

3.4.3.3 Aggressive Antiplatelet Therapy after CABG for Improving Graft Patency

Prevalence of graft occlusion is high after CABG. Aggressive antiplatelet therapy is expected to improve early post-operative graft patency. A single-center, randomized, controlled trial was performed to evaluate the effect of aspirin plus clopidogrel versus aspirin alone on saphenous vein graft occlusion at 3 months after CABG.[71] From December 2007 through December 2008, 249 consecutive patients undergoing elective CABG at Fu Wai Hospital were randomly assigned to 2 groups.[71] 124 received aspirin (100 mg) plus clopidogrel (75 mg) daily, and 125 received aspirin (100 mg) alone daily. All participants were invited for clinical follow-up and 64-slice multislice computed tomography angiography (MSCTA) analysis at 3 months post-operatively. Generalized estimating equations analysis was used to determine predictors of graft patency. Three-month MSCTA follow-up revealed that saphenous vein graft patency was 91.6% (219 of 239) in the group of aspirin plus clopidogrel versus 85.7% (198 of 231) in the group of aspirin alone (P = 0.043). In multivariate analysis, combined antiplatelet therapy independently increased venous graft patency (P = 0.045). Conclusions: Aspirin plus clopidogrel is more effective in venous graft patency than aspirin alone in the short term after CABG, but further, long-term study is needed.

101 Report on Cardiovascular Diseases in China (2011)

3.4.4 Surgical Treatment of Heart Valve Disease 3.4.4.1 Surgical Outcomes of Heart Valve Diseases in China

In Mainland China, there were three reports on surgical outcomes of large group patient with heart valve diseases in 2010.[72, 73, 74] One report focused on establishment of risk evaluation system for heart valve surgery.

Table 3-4-4 (1) Clinical Research on Valvular Heart Surgery in Mainland China in 2010 Group Period of Patients Case Male Female Age (year)

Group A[75] 1993-2004 4 437 46.2% 53.8% 46.7 Group B[76] 1995-2007 2 349 47.2% 52.8% 41±19 Group C[77] 1993-2007 913 53.2% 46.8% 46.2 (7-72)

Table 3-4-4 (2) Clinical Research on Valvular Heart Surgery in Mainland China in 2010 Cause and Onset of Disease NYHA Stage Group Rheumatic Degenerative Congenital Infection II III IV Group A[78] 82.5% 5.1% 4.3% 36.2% 51.1% 9.2% Group B[79] 83.5% 13.1% 1.7% 17.8% 65.0% 17.1% Group C[80] 81.4% 7.1% 6.0% 2.1% 31.0% 52.9% 14.6%

Table 3-4-4 (3) Clinical Research on Valvular Heart Surgery in Mainland China in 2010 Operative Proportion/Mortality in Different Heart Valve Group Operative Mortality MVR AVR BVR TVR Group A[81] 5.3% 49.6%/4.1% 19.1%/5.0% 31.3%/6.3% Group B[82] 3.4% 56.7%/2.32% 11.5%/3.32% 31.3%/5.24% 0.4%/0 Group C[83] 4.9% 78.9%/ 21.1%/ 0.9%/ Note: MVR mitral valve replacement, AVR aortic valve replacement, BVR aortic and mitral valve replacement, TVR tricuspid valve replacement,

3.4.4.2 Risk Evaluation System for Heart Valve Surgery

(1) Evaluation system for in-hospital mortality in valve replacement patients. The data from a total of 4 437 patients during January 1993 and December 2004 who underwent heart valve replacement at Anzhen Hospital were analyzed.[84] Logistic regression was used to examine the relationship between risk factors and in-hospital mortality. The mathematic model was established for the prediction of the in-hospital mortality, which was: Prob (event) = 1 / (1+ e -Z). Prob means the predicted in-hospital mortality. Z value should be calculated depending on which valve is replaced. In aortic valve replacement: Z value = -7.921 + 0.073×age + 1.479× NYHA class + 0.429 × preoperative serum creatin + 0.015× CPB time - 3.586× body surface. In mitral valve replacement: Z value = -4.475 + 0.954 × preoperative heart failure + 0.060× cardiac/ thoracic ratio + 1.867× intra-operative IABP + 0.016 ×CPB time + 0.857× NYHA class - 0.071× fractional shortening in echocardiography - 0.074×left ventricular end-systolic dimension - 1.273× rheumatic

102 Chapter 3 Prevention and Control of Cardiovascular Disease heart disease. In aortic and mitral valves replacement: Z value = -8.083 + 0.069×age +1.360×NYHA class+ 6.244×previous myocarditis + 2.917× diabetes + 2.789×previous percutaneous mitral balloon valvotomy + 0.023 × CPB time - 0.139 × body weight index. (2) Validation of the European system for cardiac operative risk evaluation (EuroSCORE) in Chinese heart valve surgery patients. Between January 2003 and December 2007, the data from a total of 1 726 consecutive patients who underwent heart valve surgery at Chang Hai Hospital were collected and scored according to the additive and logistic EuroSCORE models [85]. There were signifi cant differences in the prevalence of risk factors between the study sample and European cardiac surgery populations. The observed mortality was 4.46% overall, compared to 3.51% (additive) and 2.85% (logistic). The additive EuroSCORE model showed good calibration in predicting in- hospital mortality (H-L; p = 0.204), but the logistic EuroSCORE model underpredicted observed mortality (H-L; p = 0.038) in the entire cohort. Both, the additive and logistic EuroSCORE models showed good calibration in predicting in-hospital mortality in the medium- and high-risk subgroups, but overpredicted observed mortality in the low-risk subgroup. The discriminative power of both models for the entire cohort was poor (areas under the ROC curve of 0.644 and 0.647 for the additive and logistic models, respectively). Conclusion: The additive and logistic EuroSCORE models gave an imprecise prediction for individual operative risk in heart valve surgery patients at the authors' center. It will be necessary to re-examine the performance of the EuroSCORE model for predicting operative mortality in heart valve surgery on a multicenter database in China.

3.5 Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis excluding the coronary and intracalvarium arteries. This report is only involved in lower extremity arteriosclerosis disease (LEAD) and carotid artery arteriosclerosis (CAD).

3.5.1 Lower Extremity Arteriosclerosis Disease 3.5.1.1 Prevalence of Lower Extremity Arteriosclerosis Disease

LEAD is a common clinical syndrome in middle-older people. Many epidemiology studies were conducted on prevalence of LEAD by non-invasive methods, including Rose Claudication Questionnaire, ankle-brachial index (ABI) and pulse wave velocity (PWV), etc. The studies demonstrated that LEAD morbidity was dependent on age, risk factors and baseline diseases. The Chinese epidemiology studies were shown in Table 3.5.1 (1), and diagnosis of LEAD was based on ankle brachial index (ABI) less than 0.90.

103 Report on Cardiovascular Diseases in China (2011)

Table 3-5-1 (1) Chinese Epidemiology Studies on Prevalence of LEAD Morbidity (%) Population Years Cases Years All Male/Female Fisher in Zhoushan Area of Zhejiang 2005[86] 2 668 >35 2.1 3.0 / 1.2

Group of MUCA* 2007[87] 18 140 >35 6.0 5.4 / 9.3

The Elderly in Wanshoulu Area, Beijing 2003[88, 89] 2 124 60-95 16.4 12.7 / 18.1

Diabetes 2007[90] 1 347 >50 19.4 18.3 / 20.4

Patients with Metabolic Syndrome 2006[91] 2 115 32-91 22.5 21.7 / 23.4

Hypertensive Patients [92] 3 047 >50 27.5

Natural Population in Community 2009[93] 21 152 >18 3.04 1.8 / 4.3

Nine Community Population 2010[94] 16 446 >35 6.4 5.9 / 10.2

Uygur, Kazakhs 2010[95] 14 618 >35 6.51 4.3 / 7.9

Inner Mongolia (Mongolian) 2011[96] 1 236 (959) >18 1.9 Note: MUCA, multiple units cooperation of Chinese epidemiology cardiovascular diseases.

These literatures showed that there was a signifi cant difference in prevalence LEAD among Chinese populations. In addition, the prevalence of LEAD increased with age, with higher prevalence of females than that of males in most studies.

3.5.1.2 Risk Factors

Epidemiological study showed that prevalence of LEAD increased with age and cardiovascular risk factors. Main cause of LEAD is atherosclerosis, and all atherogenic risk factors such as smoking, diabetes, lipid disorders, hypertension and hyperhomocysteinaemia can increase the prevalence of LEAD. Two studies in Beijing showed that prevalence and severity of LEAD were positively related to age, smoking, duration of diabetes, blood glucose level, higher systolic pressure, hypercholesterolemia and higher LDL-C level.[97,98] In Uygur and Kazakhs population, the related risk factors included elder, female, overweight or obesity, higher systolic and diastolic pressure and history of CAD.[99] Sedentary lifestyle was proved to be associated with LEAD. Univariate analysis demonstrated that those with more intense activity have lower risk of LEAD (P trend < 0.05).[100] Therefore, LEAD is an important window refl ecting the systemic arteriosclerotic disease, and the early detection and treatment for LEAD are very important to deal with systemic arteriosclerotic diseases.

3.5.1.3 Impact of LEAD on Mortality

Mortality of patients with LEAD is signifi cantly higher than those without LEAD at the same age, with higher mortality in those with lower ankle brachial index (ABI). A study[101] investigated the relationship of ankle-brachial index (ABI) with all-cause mortality and cardiovascular (CV) mortality in 3 210 Chinese inpatients after 3 years of follow-up. Adjusted for other risk factors, patients with ABI ≤ 0.4 were 3.105

104 Chapter 3 Prevention and Control of Cardiovascular Disease times (95% CI, 1.936-4.979) as likely to die as those with ABI in the range of 1.0-1.4; patients with ABI ≤ 0.4 were about fi ve times (95% CI, 2.740-8.388) as likely to die of CVDs as those with ABI in the range of 1.0-1.4. Even patients with ABI in the range of 0.41-0.90 were more than 1.5 times as likely to die (relative risk=1.534, 95% CI, 1.199-1.962), or die of CVDs (relative risk=2.031, 95% CI, 1.479-2.789) as those with ABI in the range of 1.00-1.4. Low ABI is related to a higher all-cause and CV mortality compared with normal ABI.

Table 3-5-1 (2) Mortality of Patients with Different ABI during 3-year Follow-up Study Mortility ABI≤0.4 0.41-0.9 0.91-0.99 1.0-1.4 All ABI P All Cause Mortility (%) 37.7 24.4 13.2 12.1 15.7 <0.001

Cardiovascular Mortility (%) 27.5 14.5 8.1 6.3 8.9 <0.001

3.5.2 Carotid Atherosclerotic Disease 3.5.2.1 Prevalence and Risk Factors of Carotid Atherosclerotic Disease

Carotid atherosclerotic disease is a common clinical syndrome in elderly patients. Previous studies defi ned carotid atherosclerotic disease with carotid intima-media thickness (IMT) ≥0.9 mm or carotid atherosclerotic plaque (IMT 1.2-1.53 mm or a focal structure that encroaches into the arterial lumen of at least 0.5 mm).[102, 103, 104, 105] Table 3-5-2 (1) showed some epidemiological studies.

Table 3-5-2 (1) Prevalence of Carotid Atherosclerotic Disease Shown in Several Studies in China Prevalence Population Year Sample Age (y) Total Male/Female Veterans in Beijing* 2007[106] 820 ≥60 44.0 53.7/33.5

Capital Iron and Steel Company** 2008[107] 1 058 37-86 68.2 76.0/59.7

Middle-aged and Aged Population [108] 2010 2 681 43-81 60.3 66.7/56.2 in Beijing*

Physical Examination People in [109] 2011 6 142 20-92 23.0 28.4/13.7 zhejiang*** * IMT ≥ 1.3 mm; ** IMT ≥ 1.2 mm; *** IMT ≥ 1.5 mm

3.5.2.2 Risk Factors of Carotid Atherosclerosis

A population-based cardiovascular epidemiology survey was performed in a total of 1 198 residents in Shijingshan Beijing. Carotid plaque and the intima-media thickness were measured using duplex ultrasound. The intima-media thickness, the prevalence of plaque and the number of plaques were found signifi cantly positively related to blood pressure levels, pulse pressure as well as to the duration of hypertension [Table 3-5-2 (2)]. [110] The risk factors included age, body mass index (BMI), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), fasting glucose and smoking.

105 Report on Cardiovascular Diseases in China (2011)

Table 3-5-2 (2) The Relationship among Prevalence of Plaque, Mean IMT and Blood Pressure, Pulse Pressure and Duration of Hypertension Variables Plaque (%, male) Plaque (%, female) IMT mm (male) IMT mm (female)

Optimal 29.2 22.1 0.70 0.67 Stage 1 Hypertension 50.4 38.5 0.74 0.71 Stage 3 Hypertension 55.6 66.7 0.80 0.72 Pulse Pressure < 45.3 mm Hg 32.9 15.8 0.71 0.68 Pulse Pressure 45.3-59.3 47.5 28.5 0.73 0.70 Pulse Pressure > 59.3 66.1 46.8 0.76 0.72 No Hypertension 40.7 15.8 0.71 0.68 Hypertension 0.15 Year 50.0 28.5 0.73 0.70 Hypertension≥6 Year 62.1 46.8 0.76 0.72

In a study conducted among veterans in Beijing, the risk factors of carotid atherosclerosis included age, sex, obesity, smoking, hypertension and diabetes.[111] The carotid atherosclerosis was common in middle and older age Chinese in Beijing and Hypertension, diabetes, smoking and high LDL-C were independent predict factors for the risk of carotid plaque.[112] In 6 142 subjects who underwent general health screening including carotid ultrasonography, male gender, age≥50 years, blood pressure, fasting blood glucose (FBG) and low- density lipoprotein cholesterol were risk factors for carotid atherosclerosis and carotid plaque. Figure 3-5-2 showed the relationship of the prevalence of carotid plaque, age and sex.[113]

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Figure 3-5-2 Age-speciﬁ c Prevalence of Carotid Atherosclerosis (A) and Carotid Plaque (B) in 6 142 Subjects Who Underwent General Health Screening

106 Chapter 3 Prevention and Control of Cardiovascular Disease

The risk factors of carotid atheroselerosis in type 2 diabetes mellitus in Uygur people included and older age, LDL-C and fi bfi nogen.[114] A study investigated investigated the relationship between hyperglycemia and carotid atherosclerosis in Tibet population, and found that higher 1evels of HbAlc, older age, dyslipidemia and insulin resistance were the important related factors of carotid atherosclerosis.[115]

3.5.2.3 PRC-USA Collaborative Study and Cardiopulmonary Epidemiology [116]

An observational longitudinal study with a 5-year follow-up, investigated the index that best refl ects the relationship between carotid atherosclerosis and subsequent ischaemic cardiovascular disease (ICVDs) events in 1 734 subjects in rural Shi Jing Shan in Beijing. The total area (TA) of plaques, the number of plaques (NP) and the number of segments (NS) with plaque were all signifi cantly positively associated with ICVDs in participants with plaque. Carotid intima-media thickness (IMT) at baseline was signifi cantly associated with the risk of ICVDs among participants without carotid plaque [Table 3-5-2 (3)].

Table 3-5-2 (3) Carotid Atherosclerosis and Subsequent Ischaemic Cardiovascular Disease Events in 1 734 Subjects in Rural Shi Jing Shan in Beijing Index HR 95% CI P

Intima-media Thickness 1.27 1.02-1.59 0.041 Intima-media Thickness Without 1.59 1.04-2.45 0.034 Without Carotid Plaque Total Area of Plaques 1.29 1.08-55 <0.001 Number of Plaques 1.14 1.02-1.27 <0.001 Number of Segments 1.45 1.09-1.93 <0.001

CAD can be detected conveniently and feasibly by vascular ultrasound scan in the early stage of lesion, and carotid atherosclerotic progression can be retarded through quitting smoking, control of hypertension, diabetes and lipid disorders.

3.6 Arrhythmia 3.6.1 Permanent Pacemaker, Implantable Cardiaoversion Deﬁ brillator and Cardiac Resynchronization Therapy

The fi rst case of permanent pacemaker implantation in mainland China was operated in 1962 in Shanghai. Since then, the volume of implantation cases and the proportion of physiological pacemaker usage have increased gradually. In 2005, 460 hospitals were documented for being capable of permanent pacemaker implantation[117, 118, 119] and the total implantation cases reached 18 090. The male patients was accounted for 55.5%, and 23.6% of the patients was below 60 years old [Figure 3-6-1 (1)]. In 2006, the implantation number grew to 20 000.[120] Studies in 2009[121] demonstrated that the hospitals qualifi ed for pacemaker implantation were 783, and total cases reached to 47 915, of which 52% of the cases were male, 79% were patients aged above 60 years, and 17% were those aged above 80 years.

107 Report on Cardiovascular Diseases in China (2011)

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Figure 3-6-1 (1) Annual Permanent Pacemaker Implantation Cases in China (1995-2009)

Statistic data[122] indicated that the ratio of the implantation of dual chamber pacemakers over single chamber pacemakers was 51.5% in 2005, and it was 52.9% when AAI/R physiological pacemaker was introduced in China. Among all the implantation indications, sick sinus syndrome (SSS) accounted for 50.1% of the population, and atrioventricular block for 39.4%, others for 10.5%. Among all of the etiologies, 35.9% of the implanted patients suffered with coronary artery disease, 10.4% with cardiomyopathy, and 53.7% for other causes. Data of 2009 demonstrated that the ratio of dual chamber pacemaker over single chamber pacemakers was 58%, VVI mode was set in 41% of implanted patients. Among the indications, 49% of implanted patients had SSS, 38% had AVB, and 13% received pacemakers for other reasons [Figure 3-6-1 (2)].

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Figure 3-6-1 (2) Distribution of PM Implantation Indications in 2009

The fi rst ICD implantation in mainland China was implemented in 1996. The total case numbers reached 285 by 2001. In 2005, the implantation cases were 186, and the number has continued to increase annually

108 Chapter 3 Prevention and Control of Cardiovascular Disease

[Figure 3-6-1 (3)]. ICD implantations in a national study between Jan 2005 to Dec 2006 showed that 121 cases (85.2%) was implanted for class 1 indication (secondary prevention), and only 15 cases (10.6%) for class IIa recommendation (primary prevention). [123] By 2009, the total cases had grown to 1 316, of which 116 cases was for replacement. [124] In 1999, CRT started in mainland China, between 2002 and 2007, the annual growth rate of implantation was more than 30% on average. Data from 193 hospitals indicated that there were 541 CRT implantation cases in 2007, including 59 CRT-D; 401 male cases (74.12%), and age distribution ranging from 20-90 years old (mean 60 ± 12) [125] [Figure 3-6-1 (4)]. The number of implantations reached to 1 300 in 2009.

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Figure 3-6-1 (3) Annual ICD Implantation Cases in China (2000-2009)

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Figure 3-6-1 (4) Annual CRT Implantation Cases in China (2002-2009)

3.6.2 Catheter Ablation

The fi rst clinic application of radiofrequency ablation was reported in mainland China in 1991,[126] RF ablation cases have increased rapidly since 1990s.There were 10 811 reported ablation cases in 2000 in 136 qualifi ed hospitals[127] [Figure 3-6-2 (1)]. In 2006, the number of catheter ablations increased to 20 000.[128]

109 Report on Cardiovascular Diseases in China (2011)

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Figure 3-6-2 (1) Annual RFCA Cases in China (1995-2006)

In 2000, 56.3% of the ablations cases were for AVNRT, 31.7% of the cases for AVRT, others for ventricular or atrial arrhythmias [Figure 3-6-2 (2)] (AT: atrial tachycardia; AFL: atrial fl utter; IVT: idiopathic ventricular tachycardia).

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Figure 3-6-2 (2) Distribution of RFCA Indications in 2000

Analyses of nationwide registration information indicated that, from 1998 to 2007, the AF ablation cases elevated progressively, from 11 cases in 1998 to 2 620 cases in 2007[Figure 3-6-2 (3)]. The major operative modes of AF included circumferential pulmonary vein ablation and segmental pulmonary vein ablation. The total success rate was 77.1%, recurrent rate was 22.9%, and incidence of complication was 5.3%.[129] The register study of catheter ablation of AF in China which started from 2008 indicated that.[130] by Oct 5th, 2010, there were 2 808 cases performed in 54 hospitals. Of which 1946 were male, and the average age was 57.4 ± 11.4 years old. Among all the cases, 71.5% were paroxysmal AF, 22.8% persistent AF, and 5.7% permanent AF. During the 1-18 (9.6 ± 3.8) months of follow up, total success rate was 82.1%, the complication rate was

110 Chapter 3 Prevention and Control of Cardiovascular Disease

1.7%, and the incidence of severe complications such as cardiac tamponade and pulmonary vein stenosis was 0.74%. No Atrial-esophageal fi stula was reported during that period. [131]

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Figure 3-6-2 (3) Registration Numbers of RFCA of AF in China (1998-2007)

3.6.3 Atrial Fibrillation

The prevalence of AF in the population with the age above 30 years old in China was 0.77%. According to the 1990 population age structure of China, the age-adjusted AF prevalence was 0.61%, and the prevalence was higher in men than in women (0.9% vs. 0.7%). The proportion of valvular AF, NON-valvular AF and lone AF was 12.9%, 65.2% and 21.9%, respectively. The common type of stroke secondary to AF was ischemic stroke, and the incidence of stroke in patients with AF was signifi cantly higher than those without AF (12.1% vs. 2.3%) .[132] Another study indicated that[133] among the population of age above 35 years old, the prevalence of AF was 0.74% in male and 0.72% in female. Among all AF patients, the percent of the fi rst- diagnosed cases was 30.9%, paroxysmal AF was 33.0%, persistent AF was 7.2%, and permanent AF was 28.9%. The anti-coagulation study of non-valvular AF in China enrolled 988 cases that had risk of thromboembolism. In this study, patients were randomly divided into 3 groups: standard warfrin anticoagulation intensity group (INR 2.1-2.5), low warfrin anticoagulation intensity group (INR 1.6-2.0), Asprin group (200 mg/d). During the follow up of 15 months, the annually incidence of thromboembolism in the three groups was 2.3%, 2.6%, 6.4% respectively, and the incidence of embolism events was signifi cantly lower in standard and low warfarin anticoagulation intensity groups than in asprin group (P = 0.018, P = 0.044). There was no statistic difference between standard and low warfrin anticoagulation intensity groups. The incidence of severe hemorrhage was 2.9%, 2.8% and 1.0% in 3 groups, respectively (P = 0.101). Low warfrin anticoagulation

111 Report on Cardiovascular Diseases in China (2011)

(INR 1.6-2.0) was as effective as standard warfrin anticoagulation intensity group (INR 2.1-2.5) .[134]

3.6.4 Sudden Cardiac Death

A study in four regions in China among 678 718 population from July 2005 to June 2006, there were 2 983 cases of death, 284 of which was SCD (9.5%), the incidence was higher in men than in women (44.6/100 000 and 39.0/100 000). It has a relatively higher incidence of SCD in the population with the age above 25 years old, 61.7/100 000 in men and 53.3/100 000 in women. It is estimated based on this study that there are 544 000 cases of SCD in China annually. [135]

3.6.5 Other Arrhythmia

A retrospective investigation which enrolled the hospitalized patients in cardiology department of 22 provincial hospitals demonstrated that 26.8% of all cardiac patients had cardiac arrhythmias. Among all of the patients, AF is the most common arrhythmia (35.0%), followed by paroxysmal superventricular tachycardia (28.0%), sick sinus syndrome (11.9%) and ventricular premature contraction (11.6%) .[136] A study in Hubei Province included a total of 16, 681 patients with chronic systolic heart failure showed that the rate of atrial premature, atrial tachycardia, and atrial fi brillation in chronic systolic heart failure patients who were hospitalized was 35.39%, 23.57% and 40.81%, respectively. The incidence of atrial tachycardia and atrial fi brillation increased with the increment of age and reduced LVEF. (Journal of Cardiac Arrhythmias 2011, (15) 6: 405-408)

3.7 Heart Failure 3.7.1 Incidence of Heart Failure

In 1997, a study analyzed the epidemiology of heart failure in Hong Kong.[137] The mean age of the female patients was 77.5 years and that of the male patients was 72.4 years (54-85 years old). The overall incidence rate was 0.7 per 1 000 population. In the>85-year age-group, the incidence was 20 per 1 000 women and 14 per 1 000 men.

3.7.2 Prevalence of Heart Failure The survey[138] of 20 urban and rural area in 10 provinces and cities The provinces and cities include: Jiangsu, Hubei, Fujian, Guangxi, Sichuan in the south, and Beijing, Jilin, Shaanxi, Qinghai, Shandong in the north. Involves the population of 15, 518 people, and the proportion of male and female, urban and rural population are similar. As shown in Table 3-7-2 (1) and 3-7-2 (2), there were 4 million heart failure patients in 35-74 year-old Chinese, the prevalence of chronic heart failure was 0.9%, and the prevalence of male and female were 0.7% and 1.0% respectively.

112 Chapter 3 Prevention and Control of Cardiovascular Disease

Table 3-7-1 (1) Prevalence of Heart Failure in Adults (35-74 years old) in Different Age and Gender(%)

Ages (year-old) sample size Male △ Female △ Total △

35~44 6 065 0.3 0.5 0.4 45~54 4 255 0.6 1.3* 1.0 55~64 3 375 1.3 1.4 1.3 65~74 1 823 1.1 1.5 1.3 Total 15 518 0.7 1.0* 0.9 Note: * male compared to female with heart failure incidence rate, U=2.03,P < 0.05; * prevalence in different age groups χ2=28.37, P < 0.01

Table 3-7-2 (2) Prevalence of Heart Failure in Adults (35-74 years old) in the North and South, the urban and Rural (%) Regional groups sample size Male △ Female △ Total

△ North 7 654 1.3 1.5 1.4 South 7 864 0.3 0.7 0.5 urban 7 822 1.0 1.2 1.1 Rural 7 636 0.6 1.0 0.8* Total 15 518 0.7 1.0* 0.9 Note: * the north compared to the south with heart failure incidence rate, U=5.08, P<0.01; * the city compared to the rural with heart failure incidence rate, U=1.92, P<0.054

3.7.3 Precipitating Factors of Heart Failure

A study investigated the evolving trends in the epidemiologic factors and treatment of hospitalized patients with congestive heart failure in Shanghai during years of 1980, 1990 and 2000.[139] Precipitating factors were present In more than half of 2 371 episodes of hospitalization of 2 178 cases. The most common precipitating factor was infection, which accounted 40.2%, 41.2 and 38.4% in 1980, 1990 and 2000, respectively. Other precipitating factors included tachycardia arrhythmia, non-compliance of therapeutic dietary pattern, hypertension, myocardium ischemia etc.

3.7.4 Risk Factors of Heart Failure

A retrospective study [140] investigated the etiology of inpatients with chronic heart failure during the past 30 years (1973-2002) in some areas and found that there was a upward tendency of coexisting diabetes, hypertension, cerebrovasclar diseases, atrial fi brillation and left bundle-branch block In patients with heart failure, and a downward tendency of coexisting alcohol drinking and chronic obstructive pulmonary disease (COPD). A study [141] examined the medical records of 1074 consecutive patients with heart failure who were admitted to Queen Mary Hospital from Jan. 2001 to Jan. 2002 and found that the majority were women

113 Report on Cardiovascular Diseases in China (2011)

(Female 64.3%; male 35.7%). The risks for heart failure increase with age, with 95.5% of patients aged ≥ 65 years old and 50.6% of patients aged≥80 years old in this cohort. The general coexisting diseases were diabetes (33.9%) and hypertension (32.8%). In another retrospective investigation [142] of hospitalized patients with heart failure in 42 hospitals around China in 1980, 1990 and 2000, 56.7% of the patients were male and more than 60% of the patients aged 60 years old.

3.7.5 Mortality of Heart Failure

An epidemiological study enrolled 6 203 patients with heart failure in Hong Kong, [143]1997 showed that overall mortality rate was 32%. The 1-year mortality rates of the male and female patients were similar, and showed a rising trend with age. The mortality rate reached 40% for those aged >85 years. Of the patients who died in the fi rst year, 86% died after they had been discharged from hospital. In Shanghai, the hospital mortality of the patients with heart failure was 13.8%, 11.5% and 6.0% in 1980, 1990 and 2000, respectively and the survival time was shown a rising trend, with 33.6 (37.1) 40.5 months in three periods.[144] There were 196 death in this study. The major cause of death was progressive heart failure (53.2%). Death due to complications, such as infection and arrhythmia was 38.2%, and sudden death was only 8.6%. In 2 656 elderly patients with heart failure from Jul. 1973 to Dec. 2002, [145] the hospital mortality declined year by year, with 11%, 16.9%, and 8.8% in three 10-year periods. The main cause of death was pulmonary heart disease in the fi rst and second 10-year periods, and was coronary artery disease in last 10-year period. In 1 074 consecutive patients aged≥years old and with heart failure who were admitted to Queen Mary Hospital from Jan. 2001 to Jan. 2002, [146] 51 (4.7%) patients died in the fi rst year. The symptoms of 476 patients (44.3%) improved and were transferred to other hospital. And 547 patients (50.9%) went home in stable condition. A study evaluated patients with chronic heart failure from 42 hospitals in 1980, 1990 and 2000. [147] The heart failure were obviously corrected during hospitalization, the improvement rate being 15.5%, 19.6% and 22.2% (P<0.001), respectively, with signifi cantly decreased mortality of 15.4%, 12.3%, 6.2% (P <0.001). The causes of the heart failure were pump failure (59%), arrhythmia (13%), sudden death (13%) and others (14%).

3.7.6 Average Time of Hospitalization and Emergency Department Visits

In the epidemiologic study of hospitalized patients with congestive heart failure in Shanghai during years of 1980, 1990 and 2000, [148] Average time of hospitalization and emergency department visits per year declined from 1980 to 2000, with 3.1, 2.8 and 2.0 times in 1980, 1990 and 2000, respectively.

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Chapter 4 Community-based Prevention and Control of Cardiovascular Disease

4.1 General Introduction of Community-Based Prevention and Control of Cardiovascular Diseases

The exploration and practice on Community-Based Prevention and Control of Cardiovascular Diseases (CPCCVDs) in China have been carried out for over 40 years, which is a community-based comprehensive intervention on CVDs and begins with the prevention and control of HBP. The fi rst base of CPCCVDs was established in the Capital Iron and Steel Company for the prevention and control of CVDs by Fuwai Hospital in 1969 and was nominated as 'Capital Iron and Steel Company Paradigm' by WHO. Since 1970s, a series of administrative regional community bases were established for the comprehensive prevention and control of HBP and CVDs throughout the country. From 1997, pilot sites of comprehensive prevention and control of non-communicable chronic disease (NCD) were established in 24 provinces, autonomous regions and metropolises, such as Beijing, Tianjin, Shanghai and Zhejiang province. We explored the way forward and made great achievements in CPCCVDs. With the new national policy on medicine reform launched in 2009, community-based prevention and control on HBP and diabetes mellitus was included in the fundamental public health services for the fi rst time. The task of CPCCVDs is really held at the national level. During the past four decades, the population covered by comprehensive intervention and management of CPCCVDs in China increased from hundreds of people to hundreds of thousands. At fi rst, only HBP patients were intervened. Now the whole community population, including general population, high- risk population and population with diseases and multiple NCDs, such as dyslipidemia, diabetes mellitus, coronary heart disease and stroke, are managed comprehensively. The practice changed from monitoring on the incidence, death and risk factors of CVDs to emphasizing the increase of awareness, treatment and control rate in population, from specialist-based scientifi c research and project to government-based multi- sectoral collaborative prevention and control management. CPCCVDs in our country has been developing into standardization, socialization and informatization step by step.

4.2 Introduction of a CPCCVDs Case-Comprehensive Prevention and Control of Hypertension in the Community of Yuhuan County[1, 2]

Yuhuan, one of the 14 island counties in our country, edging into the 100 best comprehensive strength counties for eight times, is located in the south-east coast of Zhejiang province. At present, there are 3 county-level medical institutions, 9 community health service centres, 2 health clinics, 40 community health

122 Chapter 4 Community-based Prevention and Control of Cardiovascular Disease service station and 251 village clinics in the county. Yuhuan health bureau ranks HBP prevention and control project as the second central task of the health system, with acute infectious disease prevention and control as priority in Public health service. HBP prevention and control project was taken as the acting point and the breakthrough for shifting the focus from communicable diseases to chronic non-communicable diseases, which obtained signifi cant results.

4.2.1 The Project is Government-dominated, Health Reform-driven, Institutionally Guaranteed and with Effective Measures 4.2.1.1 Leading Group was Set Up

Yuhuan county carried out the CPCH as a livelihood project. 'The notice on establishing public health working committee and CPCH supervision team' [NO. (2009) 79] was formulated and issued by Yuhuan county people’s government offi ce in July, 2009. A multi-sector-cooperated leading group was established with deputy county director as leader and staff from fi nance, labour, association for science and technology as partners. One million RMB was allocated for supporting the special project annually. The leading group’s offi ce was set up in health bureau and implementation situation of CPCH was written into the government annual report. The above measures provided powerful organizational guarantee to the continuous progress of CPCH.

4.2.1.2 Network System on CPCH was Established

Famous CVDs specialists were organized to establish expert panel. Members of the expert panel were in charge of different villages and towns to direct standardized treatment and provide technological support. Corresponding organizations were established in Center for disease control and prevention (CDCP) and health clinics of all towns. Top leader responsibility system was practiced. Messenger and quality control staff organization was built up on county and town level. Community doctors are responsible for the management of residents over 35 years old according to the classifi cation of diseases, and perform graded follow-up intervention on hypertensive patients. The formed CPCH network system was government dominated, county-level expert panel supported, county CDCP centered, town health clinic pivoted, village clinic based, and community responsibility doctors as mainstay.

4.2.1.3 Related System was Formulated

Quality control was the key point of CPCH. The bureau leaders and HBP offi cers were responsible for supervising, town quality control members and messengers performed on-the-spot quality control during the baseline survey phase. County and town two-level system of supervision and examination was established to perform routine supervision and examination quarterly in the follow-up intervention phrase. Quality control member and messenger meetings were held regularly. Reward and punishment system was established. Flowing red fl ag competition was held in the baseline survey phrase. Advanced individuals were elected, responsibility doctors competition was held to ensure

123 Report on Cardiovascular Diseases in China (2011)

everyone reach the standard in the follow-up intervention phrase. Special assess on supervision and examination after intensive training were held to those who did not reach the standard. The average score of responsibility doctors’ evaluation is an important indicator for the annual assessment of the town CPCH. One-vote veto was put into practice.

4.2.1.4 Supporting Measures

HBP risk factors, medical history, drug therapy and non-pharmacological intervention, target organ damage, relevant blood routine examination, blood biochemical test were listed in the physical examination of new rural co-operative medical system. Files were established for those new incomers aged over 35 years old and physical examination was performed routinely to all managed members. Adjust the existing drug preferential policies. Add free delivery of clonidine hydrochloride to one of the six basic antihypertensive agents, such as captopril and indapamide. Hypertensives can get the drugs from nearby responsibility doctors or from the town health clinics. 5 common antihypertensive drugs, including nifi dipine, Acertil, telmisartan, metoprolol and Zhenju tablet were on 50% discount to improve the treatment rate. HBP management offi ce was established to perform training, consulting and educating et al. Health Special Issue was set on 'Yuhuan Today' to publicize HBP related knowledge and advances on hypertension prevention and control regularly. Public-speaking tour system and HBP club were built to realize the normalization and systematism of publicity and education.

4.2.2 Scientiﬁ c Prevention and Control, 'Sanhua' Management and Strict Quality Control with Effective Results 4.2.2.1 Scientifi c Prevention and Control, 'Sanhua' Management and Strict Quality Control

CPCH in Yuhuan experienced three stages. Firstly, CPCH in the peasants’ health framework was set up from 2007. Secondly, CPCH exploration on free drug delivery and focus on elderly was developed from 2008. Thirdly, Yuhuan became the pilot site of Zhejiang CPCH informational management in 2009 and entered 'sanhua' stage, ie scalizaion, standardization and informatization. A mass of practice proved that 'sanhua' was a scientifi c and effective CPCH administration mode. But there was no precedent of generalizing the mode in a large area around the whole county so far. Three steps baseline survey project of experimental unit, enlargement and popularization was formulated to the 180 000 administered objects after comprehensive consideration of manpower and fi nance. Baseline survey was fi nished before June, 2010 in the whole county. Filing rate on baseline survey was over 80% and standardized management rate was over 80% in the experimental town. Filing rate on baseline survey was over 70% and standardized management rate was over 60% in the rest town. The main point of 'sanhua' was standardization. First, investigator access system was strict; all baseline investigator must be trained to be eligible. Second, secondary quality control member system was established in all towns and quality control monitors was set up. There was a full-time team quality control member in each investigation team who was in charge of supervision on the site, quality control and examination on

124 Chapter 4 Community-based Prevention and Control of Cardiovascular Disease investigation forms. Third, routine meeting of quality control member and messenger was held on every Thursday afternoon to refl ect and solve problem of the survey and meeting minutes was delivered to all investigators. Fourth, strengthen supervision and direction, divide the expert panel members from CDCP and county-level health institutions into HBP group, consultant group and comprehensive group to supervise and direct each investigation team every day. Fifth, elect advanced individuals, excellent quality control members and messengers. Award excellent investigation team biweekly to promote mutual improvement. Sixth, establish and perfect reporting system of information and quality control, responsibility position of quality control and message control were set. Daily sheet and weekly progress rate of each town were reported. CDC analysed and wrote the report on message and quality control annually. During the follow-up phrase, key emphasis in work was put on the data authenticity rather than on the follow-up rate, treatment rate and control rate. Stern punishment was performed once untruthfulness was found. The core of 'sanhua' is information. Yuhuan county bought the right to use U1000 softwares and established server to sort administered objects and classify hypertensives automatically. Reminders function was used to perform classifi ed regular follow-up intervention and management.

4.2.2.2 Achivements

Yuhuan County was the only one county that carried out prevention and treatment of HBP in the whole county and ranked the three pilot sites of CPCH informational management by Zhejiang provincial bureau of health by June, 2009. HBP baseline survey was held to the registered permanent resident of over 35 years old from July 2009 to June 2010. 178 330 residents were expected to be investigated and 132 463 were actually investigated and fi led with a fi ling rate of 74.3%. 37 697 (28.5%) were detected as hypertension, and many of those were below 60 years old, which increased by 193.9% from 5 360 to 15 751. The baseline control rate of hypertension was 20.6%. After one year follow-up management from July 2010, standardized follow-up rate was 89.7%, treatment rate was 65.3% and control rate increased to 63.2%. CPCH was carried out in Yuhuan County and achieved effective results. We believe by the support from government and promotion from administrative department, by means of persisting quality control and standard trained responsibility doctors and informatization, standardized CPCH can succeed in a whole county and even a larger scope.

References

[1] Zhou W, Li S, Liu T, et al. Survey on hypertension prevalence in island regions. Jounal of cardio-cerebrovascular disease prevention and control. 2010, 10 (6): 455-457 [2] Zhou W, Li S, Liu T, et al. Survey on hypertension prevalence in a population of over 35 years in Yuhuan County, Zhejiang province. China Preventive Medicine, 2011, 12 (5): 431-433

125 Report on Cardiovascular Diseases in China (2011)

Chapter 5 Medical Expenditure of Cardiovascular Diseases

5.1 Status of Inpatient Service Utilization for Cardiovascular Diseases and CBVD Patients in China 5.1.1 Total Number of CVDs and CBVD Inpatients Discharged and the Trend in China

In 2010, the number of Cardiovascular Diseases and CBVD inpatients discharged was 11.1969 million, accounting for 11.81% of all inpatients discharged in China (including all inpatient categories); amongst which 5.8215 million were CVDs patients and 5.3754 million were CBVD patients, taking up respectively 6.14% and 5.67% of all inpatients discharged. In 2010, CVDs & CBVD inpatients discharged mainly fall into two categories, namely, ischemic heart diseases (3.8025 million, including 0.2718million of acute myocardial infarction) and ischemic stroke (3.1843 million), occupying respectively 33.96% and 28.44%; other diseases were hypertension, 1.8024 million (including 138.6 thousand cases of hypertensive heart disease and renal disease), hemorrhagic stroke, 1.1208 million and rheumatic heart disease, 0.2166 million. In addition, the number of inpatients discharged with diabetes mellitus (DM) is 1.8307 milion. From 1980 to 2010, the annual average growth rate in the number of CVDs & CBVD patients discharged was 9.54%, faster than that of all inpatients discharged (including all inpatient categories, 6.00%) during the same period. Among the diseases, the arrangement of average annual growth rate about the each disease to cardiovascular disease is respectively ischemic stroke (12.12%), ischemic heart disease (11.37%), hemorrhagic stroke (10.58%), acute myocardial infarction (8.92%), hypertension (7.87%), hypertensive heart disease and renal disease (4.95%), while the number of discharged inpatients with rheumatic heart disease (1.14%) has not changed greatly. In addition, the annual growth rate of the patients discharged with diabetes is 14.06%.

126 Chapter 5 Medical Expenditure of Cardiovascular Diseases

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Figure 5-1-4 Annual Average Growth Rates of Numbers of CVDs and Diabetes Inpatients Discharged from Hospitals (1980-2010)

128 Chapter 5 Medical Expenditure of Cardiovascular Diseases

5.2 The Expenditure of Inpatients for CVDs and CBVD in Chinese Hospital

In 2010, it had shown from the expenditure of inpatients for CVDs & CBVD, the hospitalized cost of acute myocardial infarction is totally RMB 4.287 billion, the cost of hemorrhagic stroke is RMB 12.351 billion, the cost of ischemic stroke is RMB 22.747 billion; deducting the infl uence of price factor, from 2004, the annual average growth rates were respectively 33.14%, 24.01% and 30.10%, such a rapid increase speed is related to the rapid growth of number of inpatients discharged and rising of the hospitalized expenditure per patient closely. In 2010, we can fi nd the truth from the hospitalized expenditure per capita×time with CVDs and CBVD, the cost of acute myocardial infarction is totally RMB 15 773.5, the cost of hemorrhagic stroke is RMB 11 019.8, the cost of ischemic stroke is RMB 7 143.3; deducting the infl uence of price factor, from 2004, the annual average growth rates were respectively 8.05%-6.02%and 2.37%.

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129 Report on Cardiovascular Diseases in China (2011)

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Note: Total hospitalized expenditure=growth rate per capita×time of hospitalized expenditure×the number of inpatients Source: The data above come from the China Health Statistics Yearbook (2005-2011), Ministry of Health P. R. China

5.3 Cardiovascular Medicine Market

In 2010, the total medicine purchase of hospitals with 100 or more beds was valued at RMB 312.796 billion; amongst which the total purchase of cardiovascular medicine was RMB 38.674 billion. The top fi ve types of medicine are Cereb. + Periphe. Vasotherap, All Other Cardiac Preps, Calcium Antagonists Plain (monotherapy), Cholest & Trigly Regulator, Angiotens-II Antag. Plain (monotherapy).

Table 5-3-1 Top 15 Cardiovascular Medicine in 2010 (RMB100m) Types of Medicine 2010

Cardiovascular Medicine Total 386.74

Cereb. + Periphe. Vasotherap* 128.74

All Other Cardiac Preps 63.64

Calcium Antagonists Plain (Monotherapy) 37.91

Cholest & Trigly. Regulator 27.08

Angiotens-II Antag, Plain (Monotherapy) 26.48 Coronary Therapy (not Including Calcium Antagonists Plain 22.40 and Nitrites) Nitrites & Nitrates 13.12

Ace Inhibitors Plain (Monotherapy) 11.18

130 Chapter 5 Medical Expenditure of Cardiovascular Diseases

Continued Table Table 5-3-1 Top 15 Cardiovascular Medicine in 2010 (RMB100m)

Types of Medicine 2010

Treatment for Phlebeurysma, Systemic 11.18

Beta Blocking Agent Pln (Monotherapy) 9.05

Angiotens-II Antag (Combination) 4.88

Diuretics 3.60

Antihypertensive (Not Herb) 2.88

positive Inotropic Drug 1.85

Antiarrhythmic Drug 1.40

Other CVDs Medicine 21.35 Notes:* Cereb. + Periphe. Vasotherap includes Herba Erierontis, Deproteinized Calf Blood Extractives Injection, Ginkgo Leaf Extract and Dipyridamole Injection, Ginatol, Ginkgo Biloba Extract, Egb, Interactions of Ginkgo biloba extract, Duxil, Flunarizine Hydrochloride Capsules, Mailuoning and Deproteinized Calf Blood Extractives Injection, etc. Source: data collected by National Institute of Hospital Administration, from over 1 106 hospitals with more than 100 beds all over China, including Chemicals and Chinese Traditional Patent Medicines that have proven curative effects and follow western formulation processes, such as, Salvia Miltior. Co, Ginkgo Leaf formulation and Herba Erierontis, etc. Community-Based Prevention and Control of Cardiovascular Diseases

5.4 Explanation of the Data Analysis

We selected representative inpatient medical record-based national sample in Health Statistics Yearbook, including 30 kinds of relevant cardiovascular disease (acute myocardial infarction, intracranial hemorrhage and cerebral infarction) to describe inhospital costs and trends. The number of discharged patients: due to two adjustments of disease types in related disease by Center for Health Statistics and Information, MOH, in 1987 and 2002, there was inconsistency in number of inpatient discharges. In view of this, cardiovascular hospitalization costs in 2003 were not included in this analysis. Some errors in numbers of in-patient discharges maybe present, for there are some improper diagnosis in the primary hospital. But it does not affect the growth trend. Elimination of price impact: Elimination of price changes is needed to truly refl ect the growth of medical costs, we take into account the medical care price indexes in the China healthcare Yearbook for various medical comparability.

131 Report on Cardiovascular Diseases in China (2011)

Chapter 6 Prediction of the Cardiovascular Disease in China

6.1 Future Cardiovascular Disease Incidence and Mortality in China

Recent years, China collaborated with international institutes and built up their own cardiovascular disease (CVDs) prediction model to evaluate the effect of risk factors on the incidence and mortality of CVDs and the future trend of CVDs base on data on the level and trend of risk factors, incidence and mortality of cardiovascular disease, and medical care capacity.

The Coronary Heart Disease Policy Model-China, which was developed by Columbia University Medical Center, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, and Beijing An Zhen Hospital, Capital Medical University--Beijing Institute of Heart, Lung and Blood Vessel Diseases, was the fi rst full functional predictive model of CVDs in China. The model was a Markov (state-transition) model of CVDs for adult Chinese population. It not only can forecast the future incidence and mortality of different type of CVDs but also can evaluate the cost and effectiveness of primary prevention, acute stage (30 days after onset) treatments, and secondary prevention strategies. The data on the incidence of coronary heart disease (CHD) were from Chinese Multi-provincial Cohort Study (CMCS). The data on prevalence of CHD and CHD risk factor levels were from the International Collaborative Study of Cardiovascular Disease in Asia Study (InterASIA) and China National Hypertension Survey Epidemiology Follow-up Study (CHEFS). The data on total mortality were from the Global Burden of Disease Study. The data on CHD case-fatality in acute stage was from Sino-MONICA study. The research team of Coronary Heart Disease Policy Model fi rst evaluated the incidence and mortality trends of CHD events in China over 2010-2030 due to the growing of CHD risk factor levels. [1, 2] The result showed the proportion of Chinese citizens who were greater than or equal to 65 year old would increase from 7% in 2000 to 16% in 2030[ (Figure 6-19 (1)].

132 Chapter 6 Prediction of the Cardiovascular Disease in China

Number of Population

Age

Figure6-1 (1) Age Distribution of the Chinese Population in 2000 and 2030. Distributions Based on U.S. Census Bureau International Database Projections

Annual CVDs (angina, myocardial infarction, arrest and stroke) events would increase more than 50% between 2010 and 2030 due to aging and population growth alone. Projected trends in blood pressure (increase 0.17 mmHg in female and 0.21 mmHg in male annually), total cholesterol (increase 5.4 mmol/L in both sexes), diabetes (increases 15% in both sexes), and active smoking (decline 0.58% in male and 0.13% in female annually) would increase annual CVDs events by an additional 23% (Figure 2-1, 2-2, 3-1, and 3-2), an increase of approximately 21.3 million cardiovascular events and 7.7 million cardiovascular deaths over

2010 to 2030. Events (n)

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133 Report on Cardiovascular Diseases in China (2011) Events (n)

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134 Chapter 6 Prediction of the Cardiovascular Disease in China

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6.2 The Rising Tide of Non-Communicable Diseases: a Report from the World Bank 6.2.1 Explosive Increase in the Number of People with at least One Non-Communicable Diseases

The number of NCD cases [CVDs (myocardial infarction and stroke), COPDs, DM, and lung cancer] among Chinese people over 40 will double or even triple over the next two decades, most of it during the next 10 years. Diabetes cases will be the most prevalent disease.

6.2.2 Predicted Burden of Major Non-Communicable Diseases in China[3]

The burden of the four leading causes of ill health-MI, stroke, diabetes, and COPD-is expected to increase over 2010-2030 by almost 50 percent. More than 50 percent of the disease burden will be caused by CVDs (MI and stroke); stroke has the largest health and well-being impact on an individual. The burden due to deaths from these NCDs will increase by more than 80 percent (Figure 6-2-2).

135 Report on Cardiovascular Diseases in China (2011)

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Figure 6-2-2 Total Years Lost due to NCD Morbidity per 1 000 Population and Total Years of Life Lost from Death per 1 000 Population

6.2.3 Cardiovascular Mortality

China has very high mortality rates due to the major NCDs (Figure 6-2-3). Its mortality rate for stroke is four to six times higher than that in Japan, the United States, and France; China’s mortality rate for diabetes is higher than in Japan and the United Kingdom.

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136 Chapter 6 Prediction of the Cardiovascular Disease in China

6.2.4 The Contribution of Behavioral and Nutritional Risk Factors to China’s Non-Communicable Diseases Burden

At least 580 million Chinese were estimated to have at least one modifi able NCD-related risk factor in 2010 (Figure 6-2-4). Between 70 and 85 percent of these people were under age 65. By 2030, those risk factors—behavioral and nutritional—could contribute to a 50 percent increase in China’s NCD burden if not controlled.[4]

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6.2.5 Economic Impact of the Non-Communicable Diseases Burden

(1) Recent estimates indicate that China’s overall economic burden from NCDs could be very high. In the absence of a scaled-up Government response, CVDs, stroke, and diabetes alone are expected to result in a loss of US$ 550 billion in China between 2005 and 2015.

(2) A change in adult health status can result in a 16 percent gain in hours worked and a 20 percent increase in individual income. Tackling NCDs, on top of being a valuable health investment, may thus be seen as an investment into people’s productivity and hence their earnings potential (Table 6-2-5).

Table 6-2-5 Impact of a Change in Self-assessed Health on Hours Worked and Income in China Hours Worked Income Overall +16.0% +20%

Urban +21.0% +5.2%

Rural +12.0% +14.6%

137 Report on Cardiovascular Diseases in China (2011)

(3) At the macro-economic level, reducing CVDs mortality by 1 percent per year over a 30-year period (2010–2040) could generate an economic value equivalent to 68 percent of China’s real GDP in 2010, more than PPP US$ 10.7 trillion (Figures 6-2-5). Reducing CVDs mortality by 1 percent per year produces—if the intrinsic value that is attributed to life is measured—an annual benefi t of about 15 percent of China’s 2010 GDP (PPP US$ 2.34 trillion), while a 3 percent reduction would amount to an annual benefi t of 34 percent (PPP US$ 5.40 trillion).

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138 Chapter 6 Prediction of the Cardiovascular Disease in China

References

[1] Moran A, Gu D, Zhao D, Coxson P, Wang YC, Chen CS, et al. Future cardiovascular disease in china: markov model and risk factor scenario projections from the coronary heart disease policy model-china. Circ Cardiovasc Qual Outcomes. 2010, 3 (3): 243-52. [2] Moran A, Zhao D, Gu D, Coxson P, Chen CS, Cheng J, et al. The future impact of population growth and aging on coronary heart disease in China: projections from the Coronary Heart Disease Policy Model-China. BMC Public Health. 2008, 8: 394. [3] Death Cause Surveillance from China Disease Surveillance Points, 2005, and China Nutrition and Health Survey, 2002, and China National NCD Risk Factor Surveillance, 2007. [4] China Nutrition and Health Survey, 2002, and China National NCD Risk Factor Surveillance, 2007.

139