REPORT ON CARDIOVASCULAR DISEASES IN CHINA (2013) 中国心血管病报告 2013
National Center for Cardiovascular Diseases,China 国家心血管病中心
Encyclopedia of China Publishing House 图书在版编目（CIP）数据
中国心血管病报告. 2013：英文/国家心血管中心著、译. -北京：中国大百科全书出版社， 2015.6 INBN 978-7-5000-9579-8 Ⅰ.①中… Ⅱ.①国… Ⅲ.①心脏血管疾病－研究报告－中国－2013－英文 Ⅳ .①R54 中国版本图书馆CIP数据核字（2015）第140131号
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INBN 978-7-5000-9579-8 Copyright by Encyclopedia of China Publishing House,Beijing,China,2014.4 Published by Encyclopedia of China Publishing House 17 Fuchengmen Beidajie,Beijing,China 100037 http://www.ecph,com.cn Distributed by Xinhua Bookstore First Edition 2015.6
Printed in the people's Republic of China EDITORIAL COMMITTEE for Report on Cardiovascular Diseases in China (2013)
Chief Editor: Hu Shengshou Deputy Chief Editors: Gao Runlin; Liu Lisheng; Zhu Manlu; Wang Wen;
Wang Yongjun; Wu Zhaosu Secretaries: Chen Weiwei; Sui Hui; Yang Jingang
Writing Group
Chen Weiwei; Du Wanliang; He Jianguo; Jia Weiping; Li Guangwei; Li Xiaoying; Li Xiaomei; Li Ying; Liu Kejun; Liu Jing; Luo Xinjin; Mi Jie; Sui Hui; Wang Chunning; Wang Jinwen; Wang Wei; Wang Wen; Wang Yu; Wang Zengwu; Xu Zhangrong; Yang Jingang; Yang Xiaohui; Zeng Zhechun; Zhang Jian; Zhang Shu; Zhang Yuhui; Zhao Liancheng; Zhou Xin; Zhu Jun; Zuo Huijuan
Editorial Committee
Chen Chunming; Chen Weiwei; Chen Yude; Du Wanliang; Gao Runlin; Gu Dongfeng; Hu Dayi; Hu Shengshou; Li Guangwei; Li Wei; Li Xiaoying; Li Xiaomei; Li Ying; Liu Kejun; Liu Jing; Liu Lisheng; Luo Xinjin; Mi Jie; Rao Keqin; Tang Xinhua; Wang Bin; Wang Chunning; Wang Haiyan; Wang Mei; Wang Wei; Wang Wen; Wang Wenzhi; Wang Yilong; Wang Yongjun; Wang Yu; Wang Zengwu; Wu Di; Wu Liangyou; Wu Xigui; Wu Zhaosu; Xu Zhangrong; Yang Gonghuan; Yang Xiaohui; Yao Chonghua; Zeng Zhechun; Zeng Zhengpei; Zhang Jian; Zhang Shu; Zhao Dong; Zhao Liancheng; Zhu Jun; Zhu Manlu; Zuo Huijuan
Academic Committee
Chen Chunming; Chen Haozhu; Chen Jilin; Chen Junshi; Chen Lanying; Chen Wenxiang; Chen Xuli; Chen Yude; Chen Zaijia; Cheng Xiansheng; Dai Guizhu; Ding Jinfeng; Fang Qi; Feng Jianzhang; Gao Runlin; Gao Shan; Ge Junbo; Gong Lansheng; Gu Dongfeng; Guan Heng; Hong Shaoguang; Hu Dayi; Hu Jianping; Hu Shengshou; Hua Qi; Huang Dejia; Huang Jun; Huang Tigang; Hui Rutai; Huo Yong; Jia Guoliang; Jiang Weijian; Jin Shuigao; Kong Lingzhi; Li Guangwei; Li Jianjun; Li Nanfang; Li Xiaoying; Li Yishi; Li Ying; Li Yong; Li Yunqian; Liang Wannian; Liao Yuhua; Lin Shanyan; Lin Shuguang; Liu Guozhang; Liu Lisheng; Lu Guoping; Lu Zaiying; Lu Zongliang; Lv Chuanzhen; Ma Hong; Ma Shuping; Pan Changyu; Qi Wenhang; Rao Keqin; Shen Weifeng; Sun Ming; Sun Ningling; Tang Xinhua; Wang Daowen; Wang Fangzheng; Wang Haiyan; Wang Mei; Wang Wen; Wang Xiaowan; Wu Kegui; Wu Qinghua; Wu Xigui; Wu Yinsheng; Wu Zhaosu; Xiang Kunsan; Xu Zhangrong; Xu Zhimin; Xu Chengbin; Yan Shengkai; Yan Xiaowei; Yang Xiaoguang; Yang Xinchun; Yang Yuejin; Yao Chonghua; Ye Ping; You Kai; Yu Guoying; Zeng Dingyin; Zhang Qinyi; Zhang Tingjie; Zhang Tong; Zhang Weiwei; Zhang Weizhong; Zhang Zhuo; Zhao Dong; Zhao Jizong; Zhao Lianyou; Zhao Shuiping; Zhao Yuanli; Zhou Jingchun; Zhu Dingliang; Zhu Jun; Zhu Xiaodong; Zhu Junren; Zhu Zhiming
Proofreader Ma Liyuan Preface
With rapid economic growth and associated industrialization, urbanization, the accelerated process of ageing and lifestyle changes, the risk factors for cardiovascular diseases (CVD) are more prevalent in the Chinese population, and therefore increase the incidence of CVD. The prevalence of CVD will remain an upward trend in the next 10 years. CVD is the leading cause of death for Chinese in both urban and rural area. Nowadays, 38.7% of deaths in rural area and 41.1% of deaths in urban area are caused by CVD in China. The burden of CVD remains heavy and has become a major public health issue. Effective strategies should be enforced urgently for the prevention and treatment of CVD under the supervision of the government. In May 2012, fi fteen governmental ministries, including the Ministry of National Health and Family Planning, jointly issued the Work Plan for Chronic Disease Prevention and Control in China (2012-2015), a guideline for the prevention and control of chronic diseases, especially CVD in China. We should actively follow and implement its recommendations. Since 2005, the National Center for Cardiovascular Diseases has organized experts of cardiology, neurology, nephrology, diabetes, epidemiology, community health, health economics and biostatistics and other related fi elds to compile the annual report on Cardiovascular Diseases in China. The purpose is to provide technical guidance and authoritative evaluation for cardiovascular disease prevention and treatment, produce the theoretical foundation for government legislation and strategic planning and establish a platform for international communication and cooperation.
Abbreviations CAD: Carotid Atherosclerotic Disease AAA: Abdominal Aortic Aneurysm CCEP: China Cholesterol Education Program AAI/R: Atrial sensing, Atrial pacing, Inhibited, CDS: China Diabetes Society Rate response single chamber pacing CHNS: China Health and Nutrition Survey ABI: Ankle Brachial Index CVD: Cardiovascular Diseases ACEI: Angiotensin Converting Enzyme Inhibitor CHD: Coronary Heart Disease ACS: Acute Coronary Syndrome CI: Confi dence Interval AMI: Acute Myocardial Infarction CKD: Chronic Kidney Disease BMI: Body Mass Index CNDMDS: China National Diabetes and Metabolic CABG: Coronary Artery Bypass Grafting Disorder Study
5 Report on Cardiovascular Diseases in China (2013)
COPD: Chronic Obstructive Pulmonary Disease LVEF: Left Ventricular Ejection Fraction CRT: Cardiac Resynchronization Therapy OSAHS: Obstructive Sleep Apnea Hypopnea CTEPH: Chronic Thromboembolic Pulmonary Syndrome Hypertension Met: Metabolic Equivalent DALYs: Disability Adjusted Life Years MS: Metabolic Syndrome ECMO: Extracorporeal Membrane Oxygenation PAD: Peripheral Artery Disease ESRD: End Stage Renal Disease PAH: Pulmonary Arterial Hypertension EVAR: Endovascular Aneurysm Repair PARP: Population Attributable Risk Proportion GFR: Glomerular Filtration Rate PCI: Percutaneous Coronary Intervention HbA1c: Hemoglobin A1c PTCA: Percutaneous Transluminal Coronary HDL-C: High Density Lipoprotein-Cholesterol Angiography HF: Heart Failure PWV: Pulse Wave Velocity HR: Hazard Ratio RFCA: Radiofrequency Catheter Ablation ICD: Implantable Cardioverter-Defibrillator RR: Relative Risk IHD: Ischemic Heart Disease SHS: Second-Hand Smoking IMT: Intima-Media Thickness STEMI ST Elevation Myocardial Infarction INR: International Normalized Ratio TC: Total Cholesterol IPAH: Idiopathic Pulmonary Artery Hypertension TG: Triglyceride ISH: Isolated Systolic Hypertension WC: Waist Circumference LEAD: Lower Extremity Atherosclerotic Disease WHtR: Waist-Height Ratio LDL-C: Low Density Lipoprotein-Cholesterol YLD: Year Lived with Disability LVEDD: Left Ventricular End Diastolic Diameter
Note: Cardiovascular diseases referred in this report include cardiovascular, cerebrovascular disease and their related diseases.
6 CONTENTS
Outline of the Report on Cardiovascular Diseases in China, 2013……………1
Chapter 1 Prevalence and Mortality of Cardiovascular Diseases……………10 1.1 Prevalence of Cardiovascular Diseases……………………………………………………10 1.2 Death of Cardiovascular Diseases…………………………………………………………10 1.2.1 Mortality of Cardiovascular Diseases………………………………………………10 1.2.2 Deaths Attributable to Cardiovascular Diseases among All Causes of Death………12 1.2.3 Trends of Cardiovascular Disease Mortality…………………………………………12
Chapter 2 Risk Factors of Cardiovascular Diseases…………………………15 2.1 Hypertension………………………………………………………………………………15 2.1.1 Primary Hypertension………………………………………………………………15 2.1.2 Secondary Hypertension……………………………………………………………35 2.1.3 Hypertension in Children and Adolescents…………………………………………36 2.2 Smoking……………………………………………………………………………………47 2.2.1 Prevalence of Smoking………………………………………………………………47 2.2.2 Smoking Cessation……………………………………………………………………52 2.2.3 Hazards of Smoking and Passive Smoking…………………………………………52 2.2.4 Disease Burden and Economic Cost of Tobacco Use in China………………………58 2.3 Dyslipidemia………………………………………………………………………………59 2.3.1 Lipid Levels and Prevalence of Dyslipidemia in Adults……………………………59 2.3.2 Prevalence of Dyslipidemia among Children and Adolescents………………………63 2.3.3 Effect of Dyslipidemia on Cardiovascular Diseases…………………………………64 2.3.4 Prevention and Control of Dyslipidemia……………………………………………66 2.4 Diabetes……………………………………………………………………………………69
1 2.5 Overweight and Obesity…………………………………………………………………76 2.5.1 The Current State of Obesity in China………………………………………………76 2.5.2 Diseases Related to Overweight and Obesity………………………………………79 2.6 Physical Inactivity…………………………………………………………………………81 2.6.1 Current Status, Trends, and Influence Factors of Physical Activity… ………………81 2.6.2 Physical Inactivity and Cardiovascular Diseases……………………………………85 2.7 Diet and Nutrition…………………………………………………………………………88 2.7.1 Current State and Trends of Nutritional Health………………………………………88 2.7.2 Effects of Diet on CVD and Associated Risk Factors………………………………92 2.8 Metabolic Syndrome (MS)………………………………………………………………95 2.8.1 Prevalence of MS……………………………………………………………………96 2.8.2 Risk Factors of MS…………………………………………………………………97 2.8.3 MS and CVD…………………………………………………………………………99
Chapter 3 Cardiovascular Diseases……………………………………………100 3.1 Stroke (Cerebrovascular Disease)…………………………………………………………100 3.1.1 Stroke Prevalence, Mortality and Trend in Chinese Population……………………100 3.1.2 Stroke Incidence………………………………………………………………………103 3.1.3 Clinical Characteristics of Hospitalized Patients with Stroke in China………………104 3.1.4 Clinical Trials…………………………………………………………………………109 3.2 Coronary Heart Disease (CHD) …………………………………………………………110 3.2.1 Epidemiological Studies of Coronary Heart Disease …………………………………110 3.2.2 Intervention Treatment for Coronary Heart Disease…………………………………116 3.3 Arrhythmia…………………………………………………………………………………120 3.3.1 Pacemakers, Implantable Cardioverter-defibrillators (ICD) and Cardiac Resynchronization Therapy (CRT)…………………………………………………121 3.3.2 Radiofrequency Catheter Ablation……………………………………………………123 3.3.3 Atrial Fibrillation……………………………………………………………………125 3.3.4 Other Arrhythmias……………………………………………………………………127 3.4 Heart Failure………………………………………………………………………………127
2 3.4.1 Prevalence of Heart Failure (HF)……………………………………………………127 3.4.2 Etiology and Pharmacotherapy of Heart Failure……………………………………128 3.4.3 Mortality of Hospitalized Patients …………………………………………………130 3.4.4 Research on Acute Coronary Syndrome and Acute Heart Failure …………………131 3.4.5 Proprietary Pharmaceutical Development……………………………………………131 3.5 Sudden Cardiac Death……………………………………………………………………133 3.6 Pulmonary Arterial Hypertension (PAH)…………………………………………………134 3.6.1 Screening for PAH in Patients with Congenital Heart Disease………………………134 3.6.2 Clinical Characteristics of Patients with PAH………………………………………135 3.6.3 Prognosis of Idiopathic PAH (IPAH) ………………………………………………135 3.6.4 Prognosis of Congenital Heart Disease Patients with Eisenmenger Syndrome ……136 3.6.5 Long-term Survival Rates for CTEPH Patients………………………………………137 3.6.6 Long-term Survival Rates for PAH Patients after Lung Transplantation……………138 3.7 Cardiovascular Surgery……………………………………………………………………139 3.7.1 Cardiovascular Surgery Volume in China……………………………………………139 3.7.2 Congenital Heart Disease……………………………………………………………142 3.7.3 Clinical Application of Sino-SCORE Surgical Scoring System……………………146 3.7.4 Surgical Treatment of Coronary Artery Disease……………………………………147 3.7.5 Aortic Surgery………………………………………………………………………147 3.8 Chronic Kidney Disease…………………………………………………………………150 3.8.1 Epidemiology of Chronic Kidney Disease (CKD)…………………………………150 3.8.2 Cardiovascular Complications among CKD Patients………………………………151 3.9 Peripheral Vascular Disease………………………………………………………………151 3.9.1 Lower Extremity Atherosclerotic Disease (LEAD)…………………………………152 3.9.2 Carotid Atherosclerotic Disease (CAD) ……………………………………………153
Chapter 4 Community-based Prevention and Control of CVD………………156 4.1 Overview …………………………………………………………………………………156 4.2 An Example of Community-based Prevention and Control of CVD — Shenzhen Mode for Prevention and Control of Chronic Diseases……………………………………………157
3 4.2.1 The Organizational Model of the Shenzhen Chronic Disease Prevention and Control Program……………………………………………………157 4.2.2 Primary Strategies of the Shenzhen Chronic Disease Prevention and Control System ……………………………………………………158 4.2.3 Preliminary Successes of the Shenzhen Chronic Disease Prevention and Control Model…………………………………………………………………………160
Chapter 5 Medical Expenditure of Cardiovascular Diseases…………………161 5.1 Status of Service Utilization for Patients with Cardiovascular Diseases in China………161 5.1.1 Trends in Hospitalization and Discharge of CVD …………………………………161 5.2 Hospitalization Costs of CVD……………………………………………………………163 5.3 Pharmaceutical Market of Cardiovascular Diseases………………………………………164 5.4 Content and Cited Data in This Chapter…………………………………………………165
4 Outline of the Report on Cardiovascular Diseases in China, 2013
1. Prevalence and Mortality of Cardiovascular Diseases 1.1 Prevalence of Cardiovascular Diseases
In China, the prevalence of cardiovascular diseases (CVD) is continuously increasing. Currently, an estimated 290 million individuals suffer from CVD, of which 270 million have hypertension, more than 7 million have had a stroke, 2.5 million have had a myocardial infarction, 4.5 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 of fi ve Chinese adults is affl icted by CVD.
1.2 Mortality of Cardiovascular Diseases
On the basis of 2004 and 2010 death rate data from the National Disease Surveillance Point System, the national cardiovascular mortality rate increased from 240.03 per 100 000 persons in 2004 to 268.92 per 100 000 persons in 2010. The change was mainly attributed to the increases in mortality from ischemic heart disease. Death rates attributable to ischemic heart disease, hypertensive heart disease, and cerebrovascular disease were all on the rise, with annual increases of 5.05%, 2.08%, and 1.02%, respectively. Death rate attributable to rheumatic heart disease decreased signifi cantly with an annual decrease of 7.02%. The rate of increase of CVD mortality in China has slowed down since 2009 and seems to have reached a plateau. The 2012 overall rate of death attributable to CVD was 255.0 per 100 000 . It is estimated that 3.5 million people die of CVD every year, or 9 590 Chinese die of CVD each day, i.e. 400 deaths per hour, and 1 death every 10 seconds. In 2012, 38.7% of deaths in rural area and 41.1% of deaths in urban area are caused by CVD in China, higher than those of tumors and any other diseases. 2 of every 5 deaths are caused by CVD.
2. Risk Factors of Cardiovascular Diseases 2.1 Hypertension
Hypertension is a major risk factor for stroke and coronary heart disease. More than half of all cardiovascular diseases are associated with hypertension in China. (1) According to a survey conducted in 2002, the prevalence of hypertension among Chinese adults over the age of 18 was 18.8%. The prevalence showed an upward tendency in recent years. It is higher in northern
1 Report on Cardiovascular Diseases in China (2013)
areas than in southern areas, In some northern areas, the prevalence is as high as 30%. The prevalence of hypertension in both males and females increased from 1979 to 2002. The difference in hypertension prevalence between urban and rural populations is shrinking, in 1979, the rates were 10.8% versus 6.2%, respectively, whereas in 2002 the rates were 19.3% versus 18.6%. (2) Based on geometric progression estimates, in 2012 the prevalence of hypertension among Chinese >15 years of age is 24%, indicating 270 million people nationwide had hypertension. There were at least 2 hypertensive patients in every 10 adults. (3) High-normal blood pressure: the detection rate of high-normal blood pressure among adults is increasing, it is higher in northern areas than in southern areas and higher among obese people than non- obese people. According to a survey in 2002, the detection rate was 34% in Chinese adults aged > 18 years, which represented 300 million people nationwide. Compared with normotensives, the risk of stroke, coronary heart disease and other cardiovascular diseases increased by 50% in people with high-normal blood pressure. (4) According to a survey conducted in nine provinces from 1991 to 2009, the awareness, treatment, and control rates of hypertension in Chinese adults >18 years of age were steadily increasing, but still at relatively low levels. The control rate under treatment varied dramatically among different provinces. A survey with 12 groups of middle-aged populations revealed that the awareness, treatment, and control rates as well as the control rate under treatment were 48.4%, 38.5%, 9.5% and 24%, respectively. (5) Blood pressure levels among children and adolescents of different ages and genders were increasing. The China Health and Nutrition Surveys from 1991 to 2009 showed that the prevalence of hypertension among children and adolescents had been continuously increasing, from 7.1% in 1991 to 13.8% in 2009. (6) Overweight, obesity, glucose-lipid metabolism abnormalities, family history of hypertension and birth weight greater than 4 kg are risk factors for hypertension in children and adolescents. Poor nutrition in the prenatal and early postnatal periods as well as childhood salt-sensitivity are risk factors for hypertension in early adulthood. (7) Secondary hypertension is the main cause of hypertension among hospitalized children (52.0%). Renovascular hypertension (39.9%) is the leading cause of secondary hypertension, followed by endocrine hypertension (29.8%) cardiovascular (13.9%) and CNS-related causes (8.2%). The age of children with secondary hypertension (9.1 ± 4.6 years) is lower than that of children with primary hypertension (12.3 ± 3.1 years).
2.2 Smoking
(1) According to the 2010 Global Adult Tobacco Survey-China Project, there are 356 million current smokers and 738 million secondhand smokers in people > 15 years of age. The state of smoking among adolescents is not optimistic: smoking rate among males increases signifi cantly with age and shows an accelerating upward trend at younger ages. (2) Smoking cessation: Although smoking cessation rate has increased slightly in recent years, China still faces signifi cant challenges in smoking control. The proportion of people trying smoking cessation increased
2 Outline of the Report on Cardiovascular Diseases in China, 2013 from 9.42% in 1996 to 11.5% in 2002, and up to 16.9% in 2010. The number of subjects who stopped smoking increased by 15 million. (3) Smoking and secondhand smoking are independent risk factors for cardiovascular disease. They also exacerbate the effect of blood pressure on cardiovascular death and all-cause death among hypertensive patients. (4) The direct economic loss due to smoking in China in 2005 was RMB 166.56 billion Yuan, and the indirect loss was RMB 86.11-120.50 billion Yuan, and the total loss was about RMB 300 billion Yuan, accounting for 1.5% of the 2005 Gross Domestic Product (GDP). Disability-Adjusted Life Years (DALYs) Lost for adults over 40 years of age due to smoking-related diseases was 158.2 years/1 000 people.
2.3 Dyslipidemia
(1) A national survey in 2010 showed that the prevalence of TC≥ 6.22 mmol/L among males and females over 18 years of age was 3.4% and 3.2% respectively. The prevalence of TG≥ 2.26 mmol/L among males and females was 13.8% and 8.6%, respectively. (2) Between 2007 and 2008, people at least 20 years old were surveyed for awareness, treatment and control rates for hypercholesterolemia. The awareness rate for TC≥ 6.22 mmol/L among males and females was 27.6% and 20.7%, the treatment rate was 21.4% and 14.0%, the control rate was 18.3% and 11.2%, and the control rate under treatment was 88.1% and 78.4%, respectively. The rates were much lower among people with TC≥ 5.18 mmol/L. (3) According to a survey conducted among 12 040 Chinese with dyslipidemia in 2013, 50% of them had hypertension, 37.5% had coronary heart disease, and over 30% had peripheral vascular disease. 39% of patients received lipid-lowering therapies, with the majority using statins. The percentage reaching LDL-C target was only 25.8%, it was even lower among females (22.2%) and people with BMI≥ 30 kg/m2 (17.4%). Only 19.9% and 21.1% patients with high-risk and very high-risk cardiovascular disease factors reached target LDL-C levels.
2.4 Diabetes Mellitus
(1) According to a survey in a nationally representative sample of 98 658 Chinese adults in 2010, the overall prevalence of diabetes was estimated to be 11.6% in the Chinese adults > 18 years of age. The prevalence among men was 12.1%, and among women was 11.0%. The newly diagnosed diabetes was 8.1%, 8.5% in men, 7.7% in women. The prevalence of previously diagnosed diabetes was 3.5% (3.6% in males, 3.4% in females). The prevalence of diabetes was higher in urban residents. In addition, the prevalence of prediabetes was estimated to be 50.1% in Chinese adults: 52.1% in men and 48.1% in women. Among patients with diabetes, only 30.1% (29.7% in males, 30.5% in females) are aware of their condition, only 25.8% (25.5% in males, 26.2% in females) receive treatment for diabetes, and only 39.7%
3 Report on Cardiovascular Diseases in China (2013)
(40.7% in males, 38.6% in females) of those treated have their condition controlled to target levels. The awareness, treatment and management rates for diabetes are higher in urban areas than in rural areas; higher in developed and medium developed areas than in underdeveloped areas. (2) The 3B (blood glucose, blood pressure, and blood lipids) Study enrolled 25 817 adults with type 2 diabetes at 104 hospitals. The study found only 5.6% achieved the target goals for control of blood glucose, blood lipids and blood pressure.
2.5 Overweight and Obesity
(1) In the past 10 years, the prevalence of overweight and obesity showed an upward trend. The 2010 China Chronic Disease Monitoring Program reported that the prevalence of overweight, obesity, and overweight + obesity reached 30.6%, 12.0%, and 42.6% respectively. (2) The prevalence of overweight and obesity also increased among children. The overweight, obesity, and overweight + obesity rates for children in 2010 were 9.6%, 5.0%, and 14.6%, increased by 8.7 times, 38.1 times, and 11.8 times respectively in comparison with those in 1985.
2.6 Physical Inactivity
(1) The 2010 China Chronic Disease Monitoring Program reported that rate of frequent exercise among adults was only 11.9%. (2) Physical activity was inversely associated with BMI, waist circumference and percentage body fat. The risk of diabetes is high among those who do not exercise regularly. Baseline exercise amount is inversely correlated with all-cause mortality and cardiovascular mortality.
2.7 Diet and Nutrition
(1) The China Health and Nutrition Survey revealed that the total caloric intake signifi cantly declined, but the percentage of total caloric intake from fat was much higher than the level recommended, while the percentage of total caloric from carbohydrates decreased. The dietary cholesterol intake increased obviously. Although the dietary calcium intake increased slightly, it was only half of the recommended level. The daily intake of salt was much higher than the level recommended by dietary guidelines. The consumption of vegetables, fruits and vitamin C was also insuffi cient. (2) The same situation is also seen among children. The proportion of children with the Western dietary pattern has increased, and the Western dietary pattern is becoming one of the important factors for unbalanced nutrition. The risk of obesity and hypertension is clearly elevated among children with the Western dietary pattern. (3) The risk of impaired glucose metabolism and diabetes increases signifi cantly with increases in high- fat low-carbohydrate diet scores. In populations with higher vitamin and mineral diet scores, the risk of acute
4 Outline of the Report on Cardiovascular Diseases in China, 2013 myocardial infarction is relatively low.
2.8 Metabolic Syndrome
(1) In 2002 China Health and Nutrition Survey, the prevalence of metabolic syndrome (MS) in adults was 6.6% and 13.8%, based on the defi nitions from the China Diabetes Society (CDS) and U.S. National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III), respectively. (2) The prevalence of MS in children and adolescence was 2.4% and 1.4% in 2010, based on the defi nition for Chinese pediatric metabolic syndrome and guidelines from the International Diabetes Federation (IDF), respectively.
3. Cardiovascular Diseases 3.1 Cerebrovascular Disease (Stroke)
(1) The prevalence of stroke in China presents an upward trend, it is higher in urban areas than in rural areas. Ischemic stroke accounts for 66.4% and hemorrhagic stroke accounts for 23.4% among hospitalized patients. (2) According to the 2012 China Public Health Statistics Yearbook, the mortality of cerebrovascular disease from 2003 to 2011 in China was higher in rural than in urban areas. In 2011, the mortality rate was 125.37 per 100 000 people for urban residents and 136.68 per 100 000 people for rural residents. It was estimated that 834 500 urban residents and 921 100 rural residents died of cerebrovascular disease in 2011. Data based on 2010 Global Disease Burden Study, stroke ranked fi rst among all causes of death in 2010. The number of patients died of stroke increased from 1 340 600 in 1990 to 1 726 700 in 2010. It was estimated that the number of deaths due to ischemic stroke was 426 400 in 1990 and 609,600 in 2010. (3) The China National Stroke Registry shows that disability, mortality and recurrence rates in association with stroke increase with age. The main risk factor for stroke in the very elderly group (>80 years) and the elderly group (66-80 years) is hypertension. A multistage, stratifi ed clustering sampling follow-up study of 38 949 people without stroke over the age of 35 in Fuxin Village of Liaoning Province showed that after adjustment for age, the annual incidence of stroke was 601.9 per 100 000 people (775.9 per 100 000 in males, 435.5 per 100 000 in females). (4) The CHANCE Research Study at 114 centers in China showed that among patients with transient ischemic attacks or mild strokes who received treatments within 24 hours after the onset of symptoms, the combination of clopidogrel and aspirin was superior to aspirin alone for reducing the risk of stroke in the fi rst 90 days and did not increase the risk of hemorrhage. The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) showed that among patients with acute ischemic stroke, blood pressure reduction with antihypertensive medications, compared with the absence of hypertensive medication, did not reduce the likelihood of death and major disability at 14 days or hospital discharge.
5 Report on Cardiovascular Diseases in China (2013)
3.2 Coronary Heart Disease
(1) The mortality of coronary heart disease (CHD) in China exhibited an upward trend from 2002 to 2011. In 2011, the mortality rate was 95.97 per 100 000 people in urban areas and 75.72 per 100 000 people in rural areas, higher than that in 2010 (86.34 per 100 000 people in urban areas, 69.24 per 100 000 people in rural areas). The mortality rate is higher in urban than in rural areas and higher in males than in females. (2) From 2002 to 2011, the mortality rate due to acute myocardial infarction has increased generally. The mortality of AMI in rural areas has increased rapidly since 2005. From 2009-2011, acute myocardial infarction mortality in rural areas exceeded that of urban areas (48.53 per 100 000 in rural areas, 47.36 per 100 000 in urban areas in 2011). The mortality due to acute myocardial infarction increases with age in both genders and different regions, and the trend accelerates exponentially since 40 years of age. (3) From 2007 to 2009, there were 68 390 cases of acute coronary syndrome in Beijing among adults > 25 years of age. Age-standardized incidence was 166.4 per 100 000 people (218.5 per 100 000 in males, 115.2 per 100 000 in females). The incidence increased by 8.1% in 2009 compared with that in 2007, and it was particularly high among young men. The highest increase of incidence was among males aged 35 to 44 years, which increased by 30.3%.
3.3 Arrhythmia
(1) According to an epidemic survey in 2004, the age adjusted prevalence of atrial fi brillation (AF) was 0.77% in participants aged more than 35 years (0.78% in men and 0.76 in women). About19.0% of males and 30.9% of females with AF were diagnosed with valve heart disease. After adjusted for age and gender, the study revealed that myocardial infarction, left ventricular hypertrophy, obesity and alcohol consumption were associated with an increased risk of AF. (2) A retrospective study of hospitalized patients from cardiology departments in 22 provincial hospitals showed that 26.8% of all the patients had cardiac arrhythmia. Among all of the patients, AF is the most common arrhythmia (35.0%), followed by paroxysmal supraventricular tachycardia (28.0%), sick sinus syndrome (11.9%) and premature ventricular contractions (11.6%). (3) According to the 2012 Ministry of Public Health Website Registry data, 49 502 pacemakers were implanted in 2012, indicated a 15.2% increase compared with that in 2011 (42 986 cases). Among the indications for cardiac pacing therapy, 50.5% were for sick sinus syndrome (23 995) and 38.7% were for atrioventricular block (18 387). Implantation volume for ICDs was approximately 1 553 cases in 2012, which indicated an increase of 23.5% compared with that in 2011 (1 228 cases), and dual chamber ICD accounted for 33%. Radiofrequency ablation volume was about 74 410 cases in 2012, increased of 17.5% in comparison with that in 2011, and 16.6% were for atrial fi brillation.
6 Outline of the Report on Cardiovascular Diseases in China, 2013
3.4 Heart Failure
The prevalence of chronic heart failure is 0.9% in China (0.7% in males and 1.0% in females). The prevalence increases with age. It is higher in northern China than in southern China (1.4% vs 0.5%), and higher in urban than in rural areas (1.1% vs 0.8%). In the past twenty to thirty years, the main cause for heart failure has changed from rheumatic valve heart disease to coronary heart disease.
3.5 Sudden Cardiac Death
The incidence of sudden cardiac death in China is 41.8 per 100 000 people. It is higher in males than in females (44.6 per 100 000 vs 39.0 per 100 000 ), and increases with age. There are about 544 000 sudden cardiac deaths occur annually in China.
3.6 Pulmonary Arterial Hypertension
A national survey of 31 tertiary hospitals reported the following causes of pulmonary arterial hypertension (PAH): congenital heart disease related PAH (PAH-CHD, 49.6%), idiopathic PAH (27.2%), connective tissue disease related PAH (11.6%) and chronic thromboembolic PAH (11.6%). Among inpatients treated for congenital PAH-CHD at Fuwai Hospital, the proportions of patients with atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductal arteriosus (PDA) were 27.0%, 65.9%, and 7.1% respectively. The septal defect diameters increase with age, which in turn increase the risk of PAH. Patients with VSD and PDA are more likely to have PAH.
3.7 Cardiac Surgery
The number of cardiac surgeries increased over time in the past ten years in China. There were 203 195 cases conducted in 2012. Of these surgeries, 158 597 were performed on-pump. In 2012, a total of 84 439 congenital heart defect surgeries were performed in mainland China and Hong Kong. 218 heart transplant surgeries were conducted (including 5 heart and liver combined transplants). The total number of extracorporeal membrane oxygenation (ECMO) was 399 in 2012. China is steadily developing birth defect monitoring system. The overall incidence of perinatal congenital heart defects is increasing, with dramatically various in different regions.
3.8 Chronic Kidney Disease
A chronic kidney disease (CKD) study among 47 204 adults in 13 different provinces and cities from September 2009 to September 2010 reported that the prevalence of CKD reached 10.8%, the adjusted prevalence of eGFR < 60 ml/min/1.73m2 was 1.7% and of albumin-creatinine ratio > 30 mg/g was 9.4%. The
7 Report on Cardiovascular Diseases in China (2013)
number of patients with CKD in China is estimated to be 120 million.
3.9 Peripheral Arterial Disease
Lower extremity atherosclerotic disease (LEAD) and carotid atherosclerotic disease (CAD) are diseases commonly seen in middle-aged and elderly people. Prevalence among those with risk factors is particular high, and increases with age. LEAD was detected in 30% with cerebrovascular disease and in 25% patients with ischemic heart disease, respectively. The mortality rate among patients with LEAD is much higher than those without LEAD at the same age, and is reversely correlated with ABI. The detection rate of carotid atherosclerotic plaques in adults between 43 and 81 years in Beijing is 60.3% (66.7% in males, 56.2% in females); carotid atherosclerotic plaques are mainly located at the enlargement part of carotid sinus.
4. Community Prevention and Control of CVD 4.1 Overview The fi rst hypertension prevention and treatment center in China, established in 1969 at the Capital Iron and Steel Company by Fuwai Hospital, was a model of functional population-based prevention work. The risk of stroke can be reduced by 50% via adequate BP control. Over the past 40 years, community-based prevention and treatment of cardiovascular diseases has experienced a series of changes and gradually evolved to government sponsored and multi-sectoral coordinated comprehensive preventation-control program.
4.2 Standardized Management for Chronic Diseases in Shenzhen Community
Through more than 10 years of hard work, Shenzhen has established a three-tier chronic disease prevention network with a city-level chronic disease centers at the top, district-level chronic disease prevention units in the middle, and community health centers on the foundational tier. The quantity and quality of hypertension and diabetes management gradually improved every year. In 2011, awareness, treatment and control under treatment rates of hypertension among Shenzhen residents were 59.1%, 84.9%, and 43.7% respectively, all higher than the 2010 national average levels (41.0%, 80.7%, and 22.9%, respectively).
5. Costs of CVD 5.1 Trends in Hospitalization and Discharge of CVD
In 2012, a total of 14.352 9 million patients with CVD were discharged from hospitals, which accounted for 12.24% of the total hospital discharges. Of these, 7.525 million (6.42%) were heart disease patients, and
8 Outline of the Report on Cardiovascular Diseases in China, 2013
6.827 9 million (5.82%) were cerebrovascular disease patients. Most CVD patients discharged from hospitals in 2012 had ischemic heart disease (5.047 4 million, including 0.295 2 million acute myocardial infarction) and cerebral infarction (4.121 6 million), accounting for 35.17% and 28.72% of total CVD patients, respectively. The other discharged patients had hypertension (2.239 4 million, including 0.178 1 million of them had HTN-related heart disease and/or kidney disease), cerebral hemorrhage (1.204 7 million) and rheumatic heart disease (0.238 3 million). 2.391 3 million discharged patients were related to diabetes.
5.2 Costs of Hospitalization for CVD
In 2012, total inpatient expenditure for acute myocardial infarction, intracranial hemorrhage, and cerebral infarction was RMB 4.961 billion Yuan, RMB 14.706 billion Yuan, and RMB 29.845 billion Yuan, respectively. After adjusting for infl ation, the annual increase in total inpatient expenditure for the above diseases since 2004 was 25.00%, 18.94%, and 24.80%, respectively. The average expenses for per hospitalization due to acute myocardial infarction, intracranial hemorrhage, and cerebral infarction was RMB 16 802.4 Yuan, RMB 12 207.4 Yuan, and RMB 7 241.3 Yuan, which has increased by 5.78%, 4.80%, and 0.96% annually since 2004, respectively (adjusted for infl ation).
9 Report on Cardiovascular Diseases in China (2013)
Chapter 1 Prevalence and Mortality of Cardiovascular Diseases
1.1 Prevalence of Cardiovascular Diseases
The prevalence of cardiovascular diseases (CVD) is continuously increasing in China. There are an estimated 290 million people with CVD, or one of fi ve Chinese adults is affl icted by CVD. Currently in China, at least 7 million individuals have had a stroke; 2.5 million have had a myocardial infarction; 4.5 million have heart failure; 2.5 million have rheumatic heart disease; 2 million have congenital heart disease. Based on four national surveys on hypertension from 1959-2002, the prevalence of hypertension increases by about 3.1% annually. Based on the geometric progression, the prevalence of hypertension in population over 15 years of age was estimated to be 24% in 2012, which represented 270 million people with hypertension.
1.2 Death of Cardiovascular Diseases 1.2.1 Mortality of Cardiovascular Diseases[1,2]
The increase in CVD mortality in China has slowed down since 2009, and seems to be reaching a plateau. The mortality of CVD still ranked fi rst in 2012, higher than that of cancer and other diseases (Figure 1-2-1 and 1-2-2). Since 2009, the mortality of CVD in rural areas has exceeded that of urban areas (Figure 1-2-3). It is estimated that around 3.5 million Chinese die of CVD each year, i.e., an average of 9 590 deaths every day, 400 every hour, and 1 death every 10 seconds.
[1] Ministry of Health of P.R.C., China Health Statistics Yearbook, 2009-2012. Peking Union Medical College Press. [2] National Health and Birth Control Committee, China Health and Birth Control Statistics Yearbook, 2013. Peking Union Medical College Press.
10 Chapter 1 Prevalence and Mortality of Cardiovascular Diseases
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˄ Figure 1-2-1 Mortality of Major Diseases in Rural Population (China: 1990-2012) &9'V 7XPRUV 5HVSLUDWRU\'LVHDVHV ,QMXU\7R[LFDWLRQ 'LJHVWLYH'LVHDVHV 0RUWDOLW\˄˅ ˄ XUEDQ UXUDO 0RUWDOLW\˄˅ ˄ 11 Report on Cardiovascular Diseases in China (2013) 1.2.2 Deaths Attributable to Cardiovascular Diseases among All Causes of Death[1] CVD is the leading cause of death in both rural and urban populations (Figure 1-2-4 and 1-2-5). 2 in every 5 deaths are attributed to CVD. &9'V 7XPRUV 5HVSLUDWRU\'LVHDVHV ,QMXU\7R[LFDWLRQ 2WKHUV Figure 1-2-4 Major Causes of Death in Rural Population (%) (China: 2012) &9'V 7XPRUV 5HVSLUDWRU\'LVHDVHV ,QMXU\7R[LFDWLRQ 2WKHUV Figure 1-2-5 Major Causes of Death in Urban Population (%) (China: 2012) 1.2.3 Trends of Cardiovascular Disease Mortality[2] Trends of CVD mortality, standardized mortality, and causes of death were analyzed after adjustment for underreported cases. Based on data collected from the national disease surveillance point (DSP) system between 2004 and 2011, mortality rate (per 100 000 ) attributable to CVD increased from 240.03 in 2004 to [1] National Health and Birth Control Committee, China Health and Birth Control Statistics Yearbook, 2013. Peking Union Medical College Press. [2] Liu M, Wang W, Zhou M. Trend analysis of CVD deaths in China, 2004-2010. Journal of Epidemiological Studies, China. 2014, 34(10):985-988. 12 Chapter 1 Prevalence and Mortality of Cardiovascular Diseases 268.92 in 2010, with an annual increase of 2.17%. Ischemic heart disease was the main contributor. Analyses on the causes of death showed that mortality rates attributable to ischemic heart disease, hypertensive heart disease, and cerebrovascular disease were all on the rise, with annual increases of 5.05%, 2.08%, and 1.02%, respectively. Mortality rate attributable to rheumatic heart disease decreased signifi cantly with an annual decrease of 7.02%. Table 1-2-1 Trends of Mortality Rates Attributable to Cardiovascular Diseases (China: 2004-2010) Death Rate Per 100 000 Annual Annual Gender 2004 2005 2006 2007 2008 2009 2010 Change Change (%) Total Ischemic Heart 71.15 74.44 69.49 82.18 86.99 88.23 92.03 3.84 5.05 Disease Cerebrovascular 143.38 147.85 133.29 145.96 153.44 150.58 148.58 1.47 1.02 Disease HTN-related 10.21 10.58 26.05 21.65 16.23 14.92 3.53 0.32 2.08 Heart Disease Rheumatic Heart 6.42 6.08 5.07 4.76 5.19 4.50 3.86 -0.38 -7.02 Disease Other Heart 8.87 8.83 14.67 14.00 12.04 10.57 10.92 0.30 2.66 Disease Sum 240.03 247.79 248.57 268.56 573.96 268.8 268.92 5.50 2.17 Male Ischemic Heart 73.84 76.74 72.79 86.49 92.06 94.22 97.71 4.49 5.66 Disease Cerebrovascular 156.22 59.49 145.43 159.38 169.46 165.32 165.27 2.24 1.42 Disease HTN-related 10.43 10.37 27.16 23.29 16.76 15.31 13.67 0.33 2.02 Heart Disease Rheumatic Heart 4.99 4.76 4.01 3.83 4.15 3.55 3.07 -0.28 -6.82 Disease Other Heart 8.76 8.57 15.09 14.70 13.13 11.46 12.17 0.50 4.39 Disease Sum 254.30 259.96 264.48 287.72 295.64 289.86 291.89 7.28 2.70 Female Ischemic Heart 68.34 72.03 66.00 77.66 81.68 82.04 86.13 3.18 4.38 disease Cerebrovascular 129.94 135.66 120.57 131.94 136.73 135.26 131.23 0.69 0.53 Disease HTN-related 9.99 10.79 24.88 19.93 15.68 14.52 13.39 0.30 1.97 Heart Disease Rheumatic Heart 7.91 7.46 6.17 5.72 6.27 5.50 4.69 -0.48 -7.28 Disease Other Heart 8.99 9.10 14.21 13.26 10.90 9.66 9.64 0.25 2.16 Disease Sum 225.16 235.05 231.84 248.52 251.34 246.98 245.08 3.68 1.56 13 Report on Cardiovascular Diseases in China (2013) The mortality attributable to cardiovascular diseases increased year by year, from 37.46% in 2004 to 40.73% in 2010. Among all deaths attributable to CVD, contribution from cerebrovascular disease has been stable; contribution from ischemic heart disease has increased signifi cantly; contribution from rheumatic heart disease has decreased; contributions from other CVD has not change signifi cantly (Figure 1-2-6). Other HTN-relate Cerebro Rheumatic Ischemic Male Female Percentage（%） Figure 1-2-6 Mortality of CVD in Urban and Rural Populations (China: 1990-2012) 14 Chapter 2 Risk Factors of Cardiovascular Diseases 2.1 Hypertension Hypertension is one of the most common chronic non-communicable diseases, and also the most important risk factor for cardiovascular diseases. Starting from the cut-off point of 115/75 mmHg, the relative risk of cardiovascular diseases increases with blood pressure rising. Nearly 70% of stroke and 50% of myocardial infarction are associated with hypertension. Among the 3.5 million cardiovascular deaths in China each year, more than half are related to hypertension. There are 2 million premature deaths per year may be attributable to the elevated blood pressure. Hypertension accounts for 60% of physical disability, and the medical costs of hypertension therapy are as high as RMB 30 billion Yuan annually. Hypertension seriously endangers the population’s health and results in huge economic losses for the nation. Therefore, it is of great value for the prevention and treatment of CVD to provide an up-to-date, accurate, and comprehensive insight into the epidemiology of hypertension. 2.1.1 Primary Hypertension 2.1.1.1 Prevalence of Hypertension There were four national large scale epidemiological sampling surveys on hypertension prevalence since 1958 (1958-1959, 1979-1980, 1991, and 2002, respectively). Although diagnostic criteria and diagnostic methods were somewhat different among various surveys, the prevalence of hypertension had increased sharply over the past years (Figure 2-1-1). National Surveys Prevalence Prevalence (%) (Year） Figure 2-1-1 Hypertension Prevalence Among Residents Over 15 Years Old in Four National Surveys in China 15 Report on Cardiovascular Diseases in China (2013) Diagnostic criteria of hypertension differed among the four national surveys: 1959: diastolic blood pressure (DBP) >90 mmHg, and/or systolic blood pressure (SBP) >140 mmHg for people under the age of 39, every 10 years increase in age was linked to 10 mmHg increase for the criteria of high SBP; 1979-1980: SBP≥141mmHg and/or DBP≥91mmHg, without consideration of being treated within 2 weeks; 1991: SBP≥140mmHg and/or DBP≥90mmHg, or taking anti-hypertensive medications within 2 weeks; 2002: same criteria as that in 1991. Estimated national prevalence of the investigated year. Age-standardized prevalence. All four surveys used the same criteria that referred in 1979-1980; The total population in 1964 was used as a standardized population; and all the participants were over 15 years old, blood pressure were measured in mmHg. According to the survey on the Status of Nutrition and Health of the Chinese People in 2002, the prevalence of hypertension in Chinese adults aged ≥ 18 years was 18.8% [1] . Based on the increasing trends of the prevalence and the geometric progression, it was estimated that in 2012 the prevalence of hypertension among individuals over 15 years old was 24% with the total number reaching 0.27 billion [2] . The prevalence of hypertension increases markedly with age. A higher percentage of men than women have hypertension until the age of 45. After the age 50, a higher percentage of women have hypertension than men. Nevertheless, the overall prevalence of hypertension in males was still higher than that of females (Figure 2-1-2) [3] . Male Female Total Prevalence （%） ı˄$JH˅ Figure 2-1-2 Prevalence of Hypertension by Age and Gender (China: 2002) Note: Diagnostic criteria for hypertension: SBP≥140 mmHg and/or DBP≥90 mmHg, or taking anti-hypertensive medications within two weeks. [1] Survey Report on the Status of Nutrition and Health of the Chinese People: Series One, Integrated Report in 2002. Beijing: People’s Medical Publishing House, 53-57. [2] Yan RH, Wang Y, Wang W, et al. Application of geometric progression method for estimating the 2012 hypertension prevalence in population elder than 15 years of age in China. Chinese Circulation Journal, 2013, 28(7):519-522. [3] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House, 23-36. 16 Chapter 2 Risk Factors of Cardiovascular Diseases Data from different periods [1] demonstrated that there were distinct variations between rural and urban areas. Figure 2-1-3 showed that in 2002 the standardized prevalence in urban and rural areas were 19.3% and 18.6%, respectively. The gap between the prevalence in rural and urban areas narrowed over time. Urban Rural Prevalence (%) Data from 2002 survey showed that [2] the prevalence of hypertension varied across regions; there were signifi cant differences between the north and the south except for class 3 and class 4 rural areas (Figure 2-1-4). 6RXWK1RUWK Prevalence (%) /DUJH&LWLHV 6PDOOWR &ODVV &ODVV &ODVV &ODVV 0HGLXP&LWLHV 5XUDO$UHD 5XUDO$UHD 5XUDO$UHD 5XUDO$UHD Figure 2-1-4 Prevalence of Hypertension by Region (China: 2002) Note: Diagnostic criteria for hypertension: SBP≥140 mmHg and/or DBP≥90 mmHg, or taking anti-hypertensive medications within two weeks. Urban area: four municipalities and fourteen provincial capitals are defi ned as ‘metropolitan’ and the rest cities are defi ned as ‘small- and middle-size’; rural areas are stratifi ed into four levels according to Comprehensive economic strength report of different rural regions in China, which was released by the National Bureau of Statistics of the People’s Republic of China [1] Survey Report on the Status of Nutrition and Health of the Chinese People: Series One, Integrated Report in 2002. Beijing: People’s Medical Publishing House, 53-57. [2] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House, 23-36. 17 Report on Cardiovascular Diseases in China (2013) Analysis on hypertension of different ethnic groups in the survey of Status of Nutrition and Health of the Chinese People in 2002 [3] showed that among 152 683 persons over 15 years old, Tibetans had the highest prevalence of hypertension (24.7%), the Hmong ethics had the lowest prevalence (7.7%). The prevalence of hypertension increased in most ethnics except Mongolians and the Hmong when compared with that in 1991, with the greatest increase among the Manchu (Table 2-1-1). Table 2-1-1 Comparison of the Standardized Prevalence of Hypertension by Ethnic Groups between 1991 and 2002 Male Female Total Ethnicity 1991 2002 1991 2002 1991 2002 Han 11.6 17.7 10.3 15.3 11.3 16.2 Mongolian 21.1 18.8 15.6 17.2 18.2 17.6 Muslim Chinese 10.4 16.2 9.3 16.2 9.8 16.0 Tibetan 19.5 25.6 16.4 24.0 17.8 24.7 Hmong 8.3 9.2 7.0 6.1 7.7 7.7 Zhuang 9.4 16.1 7.5 8.3 8.8 11.8 Bouyei 11.6 13.9 7.8 10.7 9.5 12.4 Manchu 13.4 23.1 11.1 18.7 12.3 20.5 There are no authoritative national surveys on prevalence of hypertension after 2002. However, using data from the 8th fi ve-year plan (1992-1994), the 9th fi ve-year plan (1998), and the 10th fi ve-year plan (2004-2005), some investigators analyzed twelve groups of comparable populations aged 35-59 years to explore the trends of hypertension prevalence. [4] The results showed that hypertension prevalence in three time periods was 21.0%, 22.4%, and 24.4%, respectively. The prevalence was different in different gender, body mass index (BMI) and rural/urban regions (Table 2-1-2). Table 2-1-2 Hypertension Prevalence of the Middle-aged in China (%) 1992-1994 1998 2004-2005 Sex Male 22.4 24.7 27.9 Female 19.8 20.4 21.9 BMI (kg/m2) <24 15.5 14.1 15.2 24-27.9 31.5 31.0 32.5 ≥28 45.9 51.2 50.5 Region Urban 20.5 25.2 26.8 Rural 19.7 21.2 22.9 Total 21.0 22.4 24.4 [3] Hu YS, Yao CH, Wang WZ, et al. Survey on the prevalence of hypertension in different ethnic groups in China in 2002. Journal of Hygiene Research, 2006, 35(5), 573-575. [4] Wang ZW, Wang X, Li X, et al. Prevalence, awareness, treatment and control of hypertension in middle-aged Chinese population. Chinese Journal of Hypertension, 2008, 16(11), 1033-1036. 18 Chapter 2 Risk Factors of Cardiovascular Diseases The 2007-2008 China National Survey of Diabetes Epidemiology [1] offered some information about hypertension as well. It showed that 26.5% of people over 20 years old had hypertension, the prevalence among the young adults (20-44 years old), the middle-aged (45-64 years old), and the elderly (65 years old) was 13.0%, 36.7%, and 56.5%, respectively. According to the data from the China Health and Nutrition Survey (CHNS) [2] , the prevalence of hypertension among people≥ 18 years old increased from 1991 to 2009 in nine provinces in China; the prevalence was 21.4% in 2009, higher than 18.8% in 2002 (Figure 2-1-5). Prevalence (%) ˄ Figure 2-1-5 Trends of Hypertension Prevalence among Adults (≥18 years old) (China: 1991-2009) (CHNS) In 2010, the Chinese Center for Disease Control and Prevention investigated 98 548 residents (≥18 years old) from 162 surveillance sites of the National Disease Surveillance System in China [3] . Results showed that 33.5% of the participants were hypertensive. A systematic analysis of 140 studies of hypertension between 2000 and 2010, demonstrated that prevalence of hypertension was 23.33% among residents over 15 years old. Meanwhile, another meta-analysis[4] reported a prevalence of 21.5% after analyzing all the studies on the prevalence of hypertension between Jan 2002 to June 2012. Although study methods and participants surveyed may differ across these studies, there is no doubt that the prevalence of hypertension in China is relatively high and appears to be increasing. In recent years, regional surveys on the prevalence of hypertension have been carried out in many areas; the results showed there were variations across regions (Table 2-1-3). [1] Gao Y, Chen G, Tian H, et al. Prevalence of hypertension in china: a cross-sectional study. PloS One, 2013, 8(6): e65938. [2] Xi B, Liang Y, Reilly KH, et al. Trends in prevalence, awareness, treatment, and control of hypertension among Chinese adults 1991-2009. International Journal of Cardiology, 2012,158(2): 326-329. [3] Li YC, Wang LM, Jiang Y, et al. Prevalence of hypertension in Chinese adults in 2010. Chinese Journal of Preventive Medicine, 2012; 46(5): 409-413. [4] Ma YQ, Mei WH, Yin P, et al. Prevalence of hypertension in Chinese cities: a meta-analysis of published studies. PloS One, 2013, 8(3): e58302. 19 Report on Cardiovascular Diseases in China (2013) Table 2-1-3 Prevalence of Hypertension by Region Standardized Survey Period Region Age (years) No of Sample Prevalence（%） Prevalence (%) 2006 Tianjin [1] ≥18 20 346 27.75 22.26 2007 Heilongjiang province[2] ≥15 10 620 30.48 25.69 2007 Shandong province[3] ≥18 21 693 55.3 32.7 2007-2008 Xinan county, Henan province[4] ≥18 20 194 30.77 20.71 2007-2009 Hangzhou[5] ≥20 42 998 27.49 — 2008 Changning district, Shanghai[6] 35-91 19 519 39.88 — 2008 Xuzhou[7] 20-75 17 500 20.87 16.39 2008-2009 Wuzhong, Ningxia province[8] ≥18 5 442 23.7 19.7 2008-2010 Fangshan district, Beijing[9] ≥40 58 308 47.2 46.1 2009 Shenzhen [10] 18-69 8 626 14.54 15.33 2009 Liaoning province[11] 18-74 25 196 28.7 — [1] Yang J, Wang JH, Zhi XL, et al. The prevalence of hypertension and its risk factors in populations of Tianjin. Chinese Journal of Preventive and Control of Chronic Non-communicable Diseases, 2010, 18(5): 472-475. [2] Fu SY, Li WM, Zhao YJ, et al. Prevalence of hypertension and risk factors in Heilongjiang province in 2007. Chinese Medical Journal, 2010, 123(6): 752-755. [3] Zhao Y, Lu F, Sun H, et al. Trends in hypertension prevalence, awareness, treatment and control rates in Shandong province of China. The Journal of Clinical Hypertension, 2012, 14(9): 637-643. [4] Han B, Yu DH, Wang CJ, et al. Prevalence, awareness, treatment and control of hypertension in rural areas of Henan. Journal of Zhengzhou University (Medical Sciences), 2009, 44(2): 337-339. [5] Fang SY, Liu QM, Song K, et al. Analysis of prevalence characters of hypertension among community crowds from the year 2007 to 2009 in Hangzhou. Prevention and Treatment of Cardio-Cerebral-Vascular Disease, 2011, 11(1): 24-26. [6] Zhang Y, Zhang W, Wang JF, et al. Prevalence and risk factors of primary hypertension in community in Changning district, Shanghai. Geriatrics & Health Care, 2012, 18(1): 19-22. [7] Chen PP, Lou PA, Yu JX, et al. Prevalence, awareness, treatment and control of hypertension in Xuzhou city. Chinese Journal of Health Care and Medicine, 2010, 12(1): 9-11. [8] Liu HY, Ma P, Xu QB, et al. Prevalence, awareness, treatment and control of hypertension in Wuzhong city, Ningxia province. The Journal of Practical Medicine, 2012, 28(2): 313-316. [9] He L, Tang X, Song Yan, et al. Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58308 residents. BMC Public Health, 2012, 12: 34-43. [10] Lei L, Zhou HB, Peng J, et al. Analysis of epidemiological tendency and risk factors for hypertension in Shenzhen. Chinese Journal of Prevention and Control of Chronic Diseases, 2012, 20(2): 146-148. [11] Tian S, Dong GH, Wang D, et al. Factors associated with prevalence, awareness, treatment and control of hypertension in urban adults from 33 communities in China: the CHPSNE Study. Hypertension Research, 2011, 34(10): 1087-1092. 20 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-1-3 Prevalence of Hypertension by Region Continued Standardized Survey period Region Age (years) No. of Sample Prevalence（%） Prevalence (%) 2009 Guangzhou [1] ≥15 23 939 11.8 — 2010 Gansu province[2] 18-85 3 000 36.7 — 2010 Yuhuatai district, Nanjing[3] ≥15 11 724 18.35 16.56 2010 Zhejiang province[4] ≥18 17 437 29.98 22.59 2011 Hulun buir, Inner Mongolia[5] ≥20 1 996 31.71 33.62 A cross-sectional population-based survey [6] was conducted to investigate the prevalence of hypertension in Hanzhong in 1982, 1998, 2004, and 2010. The study enrolled 8 575 adults (35-64 years old) in total and showed that the prevalence increased from 18.4% in 1982 to 30.5% in 2010 (Figure 2-1-6). 0DOH )HPDOH 7RWDO Prevalence(%) Figure 2-1-6 Trends in Hypertension Prevalence among Adults (35-64 years) (Hanzhong). [1] Wu X, Pan B, Chen X, et al. Useful information for hypertension management reform in community health care: prevalence, awareness, treatment and control among Guangzhou adults. Clinical and Experimental Hypertension, 2014, 36(4):227-235 [2] Dong C, Ge P, Ren X, et al. Prevalence, awareness, treatment and control of hypertension among adults in rural north-western China: a cross-sectional population survey. The Journal of International Medical Research, 2013, 41(4): 1291-1300. [3] Xu CL, Bao L, Cao H, et al. Prevalence of hypertension and related analysis of risk factors in Yuhuatai district, Nanjing city. South China Journal of Preventive Medicine, 2012, 38(1): 10-13. [4] Wang H, Zhang X, Zhang J, et al. Factors associated with prevalence, awareness, treatment and control of hypertension among adults in southern china: a community-based, cross-sectional survey. PloS One, 2013, 8(5): e62469. [5] Liang XW. Investigation of incidence rate of hypertension and its correlated risk factors in areas of Hulunbeir animal husbandry four fl ags. Modern Journal of Integrated Traditional Chinese and Western Medicine, 2012, 21(1): 11-13. [6] Zhao Y, Yan H, Marshall RJ, et al. Trends in population blood pressure and prevalence, awareness, treatment, and control of hypertension among middle-aged and older adults in a rural area of Northwest China from 1982 to 2010. PloS One, 2013, 8(4): e61779. 21 Report on Cardiovascular Diseases in China (2013) 2.1.1.2 Incidence of Hypertension There are substantial variations on the incidence of hypertension across different studies. A population-based study [1] enrolled 10 525 Chinese adults (>40 years old) who were free from hypertension at baseline and followed up for an average of 8.2 years, 28.9% of males and 26.9% of females developed hypertension by the end of the study (Figure 2-1-7). Accordingly, the annual incidence of hypertension was 3% by estimation. Male Female Incidence (%) 2YHUDOO Figure 2-1-7 8-year Cumulative Incidence of Hypertension Another study observed a total of 24 052 Chinese adults aged more than 35 years and free from hypertension at baseline [2] . During a mean of 28 months of follow-up, 26.5% of the participants developed hypertension. Those with higher blood pressure at baseline and older age were more likely to develop hypertension. <65 ≥65 ,QFLGHQFH 3HUVRQ\HDUV ,GHDO%3 1RUPDO%3 +LJKQRUPDO%3 7RWDO Figure 2-1-8 Incidence of Hypertension by Age and Baseline Blood Pressure Note: Ideal blood pressure: SBP <120 mmHg and DBP <80 mmHg; Normal blood pressure: SBP within 120-129mmHg and DBP within 80- 84mmHg; High-normal BP: blood pressure <140/90 mmHg, SBP within 130-139mmHg and/or DBP within 85-89mmHg. [1] Gu D, Wildman RP, Wu X, et al. Incidence and predictors of hypertension over 8 years among Chinese men and women. J Hypertens, 2007, 25(3): 517-523. [2] Zheng L, Sun Z, Zhang X, et al. Risk of progression to hypertension across baseline blood pressure in nonhypertensive participants among rural Chinese adults: a prospective study. Journal of Hypertension 2010, 28(6): 1158-1165. 22 Chapter 2 Risk Factors of Cardiovascular Diseases A study of 24 360 rural Chinese adults aged > 35 years and free from hypertension at baseline with a median follow-up of 28 months [1] showed that 29.6% of males and 23.4% of females developed hypertension. The age-adjusted incidence in male was higher than in female (12.75 per 100 person-years vs.10.04 per 100 person-years). 2.1.1.3 Detection Rate of High-normal Blood Pressure Survey on the Status of Nutrition and Health of the Chinese People in 2002 [2] stratifi ed data of 147 472 adults aged 18 years by blood pressure and demonstrated that the detection rate of high-normal blood pressure was 34%, representing 0.3 billion Chinese adults with high-normal BP. The defi nition of high- normal BP was based on 2005 Chinese Guideline for Prevention and Treatment of Hypertension. The detection rate was higher in men than that in women (Figure 2-1-9). The prevalence of high-normal BP in adults increased from 1991 to 2002; it increased with age at fi rst but then decreased as age continued to increase (Table 2-1-4). Female Male Total Proportion (%) 1RUPDO%3 +LJKQRUPDO +71 +71 +71 Figure 2-1-9 Proportion of Hypertension Classifi cation among Adults (China: 2002) Note: The classifi cations were stratifi ed by blood pressure according to the defi nition of hypertension by the 2005 Chinese Guideline for Prevention and Treatment of Hypertension. [1] Sun Z, Zheng L, Detrano R, et al. Incidence and predictors of hypertension among rural Chinese adults: results from Liaoning province. The Annals of Family Medicine, 2010, 8(1): 19-24. [2] Qi WH, Pan CY, Lin SY. Registry survey and treatment goal research of hypertension in some areas. Chinese Journal of Cardiovascular Disease. 2007,35(5):457-460. 23 Report on Cardiovascular Diseases in China (2013) Table 2-1-4 Detection Rate of High-normal BP among Adults (%) Male Female Total Age 1991(y) 2002(y) 1991(y) 2002(y) 1991(y) 2002(y) 18- 34.8 37.0 16.8 23.4 25.4 28.5 25- 36.0 40.3 17.4 25.1 26.0 30.9 35- 36.5 41.7 24.7 32.8 30.2 36.7 45- 35.9 40.3 30.2 36.1 32.9 38.0 55- 33.8 36.7 31.7 33.2 32.7 34.9 65- 32.3 31.6 30.1 28.9 31.2 30.3 75- 30.5 29.3 27.4 27.0 28.7 28.1 Total 35.2 38.6 23.5 30.4 29.0 34.0 Data from CHNS [1] showed that the detection rate of high-normal BP increased in nine provinces from 1991 to 2009, with a substantial higher rate in male than that in female, and peaked between the ages of 40 and 59. Table 2-1-5 Changes in the Detection Rate of High-normal BP among Adults (China: 1991-2009) 1991 1993 1997 2000 2004 2006 2009 N % N % N % N % N % N % N % Age(years) 18-39 4 517 26.8 3 953 31.2 3 788 36.2 3 869 37.3 2 841 41.7 2 551 41.4 2 202 37.8 40-59 2 657 33.6 2 712 37.4 3 192 39.0 3 796 41.5 3 962 42.6 4 175 43.7 3 868 42.8 ≥60 1 252 30.3 1 240 32.4 1 529 33.0 1 804 34.1 2 044 32.0 2 254 33.8 2 433 33.5 Gender Male 3 987 34.2 3 742 39.1 4 111 41.2 4 508 44.5 4 195 47.1 4 218 47.8 4 007 44.4 Female 4 439 25.2 4 163 28.1 4 398 32.3 4 961 32.3 4 652 34.6 4 762 34.9 4 496 33.5 Rural/Urban Urban 2 817 29.3 2 422 33.6 2 880 35.6 3 209 38.5 3 070 39.0 3 041 41.0 2 743 38.3 Rural 5 609 29.6 5 483 33.2 5 629 37.1 6 260 38.1 5 777 41.4 5 939 41.0 5 760 38.9 Total 8 426 29.4 7 905 33.2 8 509 36.6 9 469 38.2 8 847 40.6 8 980 41.0 8 503 38.7 A study [2] conducted among 15 540 Chinese adults aged 35 to 74 years showed that 21.9% of the [1] Xi B, Liang Y, Reilly KH, et al. Trends in prevalence, awareness, treatment, and control of hypertension among Chinese adults 1991-2009. International Journal of Cardiology, 2012,158(2): 326-329. [2] Yu D, Huang J, Hu D, et al. Prevalence and risk factors of prehypertension among Chinese adults. J Cardiovasc Pharmacol, 2008, 52: 363-368. 24 Chapter 2 Risk Factors of Cardiovascular Diseases participants had high-normal BP. The detection rates were higher in men and higher among those lived in northern China (25.7% in men vs 18.0% in women, 24.9% in northern China vs 20.0% in southern China, respectively). The obese population was also more likely to have high-normal BP when compared with the non-obese. Another prospective study[1] investigated the detection rate of high-normal BP in a cohort of 30 378 adults aged 35-64 years from 11 provinces/cities in China. The results showed that the standardized detection rate of high-normal BP was 32.2% in this cohort (34.2% in men and 30.2% in women). In recent years, many regional surveys were conducted to investigate the detection rate of high-normal BP, which showed substantial differences across regions ( Table 2-1-6). Table 2-1-6 Detection Rate of High-normal BP by Region Detection Rate in Male/ Region Age No. of Participants Detection Rate (%) Female (%) Fangshan District, Beijing[2] ≥40 58 308 37.8 — Communities in Harbin[3] ≥15 5 348 33.10 39.41/28.85 Chengdu[4] 40-59 2 940 41.5 47.4/38.3 Shaping District, Chongqing[5] >18 59 264 64.72 69.08/60.82 Shuiguohu District, Wuhan[6] 35-74 1 448 42.7 63.6/36.4 Liaoning Province[7] 18-74 25 196 40.5 47.7/33.6 A previous study [8], which examined the temporal trends of high-normal BP among 35-74 year-old residents in rural areas of Shandong Province, revealed that the detection rate of high-normal BP increased over time (33.8%, 61.5%, and 54.6% in 1991, 2002, and 2007, respectively). The detection rates in different age groups are shown in Figure 2-1-10. [1] Zhao D, Li CF, Wang W, et al. The 10-year cardiovascular risk in a Chinese cohort aged 35-64 years with high-normal blood pressure. Chinese Journal of Geriatric Heart Brain and Vessel Diseases, 2006, 8(11): 730-733. [2] He L, Tang X, Song Yan, et al. Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58308 residents. BMC Public Health, 2012, 12: 34-43. [3] Zhao N, Zhao JB, Zhao YJ, et al. Prevalence and risk factors of pre-hypertensive status in people from the community of Harbin. Chinese Journal of Disease Control & Prevention, 2012, 16(4): 280-284. [4] Yi YJ, Huang XB, Liu Y, et al. Prevalence and infl uential factors of prehypertension among middleaged people in Chengdu area. Sichuan Medical Journal, 2011, 33(10): 1512-1514. [5] Zhang L, Shi K, Yi D, et al. Prevalence and risk factors of prehypertension among adults in Chongqing city. Chinese Journal of public health, 2010, 26(6): 698-700. [6] Sit JW, Sijian L, Wong EM, et al. Prevalence and risk factors associated with prehypertension: identifi cation of foci for primary prevention of hypertension. Journal of Cardiovascular Nursing, 2010, 25(6): 461-469. [7] Meng XJ, Dong GH, Wang D, et al. Epidemiology of prehypertension and associated risk factors in urban adults from 33 communities in China: the CHPSNE Study. Circulation Journal, 2012, 76(4): 900-906. [8] Yang J, Lu F, Zhang C, et al. Prevalence of prehypertension and hypertension in a Chinese rural area from 1991 to 2007. Hypertension Research, 2010, 33(4): 331-337. 25 Report on Cardiovascular Diseases in China (2013) Detection Rate (%) ˄$JH˅ Figure 2-1-10 Detection Rate of High-normal BP among 35-74 Year-old Rural Residents in Shandong Province by Age Group (1991, 2002, 2007) It was reported [1] that compared with normotensives, the risk in subjects with high-normal blood pressure increased by 56% for stroke, 44% for coronary artery disease and 52% for overall cardiovascular diseases. The attributable risk (AR) of high-normal BP was 12.4%, 15.2%, and 14.4% for coronary events, stroke, and overall cardiovascular diseases, respectively. 2.1.1.4 Isolated Systolic Hypertension According to data from a 2002 survey [2] , the standardized prevalence of isolated systolic hypertension (ISH) for adults was 6.0%, 5.4% for males and 6.9% for females. By estimation, 50 million adults had ISH. Overall, the prevalence of ISH increases with age, especially after the age of 40. A higher percentage of men than women had ISH until the age of 40, the trend reversed after 40 years old (Figure 2-1-11). Male Female Total ISH Prevalence (%) 15－ 20－ 25－ 30－ 35－ 40－ 45－ 50－ 55－ 60－ 65－ 70－ 75－ ≥80（Age） Figure 2-1-11 Standardized Prevalence of ISH by Age and Gender Note: Prevalence among all age groups are adjusted for constitution of different regions. [1] Wang W, Zhao D, Sun JY, et al. Cardiovascular Risk among Chinese with High-normal BP. Chinese J of Hypertension, 2007,12:984-987. [2] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House:37-48. 26 Chapter 2 Risk Factors of Cardiovascular Diseases The prevalence of ISH is higher in the north than in the south. But unlike hypertension, the prevalence of ISH was higher for women than that for men in both the south and the north, so was the prevalence among rural residents when compared with that among urban residents (Table 2-1-7). Table 2-1-7 The Standardized Prevalence (%) of ISH among Adults by Region (2002) Urban Rural Small- and First Second Third Fourth Gender Total Large-size Middle- Class Class Class Class South North Total South North Total city Size City Area Area Area Area 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 7.5 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 the Survey on the Status of Nutrition and Health of the Chinese People in 2002 [1] , the average blood pressure in Chinese population increases with age. Before the age of 45, men have higher SBP than women, while the SBP is higher in women than in men after 45. Despite the level of DBP was lower for women at all age groups, the differences of DBP between men and women become smaller after the age of 45 (Table 2-1-8). Table 2-1-8 Average Blood Pressure in Populations Aged 15-74 SBP (mmHg) DBP (mmHg) Age (years) 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 The data of different ethnic groups [2] in the Chinese National Nutrition and Health Survey in 2002 revealed that among 152 683 analyzable participants aged over 15, the Manchus had the highest average SBP [1] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House:49-90. [2] Hu YS, Yao CH, Wang WZ, et al. Survey on the prevalence of hypertension in different ethnic groups in China in 2002. Journal of Hygiene Research, 2006, 35(5): 573-575. 27 Report on Cardiovascular Diseases in China (2013) (126.2 mmHg in men and 125.7 mmHg in women, respectively), while the Tibetans had the highest average DBP (85.7 mmHg in men and 81.6 mmHg in women, respectively), see Table 2-1-9. Table 2-1-9 The Average Blood Pressure in Population Aged Over 15 by Ethnic Group SBP (mmHg) DBP (mmHg) Ethnic group Male Female Male Female Han 123.3 120.3 78.6 75.9 Mongolian 123.3 123.3 78.2 77.1 Muslim 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 According to the data [1] collected from 162 chronic disease surveillance sites in China which included 98 548 residents aged over 18 in 2010, the average SBP was 130.8±21.3 mmHg (132.5±19.4 mmHg for men and 129.1±22.9 mmHg for women). The average DBP was 80.4±11.7 mmHg (81.21±11.7 mmHg for men and 79.5±11.7 mmHg for women). The average SBP was 130.3±20.7 mmHg for urban residents and 131.0±21.5 mmHg for rural residents, while the average DBP was 80.6±11.6 mmHg and 80.311.8 mmHg for urban and rural residents, respectively. The average blood pressures of different age groups are shown in Figure 2-1-12. 6%3'%3 %ORRG3UHVVXUH PP+J ı ˄$JH˅ Figure 2-1-12 Average Blood Pressure by Age (China: 2010) [1] Li YC, Wang LM, Jiang Y, et al. Prevalence of Chinese adults in 2010. Chinese Journal of Preventive Medicine, 2012; 46(5): 409-413. 28 Chapter 2 Risk Factors of Cardiovascular Diseases 2.1.1.6 Awareness, Treatment, and Control Rate of Hypertension Data based on Chinese National Nutrition and Health Survey in 2002 [1] revealed that the awareness rate, treatment rate, control rate, and control rate under treatment of hypertension were 30.6%, 24.7%, 6.1%, and 25% respectively. The awareness rate, treatment rate, and control rate all increased along with age, and the rates were higher in urban areas than in rural areas (Table 2-1-10). Table 2-1-10 Awareness, Treatment and Control Rate of Hypertension (%) in Chinese Population. Age Urban Rural Total 18- 17.8 11.6 13.6 45- 40.8 25.1 31.0 Awareness Rate 60- 48.5 26.8 37.6 Total 41.1 22.5 30.6 18- 11.8 7.9 9.1 45- 34.1 19.4 25.0 Treatment Rate 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 Rate 60- 11.3 3.9 7.6 Total 9.7 3.5 6.1 18- 36.3 26.8 30.7 - Control Rate by 45 29.7 20.2 25.2 Treatment 60- 26.6 19.1 24.1 Total 28.2 20.4 25.0 In 2007, the awareness rate, treatment rate, and control rate of hypertension among residents aged 15-69 were 32.7%, 27.5% and 11.6%, respectively [2] . Another study of the same time period [3] showed that the rates were 45.0%, 36.2% and 11.1%, respectively, in a cohort aged 20 or above. Previous analysis [4] on a population aged 18 or above in 9 provinces during 1991 to 2009 demonstrated [1] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House, 150-171. [2] Surveillance report of Chinese chronic disease and related risk factors: 2007 Hypertension. Chinese Center for Disease Control and Prevention: People’s Medical Publishing House, 2010. [3] Gao Y, Chen G, Tian H, et al. Prevalence of hypertension in china: a cross-sectional study. PloS One, 2013, 8(6): e65938. [4] Xi B, Liang Y, Reilly KH, et al. Trends in prevalence, awareness, treatment, and control of hypertension among Chinese adults 1991-2009. International Journal of Cardiology, 2012,158(2): 326-329. 29 Report on Cardiovascular Diseases in China (2013) that the awareness, treatment, and control rate of hypertension were rising overall, but the rates were still relatively low, and the control rate under treatment varied signifi cantly over the years (Figure 2-1-13). $ZDUHQHVV7UHDWPHQW&RQWURO7UHDWPHQWFRQWURO ˄˅ ˄ Figure 2-1-13 The Awareness, Treatment, Control, and Control under Treatment Rates of Hypertension in 9 Provinces (China: 1991-2009) One study [1] analyzed the awareness, treatment and control rate of hypertension in 12 groups of middle- aged adults. The result revealed that in 2004-2005, these three rates were 48.4%, 38.5%, and 9.5%, respectively, showing an increasing trend when compared with rates of other two periods (1992-1994 and 1998). For patients receiving anti-hypertensive medications, the control rate was 12.2%, 19.2%, and 24.0% in 1992-1994, 1998 and 2004 respectively, as shown in Figure 2-1-14. 1992－1994 1998 2004－2005 ˄˅ $ZDUHQHVV5DWH7UHDWPHQW5DWH&RQWURO5DWH7UHDWPHQW&RQWURO5DWH Figure 2-1-14 Hypertension Control Status among 12 Middle-aged Groups by Period According to the data from various regions, substantial differences existed in the awareness rate, treatment rate and control rate across regions (Table 2-1-11). [1] Wang ZW, Wang X, Li X, et al. Prevalence, awareness, treatment and control of hypertension in middle-aged Chinese population, Chinese Journal of Hypertension, 2008, 16(11):1033-1036. 30 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-1-11 Awareness, Treatment and Control Rate of Hypertension by Region Age Awareness Treatment Control Treatment Year Region No. (years) (%) (%) (%) control(%) 2007 Jiangsu Province[1] 4 317 15-69 42.1 34.1 9.3 — 2007 Shandong Provinces[2] 16 364 ≥25 26.2 22.2 3.9 17.7 Xinan County, 2007-2008 [3] 20 194 ≥18 65.0 62.2 19.4 31.3 Henan Province 2008 Beijing[4] 5 760 18-79 42.5 35.9 11.8 — 2008 Guangzhou[5] 7 026 15-69 31.6 28.8 12.6 — 2008 Xuzhou[6] 17 500 20-75 42.19 34.12 9.27 — 2009 Liaoning[7] 25 196 18-74 42.9 28.2 3.7 12.9 2009 Guangzhou[8] 23 939 ≥15 54.4 49.3 23.3 43.6 2009 Gansu Province[9] 3 000 18-85 37.0 31.2 5.6 18.1 2010 Zhejiang Province[10] 17 437 ≥18 54.33 46.34 18.26 — 2010 Hanzhong[11] 2 476 35-64 38.4 17.4 3.5 17.5 [1] Pan XQ, Lv SR, Xiang QY, et al. Epidemiological study of hypertension in Jiangsu province. Jiangsu journal of preventive medicine, 2010; 21(2): 17-19. [2] Li H, Meng Q, Sun X, et al. Prevalence, awareness, treatment, and control of hypertension in rural china: results from Shandong province. Journal of hypertension, 2010, 28(3): 432-438. [3] Han B, Yu DH, Wang CJ, et al. Prevalence, awareness, treatment and control of hypertension in rural areas of Henan. Journal of Zhengzhou University (Medical Sciences), 2009, 44(2): 337-339. [4] Cai L, Liu A, Zhang L, et al. Prevalence, awareness, treatment, and control of hypertension among adults in Beijing, china. Clinical and experimental hypertension, 2012; 34(1): 45-52. [5] Zhou Q, Pan BY, LIN GZ, et al. Prevalence, awareness, treatment and control of hypertension in 15-69 years old residents in Guangzhou. Chinese Journal of Prevention and Control of Chronic Non-communicable Diseases, 2010, 18(6): 587-589. [6] Chen PP, Lou PA, Yu JX, et al. Prevalence, awareness, treatment and control of hypertension in Xuzhou city. Chinese Journal of Health Care And Medicine, 2010, 12(1): 9-11. [7] Tian S, Dong GH, Wang D, et al. Factors associated with prevalence, awareness, treatment and control of hypertension in urban adults from 33 communities in China: the CHPSNE Study. Hypertension Research, 2011, 34(10): 1087-1092. [8] Wu X, Pan B, Chen X, et al. Useful information for hypertension management reform in community health care: prevalence, awareness, treatment and control among Guangzhou adults. Clinical and Experimental Hypertension, 2013. [Epub ahead of print] [9] Dong C, Ge P, Ren X, et al. Prevalence, awareness, treatment and control of hypertension among adults in rural north-western China: a cross-sectional population survey. The Journal of International Medical Research, 2013, 41(4): 1291-1300. [10] Wang H, Zhang X, Zhang J, et al. Factors associated with prevalence, awareness, treatment and control of hypertension among adults in southern china: a community-based, cross-sectional survey. PloS One, 2013, 8(5): e62469. [11] Zhao Y, Yan H, Marshall RJ, et al. Trends in population blood pressure and prevalence, awareness, treatment, and control of hypertension among middle-aged and older adults in a rural area of Northwest China from 1982 to 2010. PloS One, 2013, 8(4): e61779. 31 Report on Cardiovascular Diseases in China (2013) An epidemiology survey recruited 5 086 hypertensive outpatients aged over 18 years from department of cardiology, nephrology and endocrinology of 92 tertiary hospitals in 22 cities across China [1] . Overall, controlled BP was achieved in 30.6% of patients. The control rate (SBP < 140 mmHg and DBP < 90 mmHg) was 45.9% in uncomplicated hypertensive patients, 31.3% in hypertensive patients with coronary artery disease, 14.9% in patients with diabetes, and 13.2% in patients with renal dysfunction. Another research [2] among 26 655 outpatients demonstrated that the control rates were 50.2% and 56.7% respectively after 4 and 12 weeks of antihypertensive medication therapy. Control rate varied across different hypertension types, as well as different risk stratifi cations. Control rate decreased along with increased risk factor stratifi cation. Control rates were signifi cant lower for hypertensive patients with diabetes or renal disease when compared with those without such comorbidities (Table 2-1-12). Table 2-1-12 Control Rate by Different Hypertension Types (%) Duration of Medium- Very With With Renal ISH IDH SDH Low-risk High-risk Total Treatment risk High-risk Diabetes Disease 4 56.0 69.1 48.1 84.6 69.6 43.7 40.9 18.9 27.7 50.2 12 57.9 72.6 55.6 93.9 79.5 54.1 49.9 30.3 45.5 56.7 ISH：isolated systolic hypertension; IDH: isolated diastolic hypertension; SDH: systolic-diastolic hypertension. 2.1.1.7 Factors Affecting Hypertension Prevalence Data from the 2010 Chinese guideline for the prevention and treatment of hypertension [3] showed that risk factors associated with hypertension in Chinese population included high sodium and low potassium diet, obesity and overweight, alcohol consumption, mental stress, age, family history of hypertension, lack of physical activity, etc. The risk of developing hypertension increased exponentially with age for both men and women. For instance, the risk for men aged 65-74 years is 22 times as high as for men aged 15-24 years; while for women, the risk in 65-74 years of age group is 57 times as high as for those 15-24 years of age. Men have a higher risk of developing hypertension than women until 45 years of age, after that, women than men have a higher risk of developing hypertension [4] . Table 2-1-13. [1] Hu DY, Liu LS, Yu JM, Et Al. National survey of blood pressure control rate in Chinese hypertensive outpatient status. Chinese Journal of Cardiology, 2010, 38(3): 230-238. [2] Qi WH, Pan CY, Lin ST. Registry survey and treatment goal research of hypertension in some areas. Chinese Journal of Cardiovascular Disease. 2007,35(5):457-460. [3] Revision committee of Chinese guideline for the management of hypertension. 2010 Chinese guideline for the prevention and treatment of hypertension. Chinese Journal of Cardiology, 2011, 39(7): 579-616. [4] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House, 150-171. 32 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-1-13 Relative Risk of Hypertension by Age and Gender Male Female Age Group (years) Prevalence (%) OR (95%CI) Prevalence (%) OR (95%CI) 15-24 4.76 1.00 2.13 1.00 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） 65-74 52.46 22.07（19.64-24.79） 55.70 57.77（50.09-66.63） A previous study [1] showed that the risk for hypertension among those with family history was twice as high as those without one; the obese and overweight were more likely to develop hypertension compared with those with normal weight; more alcohol intake, higher triglyceride, higher total cholesterol, and lower HDL-C were associated with higher risk of hypertension (Table 2-1-14). Table 2-1-14 Risk of Developing Hypertension by Risk Factors Risk Factors Level Prevalence (%) OR (95% CI) Family History of Hypertension No 18.22 1.00 Yes 30.38 1.96（1.90-2.20） Alcohol Intake (g/d) <4.80 24.04 1.00 4.80- 23.65 0.98（0.86-1.12） 10.51- 26.25 1.13（0.99-1.28） 19.94- 30.20 1.37（1.20-1.55） ≥40.03 35.22 1.72（1.52-1.94） Obesity and Overweight Thin 13.7 0.8（0.8-0.9） Normal 16.5 1.00 Overweight 33.3 2.5（2.5-2.6） Obesity 51.2 5.3（5.1-5.5） Triglyceride Normal 20.69 1.00 High 37.20 2.27（2.15-2.40） Total Cholesterol Normal 21.29 1.00 High 43.26 2.82（2.56-3.11） Normal 22.68 1.00 High Density Lipoprotein Cholesterol Low 25.47 1.17（1.08-1.26） [1] Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four, Hypertension in 2002. Beijing: People’s Medical Publishing House, 150-171. 33 Report on Cardiovascular Diseases in China (2013) A study [1] exploring hypertension prevalence among hypertensive patients’ offspring showed that the hypertension prevalence was signifi cantly higher among those with a family history of high blood pressure compared with those without the family history. For participants with the family history of hypertension, overweight, obesity, smoking, alcohol consumption, and high-salt diet were all associated with higher risk of hypertension (Table 2-1-15). Table 2-1-15 Risk Factors for Hypertension Prevalence (%) Risk Factors Offspring of Hypertensive OR(95%CI) Control Group Patients Overweight and Abdominal Obesity 17.14 30.87 3.11（2.23-3.91） Alcohol Consumption 13.21 29.23 2.28（1.14-3.76） Smoking 10.71 23.65 2.11（1.15-3.77） High Salt Intake Diet 31.43 33.33 3.83（2.17-4.21） Analysis of data from several regional surveys [2, 3, 4, 5, 6, 7, 8, 9, 10, 11] across China on risk factors of hypertension, showed that older age, male, overweight and obesity, alcohol abuse, smoking, dyslipidemia, history of [1] Zou CN, Zhang XJ, Chen M. Survey of blood pressure among hypertensive patients’offspring in four districts of Kunming. Chinese Journal of Clinicians, 2012, 6(4): 1014-1015. [2] Fu SY, Li WM, Zhao YJ, et al. Prevalence of hypertension and risk factors in Heilongjiang province in 2007. Chinese Medical Journal, 2010, 123(6): 752-755. [3] Zhao Y, Lu F, Sun H, et al. Trends in hypertension prevalence, awareness, treatment and control rates in Shandong province of China. The Journal of Clinical Hypertension, 2012, 14(9): 637-643. [4] Chen PP, Lou PA, Yu JX, et al. Prevalence, awareness, treatment and control of hypertension in Xuzhou city. Chinese Journal of Health Care And Medicine, 2010, 12(1): 9-11. [5] Tian S, Dong GH, Wang D, et al. Factors associated with prevalence, awareness, treatment and control of hypertension in urban adults from 33 communities in China: the CHPSNE Study. Hypertension Research, 2011, 34(10): 1087-1092. [6] Wu X, Pan B, Chen X, et al. Useful information for hypertension management reform in community health care: prevalence, awareness, treatment and control among Guangzhou adults. Clinical and Experimental Hypertension, 2014, 36(4): 227 - 235. [7] Wang H, Zhang X, Zhang J, et al. Factors associated with prevalence, awareness, treatment and control of hypertension among adults in southern china: a community-based, cross-sectional survey. PloS One, 2013, 8(5): e62469. [8] Liang XW. Investigation of incidence rate of hypertension and its correlated risk factors in Hulunbeir animal husbandry four fl ags. Modern Journal of Integrated Traditional Chinese and Western Medicine, 2012, 21(1): 11-13. [9] Sun Z, Zheng L, Detrano R, et al. Incidence and predictors of hypertension among rural Chinese adults: results from Liaoning province. The Annals of Family Medicine, 2010, 8(1): 19-24. [10] Wang W, Zhao D, Sun JY, et al. The Impact of High-normal Blood Pressure on Risk of Cardiovascular Diseases in Chinese Multi-provinces Cohort Study. Chinese Journal of Hypertension, 2007, (12): 984-987. [11] Zhou Q, Pan BY, LIN GZ, Et Al. Prevalence, awareness, treatment and control of hypertension in 15-69 years old residents in Guangzhou. Chinese Journal of Prevention and Control of Chronic Non-communicable Diseases, 2010, 18(6): 587-589. 34 Chapter 2 Risk Factors of Cardiovascular Diseases hypertension, diabetes, level of education, were all risk factors for hypertension. A cross-sectional study [1] exploring the association between dietary patterns and hypertension among Chinese adults demonstrated that patients with traditional northern diet pattern presented signifi cantly higher blood pressure; meanwhile, the southern diet pattern was associated with lower risk of hypertension. Additionally, several studies [2, 3, 4] revealed that the majority of the Chinese were quite sensitive to sodium, and high sodium and low potassium diet was an important risk factor for hypertension. Besides, an analysis [5] of plasma 25(OH)D level in association with BP was performed among 1 460 participants aged 40-74 years in Shanghai. Results showed that 25(OH)D levels were inversely related to blood pressure levels and hypertension prevalence among middle-aged and elderly men. 2.1.2 Secondary Hypertension At present, there is still few data of large-sample survey on secondary hypertension, but based on retrospective epidemiological studies, it is estimated that patients with secondary hypertension account for 5%-10% of total hypertensives. Common etiologies for secondary hypertension include renal parenchymal hypertension, renovascular hypertension, endocrinopathies, obstructive sleep apnea hypopnea syndrome (OSAHS), and psychological factors. [6] One study among 2 274 hospitalized hypertensive patients aged 14-92 year found that 14% of patients were diagnosed with secondary hypertension [7] . Figure 2-1-15 shows a breakdown of the causes associated with secondary hypertension. [1] Wang D, He Y, Li Y, Et Al. Dietary patterns and hypertension among Chinese adults: a nationally representative cross-sectional study. BMC Public Health, 2011, 11(1): 925. [2] Liu Z. Dietary sodium and the incidence of hypertension in the Chinese population: a review of nationwide surveys. American Journal of Hypertension, 2009, 22(9): 929-933. [3] Wang JG, Li Y. Characteristics of hypertension in Chinese and their relevance for the choice of antihypertensive drugs. Diabetes Metabolism Research and Reviews, 2012, 28 (Suppl 2): 67-72. [4] Chen J. Epidemiology of hypertension and chronic kidney disease in China. Current Opinion in Nephrology and Hypertension, 2010, 19(3): 278-282. [5] Dorjgochoo T, Ou Shu X, Xiang YB, Et Al. Circulating 25-hydroxyvitamin D levels in relation to blood pressure parameters and hypertension in the shanghai women's and men's health studies. British Journal of Nutrition, 2012,108(3): 449-458. [6] Chen J. Epidemiology of hypertension and chronic kidney disease in China. Current Opinion in Nephrology and Hypertension, 2010. 19(3): 278-282. [7] Wang ZH, Chu SL, Chen SX. Analysis of etiology and risk factors of in-patients with hypertension. Chinese Journal of Hypertension, 2005, 13(8): 504-509. 35 Report on Cardiovascular Diseases in China (2013) 5HQDO3DUHQFK\PDO 5HQRYDVFXODU 3ULPDU\+\SHUDOGRVWHURQLVP &XVKLQJ6\QGURPH 3KHRFKURPRF\WRPD 2WKHU Figure 2-1-15 Causes of Secondary Hypertension in Hospitalized Patients (%) Another study analyzed etiology of 7 809 hospitalized hypertensive patients from 1999 to 2008, showing that secondary hypertension accounted for 24.9% of all cases. [8] OSAHS and primary hyperaldosteronism were the leading causes of secondary hypertension. The prevalence of secondary hypertension increased signifi cantly during the 10 years and was higher in 2008 than in 1999 (39.3% vs 9.5%). In addition, the proportion of secondary hypertension increased remarkably in recent years in hospitalized hypertensive patients. 2.1.3 Hypertension in Children and Adolescents 2.1.3.1 Status and Evaluation Criteria of BP for Children and Adolescents Blood pressure levels in children and adolescents (under 18 years, collectively referred to as “children” below) steadily increase with age and developmental growth and reach adult levels by 18 years. During that period, there are signifi cant differences in blood pressures between males and females. Because of this, the evaluation of blood pressure levels of children must consider age, sex, and/or height, and use the 90th, 95th, and 99th percentile of the population average blood pressure levels as diagnostic cut-offs for “high-normal blood pressure”, “hypertension,” and “severe hypertension.” In 2010, the Chinese Children and Adolescent Blood Pressure Reference Standard Development Working Group produced the “Chinese Children and Adolescent Blood Pressure Reference Guidelines ” for Han Chinese Children aged 3-17 years [9] (Tables 2-1-16 and 2-1-17). These standards are based on current clinical and epidemiological studies in Chinese pediatric research that primarily use auscultatory method to measure blood pressure in children. These studies developed diagnostic standards for diastolic blood pressure (DBP) based on the 4th and 5th Korotkoff sounds (DBP-K4 and DBP-K5), respectively. The 2010 Chinese Guide for Prevention and Treatment of [8] Li NF, Lin L, Wang L, et al. Etiology Analysis for Hospitalized Hypertensive patients:10 Years Report from the Department of Hypertension(1999-2008). Chinese Journal of Cardiovascular Diseases, 2010, 38(10): 939-942. [9] Revision committee of Chinese guideline for the management of hypertension. 2010 Chinese guideline for the management of hypertension. Chinese Journal of Cardiology, 2011, 39(7): 579-616. 36 Chapter 2 Risk Factors of Cardiovascular Diseases Hypertension expanded the chapter on children hypertension and the aforementioned standards. In recent epidemiological literature on children hypertension in China, besides using Chinese criteria mentioned above, some have used the 2004 American guidelines for high blood pressure in children and adolescents. [1] The distinguishing feature of the American guidelines is to use K5 as the reference point for DBP and to consider the effect of height on blood pressure aside from sex and age. When comparing the two guidelines, the Chinese guidelines are highly convenient and applicable, but may cause false-positive misdiagnoses among those children whose elevated blood pressure maybe caused by their greater height. The American guidelines only established the fi fth Korotkoff sound (K5) as the defi nition of DBP, but K5 is inaudible or very low in 20%-40% of very young children (<12 years). If DBP is based on K4 sounds, the detection rates of high blood pressure in children may be overestimated. Considering the effect of height on blood pressure for every child is not necessary and greatly increases the workload for the clinician at the same time. It is recommended to record DBP values at both K4 and K5 sounds when measuring blood pressure via auscultatory method. With the advent and use of oscilloscopes, those problems should be solved. The phenomenon of white-coat hypertension is a major problem in epidemiological research on children blood pressure. Because of this, it is must be discreet before confi rming a child as having hypertension. Elevated BP must be confi rmed on 3 non-same-day repeated blood pressure readings according to 2010 Chinese Guide for Prevention and Treatment of Hypertension. A Beijing-based study discovered that the prevalence of hypertension at second and third measurements in 2-weeks intervals was 28% and 17% of the fi rst measurement, decreases of 72% and 83% respectively. [2] Repeated measurements are required to confi rm the diagnosis of hypertension in children and therefore can greatly reduce the false-positive rate of hypertension. In recent years, several domestic epidemiological surveys reported the hypertension detection rates based on both single and repeated measurements for the ease of inter-study comparisons. The majority of Chinese studies base the determination of children hypertension on measurements at one time point (regardless of how many times blood pressure was measured at that point). Thus, without specifi c clarifi cation, prevalence data on children hypertension mentioned in this report is based on single time point measurements. [1] The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics, 2004; 114 (2 Suppl 4th Report): 555-576. [2] Meng LH, Liang YJ, Liu JT, et al. Prevalence and risk factors of hypertension based on repeated measurements in Chinese children and adolescents. Blood Pressure, 2013, 22(1): 59-64. 37 Report on Cardiovascular Diseases in China (2013) Table 2-1-16 Diagnostic Criteria for Male Children (mmHg) SBP DBP-K4 DBP-K5 Age P90 P95 P99 P90 P95 P99 P90 P95 P99 3 102 105 112 66 69 73 66 69 73 4 103 107 114 67 70 74 67 70 74 5 106 110 117 69 72 77 68 71 77 6 108 112 120 71 74 80 69 73 78 7 111 115 123 73 77 83 71 74 80 8 113 117 125 75 78 85 72 76 82 9 114 119 127 76 79 86 74 77 83 10 115 120 129 76 80 87 74 78 84 11 117 122 131 77 81 88 75 78 84 12 119 124 133 78 81 88 75 78 84 13 120 125 135 78 82 89 75 79 84 14 122 127 138 79 83 90 76 79 84 15 124 129 140 80 84 90 76 79 85 16 125 130 141 81 85 91 76 79 85 17 127 132 142 82 85 91 77 80 86 Note: high-normal hypertension: SBP and/or DBP≥P90-< P95, or for children≥12 years old, SBP and/or DBP≥120/80 mmHg plus < P95; hypertension: SBP and/or DBP≥P95-< P95; severe hypertension: SBP and/or DBP≥P99. Table 2-1-17 Diagnostic Criteria for Female Children (mmHg) SBP DBP-K4 DBP-K5 Age P90 P95 P99 P90 P95 P99 P90 P95 P99 3 101 104 110 66 68 72 66 68 72 4 102 105 112 67 69 73 67 69 73 5 104 107 114 68 71 76 68 71 76 6 106 110 117 70 73 78 69 72 78 7 108 112 120 72 75 81 70 73 79 8 111 115 123 74 77 83 71 74 81 9 112 117 125 75 78 85 72 76 82 10 114 118 127 76 80 86 73 77 83 11 116 121 130 77 80 87 74 77 83 12 117 122 132 78 81 88 75 78 84 13 118 123 132 78 81 88 75 78 84 14 118 123 132 78 82 88 75 78 84 15 118 123 132 78 82 88 75 78 84 16 119 123 132 78 82 88 75 78 84 17 119 124 133 79 82 88 76 78 84 Note: high-normal hypertension: SBP and/or DBP≥P90-< P95, or for children≥12 years old, SBP and/or DBP≥120/80 mmHg plus < P95; hypertension: SBP and/or DBP≥P95-< P95; severe hypertension: SBP and/or DBP≥P99. 2.1.3.2 Epidemiological Trends and Distributional Characteristics of Hypertension in Children and Adolescents (1) Analysis of data from 190 000 Han Chinese children aged 7 to 17 years across 30 provinces and cities in the National Student Health Study 2005-2010 found there was an increasing trend in blood pressure levels 38 Chapter 2 Risk Factors of Cardiovascular Diseases regardless of age and gender. [1] The SBP and DBP among male students had respectively increased by 1.5 mmHg (95% CI: 1.4-1.7) and 1.1 mmHg (95% CI: 1.1-1.2), and among female students had respectively increased by 1.2 mmHg (95% CI: 1.1-1.3) and 1.0 mmHg (95% CI: 1.0-1.1). The differences were statistically signifi cant (p<0.001). The increase of SBP in male and female students was higher than that of DBP. SBP elevation in male students was signifi cantly higher than that of female students (Figure 2-1-16). 6%3 6%3 '%3 '%3 $YHUDJH%3 PP+J $JH 0DOH )HPDOH Figure 2-1-16 Trends in Blood Pressure Level, Age 7-17 (China: 2005-2010) (2) The Chinese Health and Nutrition Surveys examined blood pressures of children and adolescents aged 6 to 17 years in 7 provinces and cities throughout the country in 1991, 1993, 1997, 2000, 2004 and 2009. [2, 3] The surveys showed that during 1991-2009, there had been a continuously increasing trend in the prevalence of childhood hypertension, from 7.1% in 1991 to 13.8% in 2009 (Figure 2-1-17), indicating that the average annual increase was estimated to be 0.47%. [1] Dong B, Wang HJ, Wang Z, et al. Trends in blood pressure and body mass index among Chinese children and adolescents from 2005 to 2010. American Journal of Hypertension, 2013, 26(8): 997-1004. [2] Liang YJ, Xi B, Hu YH, et al. Trends in blood pressure and hypertension among Chinese children and adolescents: China health and nutrition surveys 1991-2004. Blood Pressure, 2011, 20(1): 45-53. [3] Xi B, Liang Y, Mi J. Hypertension trends in Chinese children in the national surveys, 1993 to 2009. International Journal of Cardiology, 2013, 165 (3): 577-579. 39 Report on Cardiovascular Diseases in China (2013) 0DOH )HPDOH 7RWDO 3UHYDOHQFH˄˅ ˄ (3) Epidemiological status of children hypertension in different regions. Recently, large-sample surveys on hypertension in children were conducted consecutively in Beijing, Changsha, Yunnan, and Xinjiang (Table 2-1-18). These studies included Han Chinese populations and many ethnic minorities, and used the “Chinese Children and Adolescent Blood Pressure Reference Guidelines” to defi ne hypertension. The reported prevalence rates were all based on single time-point measurements. Table 2-1-18 Prevalence of Hypertension in Children by Region and Population Characteristics Survey Survey period Survey size Diagnostic Prevalence Ethnic group Age (years) DBP region (year) (persons) method (%) Beijing [3] 2004 Han Chinese 6-18 K4 19 598 Auscultation 8.5 [4] Han Chinese and Yunnan 2005 3-6 K4 15 877 Auscultation 7.1 11 other groups Changsha [5] 2009 Han Chinese 12-17 K4 88 947 Auscultation 3.1 Xinjiang [6] 2009 Kazakh 7-14 K4 2 438 Auscultation 5.6 [1] Liang YJ, XI B, HU YH, et al. Trends in blood pressure and hypertension among Chinese children and adolescents: China health and nutrition surveys 1991-2004. Blood pressure, 2011,20(1): 45-53. [2] Xi B, Liang Y, Mi J. Hypertension trends in Chinese children in the national surveys, 1993 to 2009. International Journal of Cardiology 2013; 165(3): 577-579. [3] Chen F, Wang Y, Shan X, et al. Association between childhood obesity and metabolic syndrome: evidence from a large sample of Chinese children and adolescents. PLoS One, 2012. 7(10): e47380. [4] Zhang W, Guo ZH, Liu JT, et al. Investigation of Blood Pressure Levels and Standards for Hypertension Diagnosis in 3- to 6-year-old Children in Yunnan Province. Chinese Journal of Hypertension, 2012, 3: 260-264. [5] Cao ZQ, Zhu LP, Zhang T, et al. Blood Pressure and obesity among adolescents: a school-based population study in China. American Journal of Hypertension, 2012. 25(5): 576 – 582. [6] Xu YJ, Li M, Xu PR, et al. Correlation between Obesity Index and Blood Pressure in Kazak Childhood from Yili, Xinjiang. Chinese Journal of Epidemiology, 2012, 8(33): 774-778. 40 Chapter 2 Risk Factors of Cardiovascular Diseases 2.1.3.3 Prevalence of Hypertension in Children by Repeated Measurements A study in Beijing of 6 692 Han Chinese children and adolescents 3 to 18 years of age (3 327 males; 49.7%) who were observed 3 times between 2009 and 2010 found the prevalence of hypertension was 18.2%, 5.1% and 3.1% on the fi rst, second and third visits, respectively. The prevalence of hypertension after three separate visits was 17% of that prevalence of fi rst screening; in other words, the prevalence on the fi rst visit is 5.9 times of that on the third visit. [1] This was the only one hypertension study on mainland China up to now that employed non-same-day measurements at three separate visits to assess blood pressure in children and adolescents. The Chinese Children and Adolescent Blood Pressure Reference Guidelines stipulated that high-risk children, detected by one blood pressure measurement, still need to repeat measurements from at least two different time points and exclude white-coat hypertension before confi rming hypertension. Because of this, monitoring the dynamic change of blood pressures in children is more meaningful than single time point measurements. [2] We recommend that future studies on childhood hypertension should use multiple time point measurements (at least measurements on two occasions) to produce more accurate results. 2.1.3.4 Risk Factors of Hypertension in Children (1) Overweight and Obesity A close relationship exists between obesity and hypertension in children. Body mass index (BMI), waist circumference (WC), and weight-height ratio (WHtR) are commonly used metrics to assess childhood obesity status and obesity type. An analysis of blood pressure and body type among 40 495 Han Chinese students of ages 7-10 years (20 175 males; 49.8%) in National Student Health Survey 2010 showed that there was statistically difference of BP level in different body types. The students with complex obesity had the highest prevalence of hypertension, followed by students with abdominal obesity and those with normal body weight [3] (Figure 2-1-18). [1] Meng LH, Liang YJ, Liu JT, et al. Prevalence and risk factors of hypertension based on repeated measurements in Chinese children and adolescents. Blood Pressure, 2003, 2(1): 59-64 [2] Mi J, Wang TY, Meng LH, et al. Development of Blood Pressure Reference Standards for Chinese children and adolescents. Chinese J of Evidence Based Pediatrics.2010, 5(1):4-14. [3] Wu L, Ma J, Fu LG, et al. Association between Abdominal Obesity and Blood Pressure among 7-10 Years Old Chinese Children. Chinese Journal of Preventive Medicine, 2013, 8(47): 689-694. 41 Report on Cardiovascular Diseases in China (2013) Normal Body Abdominal Obesity Complex Obesity (OHYDWHG%3'HWHFWLRQ5DWH˄˅ Male Female Figure 2-1-18 Elevated Blood Pressure by Gender and Body Type Note: (1) Elevated blood pressure: SBP and/or DBP greater than the 95th percentile SBP/DBP values of students of same age and gender from the 2010 survey; (2) Abdominal obesity: normal BMI, elevated WHtR; complex obesity: elevated BMI and WHtR; (3) Elevated BMI: Based on underweight, normal, overweight, or obese categorization from the 2006 WHO Juvenile Malnutrition Guidelines and the Working Group on Obesity in China’s Chinese School-aged Children and Adolescent Overweight and Obesity BMI Categorization Guidelines, elevated BMI is defi ned as overweight and/or obese; elevated WHtR: WHtR > 0.46. A study that recruited 8 194 Han Chinese school-aged children of ages 7-17 years from urban and rural settings in Anhui province stratifi ed male and female students of every age based on scores assigned to their waist circumferences on a 100 point scale in 10 point increments [1] . The results showed that the prevalence of hypertension in male and female students increased signifi cantly with the increasing of point values of waist circumference (males: χ2 = 63.9, p<0.001; females: χ2 = 29.87, p<0.001). Using those with waist circumferences < P30 as the control group, after controlling for location and age, the odds ratio for hypertension began to increase and reached statistical signifi cance when male waist circumference increased to P60 and female waist circumference increased to P70. After these points, the odds-ratio of hypertension continues to increase dramatically with the increasing of waist circumference (Figure 2-1-19). [1] Zhu P, Wang FY, Zhao YQ, et al. Association between waist circumference development curve of children and hypertension and risk of hypertension. Chinese Journal of Pediatrics, 2012, 1(50): 56-61. 42 Chapter 2 Risk Factors of Cardiovascular Diseases +\SHUWHQVLRQ5LVN˄25˅ 3a3a3a3a 3a3a3 a3a3a3a3a3a3a3 a 0DOH )HPDOH Figure 2-1-19 Association of Hypertension Prevalence and Waist Circumference among 7-17 Years Old Chinese Children A study from Shanghai analyzed the association between blood pressure and body weight in 78 114 school children (40 105 males, 51.3%). The diagnosis of overweight and obesity was based on the Working Group on Obesity in China (WGOC) [1] . The results showed that after adjusting for age and gender, BMI and WC were independently positively correlated with SBP and DBP. The prevalence of high SBP, DBP and hypertension were markedly higher among overweight and obesity children than normal weight group. As a result, the risk of developing hypertension among children with overweight or obesity was 1.5-2.2 times that of children with normal weight (Figure 2-1-20). The prevalence of hypertension increased with obesity stages (p<0.0001). Hypertension Prevalence（%） Normal Overweight Obese Normal Overweight Obese BMI status WC status Figure 2-1-20 Hypertension Prevalence by BMI and WC Stratifi cation [1] Lu X, Shi P, Luo CY, et al. Prevalence of hypertension in overweight and obese children from a large school-based population in Shanghai, China. BMC Public Health, 2013, 13: 24.doi: 10.1186/1471-2458-13-24. 43 Report on Cardiovascular Diseases in China (2013) (2) Abnormal Glucose and Lipid Metabolism A multi-center children hypertension survey from Harbin, Beijing, Jinan, Shanghai, Chongqing and Guangzhou published in 2012 reported that after adjusting for age, gender, BMI, socioeconomic level, parental educational levels, and age of puberty, the risk of developing hypertension among children in the hypertriglyceridemia, hyperglycemia, metabolic syndrome, and high HOMR-IR index groups was higher than among healthy children (p < 0.0001). [1] (3) Family History of Hypertension The Beijing Children and Adolescent Metabolic Syndrome Research Group surveyed 19 088 children of ages 6-17 years (9 319 males, 48.8%) in 2004. [2] Hypertension was defi ned as SBP and/or DBP that is ≥ 95th percentile for gender and age on single time-point measurements. The study analyzed the association between children hypertension and parental history of hypertension. The results showed that the hypertension prevalence rates for children categorized into 4 groups designated as “both parents without hypertension,” “paternal hypertension,” “maternal hypertension,” and “both parents with hypertension” were 8.72%, 13.83%, 12.60% and 11.50% (p < 0.001), respectively (Table 2-1-19). Table 2-1-19 Association between HTN in Children and Parental HTN Family History of HTN HTN Prevalence (%) OR（95%CI） Both Parents without HTN 8.7 1 Paternal HTN 13.8 1.68（1.39-2.06） Maternal HTN 12.6 1.56（1.16-2.09） Both Parents with HTN 11.5 1.27（0.67-2.41） (4) Birth Weight In a 18-year follow-up cohort study in Wuyi in 1993-1995, infants with birth weights ≥ 4 kg were categorized into the exposure group, and infants weighing between 2.5 kg and 4 kg were designated as the control group. [3] After adjusting for gestational age, gender, maternal occupation, maternal age at delivery, maternal antenatal body weight and other factors, the exposure group’s average SBP (110.8 ± 9.4 mmHg) was markedly higher than that of the control group (109.3 ± 9.3 mmHg) (p = 0.0002). (5) Salt Sensitivity A cohort study among children with 18-year follow-up in Hanzhong village in Shanxi [4] found that among [1] Xu H, Hu X, Zhang Q, et al. The Association of hypertension with obesity and metabolic abnormalities among Chinese children. International Journal of Hypertension. 2011: 987159.doi: 10.4061/2011/987159. [2] Xi B, Mi J, Wang L, et al. Family Aggregation of Primary Hypertension among Children and Adolescents in Beijing. Zhonghua Liu Xing Bing Xue Za Zhi, 2008, 29(9): 849-854. [3] Li Y, Wu J, Yu J, et al. Is fetal macrosomia related to blood pressure among adolescents? A birth cohort study in China. Journal of Human Hypertension, 2013, 27(11): 686-692. [4] Mu J, Zheng S, Lian Q, et al. Evolution of blood pressure from adolescents to youth in salt sensitivities: a 18-year follow-up study in Hanzhong children cohort. Nutrition Journal, 2012,11:70. 44 Chapter 2 Risk Factors of Cardiovascular Diseases salt-sensitive children (age 6-15 years), their SBP (122.9 ± 13.1 mmHg) and DBP (78.2 ± 10.4 mmHg) in early adulthood (age 24-33 years) appeared higher compared to those of non-salt-sensitive counterparts (SBP 117.3 ± 12.4 mmHg, p <0.01; DBP 74.7 ± 10.8 mmHg, p < 0.05). Furthermore, compared with the non-salt- sensitive children, they have a 1.34-times greater rate of developing hypertension (RR = 2.34, 95% CI: 1.04- 5.25), indicating that salt sensitivity in childhood is a risk factor of hypertension in early adulthood. (6) Poor Prenatal and Postnatal Nutrition The 2009 Chinese Health and Nutrition Survey analyzed blood pressures and other parameters among 1 415 adults (681 males, 48.1%) who were exposed to the 1959-1961 Great Famine during the fetal-newborn period (age <1 year) and infant-preschool period (age 1-5 years). [1] The defi nition of hypertension was based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The results showed that, after adjusted for age, marital status, BMI, waist circumference, smoking, alcohol use and other factors, the females in the fetal-newborn and infant-preschool exposure groups were 1.62 times (OR = 1.62; 95% CI: 1.01-2.61) and 1.78 times (OR = 1.78; 95% CI: 1.15- 2.74) more likely to develop adult hypertension compared with the control groups. The differences were statistically signifi cant (P < 0.05). However, no statistically signifi cant increases in mean BP or hypertension risk were seen among men. (Figure 2-1-21), suggesting that the infl uence of early malnutrition on adult hypertension was gender-specifi c. Control Fetal-newborn Infant-preschool Adulthood HTN Prevalence (%) Male Female Figure 2-1-21 Adulthood HTN Prevalence by Different Early Exposure to the Great Famine Note: (1) The Great Famine was from 1959 to 1961; (2) The control group includes those born between Oct 1, 1962 and Sept 30, 1964. The fetal-newborn exposure group includes those born between Oct 1, 1959 and Sept 30, 1961. The infant-preschool exposure group includes those born between Oct 1, 1956 and Sept 30, 1958. [1] Chen H, Nembhard WN, Stockwell HG. Sex-specifi c effects of fetal exposure to the 1959-1961. Chinese Famine on Risk of Adult Hypertension. Maternal and Child Health Journal, 2014, 18(3): 527-533. 45 Report on Cardiovascular Diseases in China (2013) 2.1.3.5 Prediction of Adult Hypertension and Target-Organ Damage Based on Childhood Blood Pressure Levels Analysis of data from the Beijing Child Blood-Pressure Study (BBS), which included 412 children 6-18 years of age who were followed-up 18 years, discovered after controlled for age, gender, adult height and BMI and other factors, the odds ratio of developing adult hypertension among children who were diagnosed with hypertension (SBP/DBP > P95) was 4.63 compared with those with normal baseline blood pressures (OR = 4.63; 95% CI: 2.09-10.25). [1] Pubertal hypertension (Tanner stage II and beyond) predicted a higher risk of adult hypertension than pre-pubertal (male testes and female breast development at Tanner stage I) hypertension, with odds ratios (95% confi dence intervals) of 10.00 (3.03-33.07) and 2.71 (0.83-8.85), respectively. [2] The Hanzhong Child Hypertension Cohort 18-year follow-up study in Shanxi showed that 28% of children with elevated blood pressures became hypertensive in adults, signifi cantly higher than children with normal blood pressures (4.1%, RR = 6.88, P < 0.01). [3] The Hanzhong study further revealed that the brachial artery fl ow-mediated dilatation measurements (FMD) among adults in the child cohort with elevated blood pressure (0.103 ± 0.004 mm) were lower than those of their counterparts in the cohort with normal blood pressure (0.117 ± 0.05 mm). The difference showed statistical signifi cance (p <0.05). The former group’s arterial elasticity index (C2) (12.93 ± 3.31 ml/mmHg x 10) was also signifi cantly smaller than that of the latter group (15.21 ± 4.11 ml/mmHg x 10) (p<0.01). A study that monitored kidney function in a Beijing cohort found that the risk of developing cardiac and renal damage among people who were hypertensive in childhood and remained so during adulthood was 3 times higher than that of people with normal blood pressures (OR = 4.07, 95% CI: 1.47-11.27). [4] 2.1.3.6 Evaluation for Secondary Hypertension A retrospective study was conducted among 304 hypertensive children who were admitted to Beijing Children’s Hospital during January 1, 2003-December 31, 2007. Hypertension was diagnosed according to the Chinese guideline for childhood hypertension from Zhu Futang’s Practical Pediatrics and the 2004 the American National High Blood Pressure Education Program (NHBPEP) Working Group on High Blood Pressure in Children and Adolescents. [5] The results showed that the majority of pediatric inpatients had [1] Zhao D, Zhang M, Chen F, et al. Predictive study of childhood hypertension on the risk of adulthood hypertension. J of Beijing Medicine, 2008,30:657-660. [2] Liang YJ, Mi J. Pubertal hypertension is a strong predictor for the risk of adult hypertension. Biomedical and Environmental Sciences, 2011, 24(5): 459-466. [3] Mou JJ, Liu ZQ. Research on risk factors of juvenile cardiovascular diseases - Shanxi Child Hypertension Cohort. Chinese Journal of Cardiovascular diseases, 2008, 36(Suppl): 115-116. [4] Zhao D, Zhang M, Mi J, et al. Effect of blood pressure status changes from childhood to adulthood on hypertension related cardiac renal function in adulthood. Chinese Journal of Pediatrics, 2008, 46(10): 763-768. [5] Liu C, Du ZD, Li X, et al. Etiology and differential diagnosis of admitted children with hypertension. Journal of Capital Medical University, 2010, 31(2): 187-191. 46 Chapter 2 Risk Factors of Cardiovascular Diseases secondary hypertension (52.0%), male children had a higher prevalence of HTN (79.5% for primary HTN; 65.2% for secondary HTN) than female children. The average age of children with secondary hypertension (9.1 ± 4.6 years) was lower than that of children with primary hypertension (12.3 ± 3.1 years). Table 2-1-20. Table 2-1-20 HTN Type, Percentage and Average Age of 304 Children HTN type Cases Percentage(%) Age (x±s, years) Primary HTN 146 48.0 12.3±3.1 Secondary HTN 158 52.0 9.1±4.6 Total 304 100.0 — Analysis of the etiologies of secondary hypertension among 158 children showed that renal hypertension was the leading cause, followed by endocrinal hypertension, cardiovascular, CNS-related and other unclassifi ed causes (Table 2-1-21). Table 2-1-21 Breakdown of Secondary HTN Etiology of 158 Juvenile Cases Order Etiologies Cases Percentage(%) 1 Renal 63 39.9 2 Endocrinal 47 29.8 3 Cardiovascular 22 13.9 4 CNS-related 13 8.2 5 Other (stress, infection, congenital) 13 8.2 Total 158 100.0 2.2 Smoking 2.2.1 Prevalence of Smoking 2.2.1.1 Current Status of Smoking (1) China has remained as one of the countries with the highest male smoking rates in the world since 1984. The percentage of men who reported smoking declined between1996 and 2010. The Global Adult Tobacco Survey (GATS)-China Project in 2010, covering population of China’s 28 provinces, demonstrated that the total smoking rate in men over 15 years of age was 62.8% with a current smoking rate of 52.9%; the overall number of male smokers was 340 million, including 290 million current smokers. The overall smoking prevalence in women was 3.1% (2.4% of current smokers); the number of female smokers was 16.39 million, including 10.46 million current smokers). Compared with 1996 and 2002, standardized smoking rate remained unchanged, despite of a slight reduction in male smoking prevalence. It is estimated 47 Report on Cardiovascular Diseases in China (2013) that the total number of smokers is 356 million among subjects over 15 years of age, higher than the number in 2002. The number of current smokers is near 310 million, which was not signifi cantly different from that in 2002. From 1996 to 2002, smoking rates across all age groups, with the exception of youth, showed various extents of reduction. From 2002 to 2010, smoking rate in males between the ages of 40 and 59 showed an upward trend (Figure 2-2-1). Although the overall smoking prevalence was still relatively low in women, the smoking rate in young females is slightly increasing (Figure 2-2-2). The overall smoking rate was signifi cantly higher in rural residents than in urban residents (29.8% vs 26.1%). It was higher in rural males than in urban males (56.1% vs 49.2%), while it was signifi cantly higher in urban females than that in rural females (2.6% vs 2.2%) (Table 2-2-1 and 2-2-2). [1, 2, 3, 4] Table 2-2-1 Comparison of Smoking Prevalence among Chinese over 15 Years of Age Sample Males Smoking Female Smoking Survey Time Age (year) Total (%) Size Rate(%) Rate (%) 1984 519 600 15- 61.0 7.0 33.9 1996 122 700 15- 66.9 4.2 37.6 2002 16 056 15-69 66.0 3.1 35.8 2010 13 354 15-69 52.9 2.4 28.1 Note: the defi nition of smoking differed in the four surveys National smoking sampling survey in 1984. Defi nition of a smoker was a current smoker, who smoked more than 1 cigarette per day, and had been smoking for more than 1 year continuously. National epidemiological survey of smoking behavior in 1996. Defi nition of a smoker was a current smoker, who smoked more than 1 cigarette per day, and had been smoking for more than 6 months in total. Smoking and passive smoking survey in Chinese population, 2002. Defi nition of a smoker was a current smoker, who had smoked more than100 cigarettes continuously or accumulatively. Global Adult Tobacco Survey (GATS)-China Project, 2000. Smoking rate means current smoking rate. Table 2-2-2 Current Smoking Rate in Chinese Population over 15 Ages of Age－GATS, China, 2010 Demographic Characteristics Total Male Smoking Rate Female Smoking Rate Overall Smoking Rate 28.1 52.9 2.4 Age Groups 15-24 Years Old 17.9 33.6 0.7 25-44 Years Old 31.0 59.3 1.6 45-64 Year Old 33.6 63.0 3.2 ≥65 Years Old 22.7 40.2 6.7 Region Urban 26.1 49.2 2.6 Rural 29.8 56.1 2.2 [1] Yang GH. Smoking and passive smoking in Chinese population, 2002. Journal of Epidemiology, 2005,26(2):77-83. [2] Yang GH, Fan LX, Tan J, et al. Smoking in China: Findings of the 1996 National Prevalence Survey. JAMA, 1999,282(13):1247- 1253. [3] Yang GH. Global Adult Tobacco Survey (GATS)-China Report, 2010. Beijing: Three-Gorgas Press, 2011,11. [4] Yang GH, Li Q, Jason Hsia. Prevalence of smoking in China in 2010. N Engl J Med, 2011, 364(25): 2469-2470. 48 Chapter 2 Risk Factors of Cardiovascular Diseases 6PRNLQJ5DWH˄˅ ˄ Figure 2-2-1 Current Smoking Rate in Men by Age (1996, 2002, 2010) \ \ \ 6PRNLQJ5DWH ˄ Figure 2-2-2 Current Smoking Rate in Females by Age (1996, 2002, 2010) (2) In 2010, National Tobacco Control Offi ce employed a multi-stage randomized sampling method to investigate the status of smoking, passive smoking and smoking cessation in midwestern rural residents. [1] 5 486 residents between the ages of 15 and 69 from 16 counties 84 administrative villages in Shanxi province, Gansu province, Qinghai province and Xinjiang province (autonomous regions) were enrolled. The study demonstrated that the overall smoking rate was 20.9% (44.8% for males, 2.0% for females). Signifi cant differences existed in smoking rates in populations with different ages, ethnic backgrounds, education levels and occupations (p<0.001). Residents between the ages of 50 and 55 had the highest rate of smoking (30.5%). Smoking rate in Han population was higher than that of ethnic minorities (27.7% vs 16.3%). People graduating from high schools and technical secondary schools had the highest smoking rate (28.2%) among all education levels. Smoking rate was higher in rural residents working in animal husbandry and non- agriculture labors than that in those engaged in agricultural labors (33.3%, 40.0% and 24.6%, respectively). [1] Zhang L, Cui Y, Wang C, et al. Survey on status of cigarette smoking in youths from three cities of China. Chinese Journal of Epidemiology, 2012,33(7): 137-139. 49 Report on Cardiovascular Diseases in China (2013) (3) Smoking rates among male doctors and teachers declined during 2002-2010. Smoking rates of Chinese male doctors and teachers exceeded 50% in both 1996 and 2002. [1, 2] GATS 2010 demonstrated that current smoking rates of male medical personnel and teachers aged 15-69 years dramatically reduced to 40% and 36.5% respectively. However, China remained one of the countries with the highest smoking rates in male doctors around the world. [3, 4] (4) Smoking status in Chinese youth. National survey in 2005 found that among undergraduate and middle school students of 11-23 years old, 50.9% males and 23.0% females had tried smoking with the current smoking rates of 22.4% and 3.9% in males and females, respectively. Current smoking rate in male students increased with age. [5] Smoking became more and more common in younger individuals. Among those who reported ever trying cigarettes, 55.9% of males and 57.0% of females smoked a whole cigarette for the fi rst time before 13 years of age. GATS in 2010 illustrated that 52.7% of the current smokers between the ages of 20 and 34 became daily smokers before the age of 20. A randomized survey, conducted among 11 171 middle school students in Hangzhou city, Taiyuan city and Guiyang city in 2009, demonstrated that the percentage of students who reported ever trying smoking was 26.2% (95% CI: 23.6-29.1), 39.9% for males and 12.5% for females. Current smoking rate was 12.5% (95% CI: 11.1-14.2), 21.9% for males and 3.2% for females. Statistically signifi cant smoking rates were found among different school types and cities. Technical secondary schools had the highest smoking rate (25.8%), followed by high schools (7.9%) and middle schools (6.3%). Smoking rate was inversely related to city economic status. The average age of middle school students was 11.9 years old when they took their fi rst cigarette. Near 50% of current smokers had no intention of trying to quit smoking. [6] 2.2.1.2 Passive Smoking (1) Passive smoking, or second-hand smoking (SHS), is defi ned as non-smokers who are exposed to tobacco smoke from smokers at home or at work. Results of three surveys in 1996, 2002, and 2010 indicated rising SHS exposure levels in the recent decade (Figure 2-2-3). In 2002, the percentage of passive smoking in non-smokers was up to 51.9%, which represented 540 million passive smokers. According to GATS, there were 738 million Chinese non-smokers exposed to SHS in 2010. [7] [1] Yang GH. Smoking and passive smoking in Chinese population, 2002. Journal of Epidemiology, 2005,26(2): 77-83. [2] Yang G, Fan L, Tan J, et al. Smoking in China: Findings of the 1996 national prevalence survey. JAMA, 1999,282(13): 1247- 1253. [3] Yang GH. Global Adult Tobacco Survey (GATS)-China Report, 2010. Beijing: Three-Gorgas Press, 2011.11. [4] Yang G, Li Q, Hsia J. Prevalence of smoking in China in 2010. N Engl J Med, 2011,364(25): 2469-2470. [5] Ji CY. Health status and risky behaviors - an integrated survey report of Chinese adolescent, 2005. Beijing: Peking University Medical Press, 2007. [6] Zhang L, Cui Y, Wang C, et al. Survey on status of cigarette smoking in youths from three cities of China. Chinese Journal of Epidemiology, 2012, 33(7): 137-139. [7] Yang GH. Global Adult Tobacco Survey (GATS)-China Report, 2010. Beijing: Three-Gorgas Press, 2011,11. 50 Chapter 2 Risk Factors of Cardiovascular Diseases ([SRVXUH5DWH˄˅ 8UEDQ5XUDOMale)HPDOH Figure 2-2-3 Exposure of Second-hand Smoking by Region in 1996, 2002, and 2010 Note: Variations among questions regarding second-hand or passive smoking in these three surveys: In the surveys of 1996 and 2002, passive smoking was identifi ed by asking “How frequent did you inhale smoke exhaled by smokers for more than 15 minutes per day in the last 30 days?” and with frequency of at least one day per week, 15 minutes per day. GATS in 2010 identifi ed second-hand smoking by asking “In general, how many days during a week are you exposed to second-hand smoke?” and with frequency of at least one day per week. (2) Passive smoking in rural population. In 2010, the overall passive smoking rate was 37.8% in residents aged 15 to 69 in four provinces/regions located in the midwestern part of China. The gender-specifi c rates of passive smoking were 31.9% for males and 40.4% for females with the risk of passive smoking signifi cantly higher for women than for men (x2=27.00, p<0.001). [1] Figure 2-2-4 demonstrated passive smoking rate by exposure site. Male Female 7RWDO 3DVVLYH6PRNLQJ5DWH˄˅ $W+RPH ,Q3XEOLF3ODFH 2WKHU3ODFH Figure 2-2-4 Passive Smoking Rate in Rural Population by Exposure Site in China's Four Provinces/Regions (%) [1] Zhang L, Cui Y, Wang C, et al. Survey on status of smoking, passive smoking and smoking cessation in rural areas of the midwestern provinces in China. Chinese Journal of Epidemiology, 2013, 34(2): 137-139. 51 Report on Cardiovascular Diseases in China (2013) 2.2.2 Smoking Cessation In recent years, smoking cessation rate had increased slightly in individuals aged 15 and above, from 9.42% in 1996 to 11.5% in 2002, then to 16.9% in 2010. The number of people who stopped smoking increased by 15 million. In 2010, GATS-China project showed that 16.1% of current smokers intended to give up smoking within the next 12 months. [1] Since 2002, the proportion of current smokers without intention of quitting smoking had not changed (44% in 2002, vs 44.9% in 2010). The re-smoking rate was 10.5%, 32.5%, and 33.1% in 1996, 2002, and 2010, respectively. [2, 3] In 2010, the rate of smoking cessation was only 1.9% among rural residents aged 15-69 years in China’s four central-west provinces. [4] 2.2.3 Hazards of Smoking and Passive Smoking Smoking and passive smoking is one of the major preventable risk factors of death in Chinese adults. Relative risk (RR) of death and population attributable risk (PAR) of death were 1.23 (95% CI: 1.18-1.27) and 7.9% in Chinese population; for men, RR was 1.18(1.13-1.23), PAR was 10.0%; for women, RR was 1.27(1.19-1.34), PAR was 3.5%, respectively. [5] 2.2.3.1 Impact of Smoking on Mortality, Death and Prognosis of CVD (1) Smoking is an independent risk factor for cardiovascular diseases. A multi-province and city cohort study on cardiovascular disease risk factors with 10-year follow-up among 30 000 individuals 35 to 64 years old demonstrated that smoking was one of the independent risk factors for acute coronary heart disease and acute ischemic stroke. 19.9% of acute coronary heart disease events and 11.0% of acute ischemic stroke events were attributed to smoking. Multivariate analysis showed that in comparison with nonsmokers, cigarette smoking resulted in a 1.75 times risk for coronary events, 1.37 times risk for ischemic stroke events, and 1.21 times risk for hemorrhagic stroke events. [6] These fi ndings were confi rmed by another Chinese- American cohort study, which followed 10 000 subjects for up to 15 years, that 31.9% of ischemic CVD, including coronary heart disease and ischemic stroke, were attributed to smoking in individuals aged 35-59 [7] . Compared with non-smokers, the relative risk of ischemic CVD was doubled in male smokers [1] Yang GH. Global Adult Tobacco Survey (GATS)-China Report, 2010. Beijing: Three-Gorgas Press, 2011,11. [2] Yang GH. Smoking and passive smoking in Chinese population, 2002. Journal of Epidemiology, 2005, 26(2): 77-83. [3] Yang G, Fan L, Tan J, et al. Smoking in China: Findings of the 1996 national prevalence survey. JAMA, 1999, 282(13): 1247- 1253. [4] Lin X, Jiang Y, Li Q, et al. Survey on status of cigarette smoking in youths from three cities of China. Chinese Journal of Epidemiology, 2012, 33(7): 676-680. [5] He J, Gu D, Wu X, et al. Major causes of death among men and women in China. N Eng J Med, 2005, 353: 1124-1134. [6] Gu D, Kelly TN, Wu X, et al. Mortality attributable to smoking in China. N Engl J Med, 2009, 360(2): 150-159. [7] Zhou BF. Prospective study for characters of risk factors of cardiovascular diseases in Chinese population. Chinese Journal of Epidemiology, 2005, 26(1): 58-61 52 Chapter 2 Risk Factors of Cardiovascular Diseases (RR=2.04), and increased by 59% in female smokers (RR=1.59). [1] (2) Smoking exacerbated the effect of blood pressure on the risk of cardiovascular and all-cause mortality among hypertensive patients. [2] In order to verify smoking’s effect on cardiovascular and all-cause mortality in hypertensive patients, researchers conducted a prospective cohort study among 36 493 hypertensive subjects over 40 years old with an average 8.2 years follow-up from 1991 to 2000. The study showed that the multi-variable adjusted relative risk (MRR) of cardiovascular mortality among patients who smoked 0.1-19 pack-year and more than 20 pack-year was 1.19 (95% CI: 1.07-1.31) and 1.33 (95% CI: 1.23-1.45) (linear regression test, p<0.001 for both), respectively, compared with never smokers. The RR of all-cause mortality demonstrated a similar trend. Dose-response relationship (all with p≤0.01) existed between different smoking amount (pack-year) and different SBP groups (140-159, 160-179, ≥ 180 mmHg), different DBP groups (<90, 90-94, 100-109 mmHg), different pulse pressure groups (50-59, 60-69, ≥ 70 mmHg), for both cardiovascular mortality and all-cause mortality. In addition, compared with never smokers with phase 1 hypertension, those who smoked more than 2 packs per year with phase 3 hypertension had RRs of 3.06 (2.64-3.54) and 2.51 (2.24-2.80) for cardiovascular and all-cause mortality respectively. The study confi rmed that smoking not only signifi cantly increased the risk of CVD and all-cause mortality among hypertensive patients, but the synergistic effect on the risk of CVD and all-cause mortality existed between cigarette smoking and blood pressure category. (Table 2-2-3 and Table 2-2-4). Therefore, apart from hypertension management, smoking cessation should be an essential component for preventing smoking related death. Table2-2-3 Relative Risk of All-cause Mortality in Hypertensive Patients by Smoking Amount (pack-year) and Blood Pressure Multi-variable Adjusted RRa (95% CI) Pack-years PYsb N 0 0.1-19 ≥ 20 Pc SBP(mmHg) <130 17 987 153 1 0.95(0.56-1.60) 1.27(0.82-1.97) 0.27 130-139 30 163 368 1 1.67(1.22-2.27) 1.89(1.46-2.45) <0.001 140-159 144 923 3 344 1 1.23(1.11-1.37) 1.41(1.28-1.54) <0.001 160-179 57 074 1 982 1 1.23(1.07-1.41) 1.17(1.03-1.32) 0.02 ≥180 26 596 1 347 1 1.15(0.97-1.37) 1.35(1.16-1.56) <0.001 DBP(mmHg) <90 116 311 3 596 1 1.19(1.07-1.32) 1.31(1.20-1.43) <0.001 90-94 84 637 1 594 1 1.31(1.13-1.52) 1.51(1.33-1.72) <0.001 [1] Wang W, Zhao D, Sun JY. A multi-province and city cohort study on cardiovascular disease risk factors and relative risks of different types of cardiovascular diseases. Journal of Cardiovascular Diseases, China. 2006; 34(12): 1133-1137. [2] Ge Z, Hao Y, Cao J, et al. Does smoking exacerbated the effect of blood pressure on the risk of cardiovascular and all-cause mortality among hypertensive patients? J Hypertens, 2012, 30(12): 2307-2313. 53 Report on Cardiovascular Diseases in China (2013) Table2-2-3 Relative Risk of All-cause Mortality in Hypertensive Patients by Smoking Amount (pack-year) and Blood Pressure Continue Multi-variable Adjusted RRa (95% CI) Pack-years PYsb N 0 0.1-19 ≥ 20 Pc 95-99 28 082 634 1 1.36(1.05-1.75) 1.29(1.04-1.60) 0.02 100-109 34 967 883 1 1.33(1.08-1.64) 1.54(1.29-1.83) <0.001 ≥110 12 656 487 1 1.05(0.79-1.38) 1.14(0.89-1.44) 0.30 PP(mmHg) <30 4 542 47 1 1.14(0.45-2.90) 1.67(0.76-3.66) 0.20 30-39 20 440 205 1 1.04(0.67-1.59) 1.11(0.77-1.61) 0.57 40-49 38 978 538 1 1.58 (1.22-2.04) 1.71(1.38-2.13) <0.001 50-59 58 018 1 065 1 1.27(1.05-1.53) 1.31(1.12-1.53) 0.001 60-69 63 530 1 558 1 1.14(0.97-1.33) 1.39(1.22-1.58) <0.001 ≥70 91 144 3 781 1 1.21(1.10-1.35) 1.30(1.19-1.42) <0.001 Note: a Adjusted by age, sex, BMI, physical activity, education, alcohol consumption, geographic regions. b PYs: person years, the number of person years of follow-up. Pc : p-value of linear regression test. Table 2-2-4 Relative Risk a of Cardiovascular Mortality and All-cause Mortality in Hypertensive Patients by Smoking Amount (pack-year) and Blood Pressure b Grade of Cardiovascular Mortality All-cause Mortality Hypertension Pack-year Pack-year PYs N 0 0.1-19 ≥20 Pc N 0 0.1-19 ≥20 Pc 1.14 1.33 1.25 1.46 Grade 1 176 509 1 750 1 <0.001 3 624 1 <0.001 (0.98-1.33) (1.17-1.50) (1.13-1.38) (1.37-1.59) 1.28 1.36 1.29 1.25 Grade 2 67 250 1 111 1 <0.001 2 051 1 <0.001 (1.06-1.54) (1.16-1.59) (1.13-1.48) (1.11-1.41) 1.18 1.32 1.12 1.28 Grade 3 32 894 924 1 0.002 1 519 1 <0.001 (0.96-1.45) (1.11-1.58) (0.95-1.31) (1.12-1.47) Note: a: Adjusted by age, sex, BMI, physical activity, education, alcohol consumption, geographic regions. b: According to the classifi cation system in Guidelines for Hypertension Prevention and Control in China, 2010. Pc: p-value of linear regression test. (3) Smoking increased risk of stroke morbidity and mortality. [3] A prospective cohort study among 169 871 hypertensive subjects over 40 years of age with an average follow-up of 8.3 years in 1991 showed that relative risks of stroke morbidity and mortality were 1.28 (1.19-1.37) and 1.13 (1.03-1.25) among male [3] Kelly TN, Gu D, Chen J, et al. Cigarette smoking and risk of stroke in the Chinese adult population. Stroke, 2008, 39(6): 1688- 1693. 54 Chapter 2 Risk Factors of Cardiovascular Diseases current smokers, 1.25 (1.13-1.37) and 1.19 (1.04-1.36) among female current smokers, respectively. (4) Impact of smoking and smoking cessation on long-term outcome of patients after coronary artery bypass grafting (CABG) .[1] A survey conducted among 2 457 patients who underwent CABG from 2004 to 2005 with follow-up of 4.27-6.41 years (average 5.09 years) aimed to observe mortality, major adverse cardio- and cerebrovascular events and angina pectoris (Table 2-2-5). Patients were divided into never smokers and ever smokers based on pre-operative smoking history. The ever smokers were further divided into the current smokers (persistent smokers) who smoked before and after CABG and former smokers who stopped smoking before CABG, quitters who stopped smoking after CABG. The percentage of persistent smokers was relatively high (22.1%). After adjusting baseline characteristics, relative risk for tumor related death (RR:2.38, 95% CI: 1.06-5. 36 ), major adverse cardiovascular or cerebrovascular events (RR:1.26, 95% CI: 1.01-1.57) and angina pectoris (RR: 1.29, 95% CI: 1.04-1.59) were signifi cantly higher in ever smokers than in never smokers. Similarly, relative risk of death from all causes (RR :2.60, 95% CI: 1.53- 4. 46), cardiac death (RR: 2.51, 95% CI:1.32-4.78 ), tumor cause death ( RR :5. 12,95% CI: 2.08-12.59 ), major adverse cardiovascular or cerebrovascular events (RR:1.83, 95% CI: 1.42-2.34) and angina pectoris (RR: 1.69, 95% CI:1.33-2.16) were also signifi cantly higher in current smokers than in never smokers. Outcome was similar between patients who stopped smoking and never smokers (All p>0.05). Table 2-2-5 Adverse Events in Patients with Different Smoking Status [n (%)] Never Ever Smokers (n=1 441) Events Smokers Pre-CABG Quitters Post-CABG Quitters Persistent Smokers Total (n=1 016) (n=403) (n=496) (n=542) (n=1 441) All Causes a a 41(4.1) 16(4.0) 15(3.0) 47(8.7) 78(5.4) Mortality Cardiac Mortality 23(2.3) 8(2.0) 9(1.8) 26(4.8)a 43(2.9)a Tumor-related a a 11(1.1) 4(1.0) 4(0.8) 16(3.0) 24(1.7) Mortality Postoperative a a 19(1.9) 10(2.5) 10(2.0) 24(4.4) 44(3.1) Stent Repeat CABG 5(0.5) 4(0.2) 5(0.4) 2(0.4) 5(0.3) Revascularization 24(2.4) 14(3.5) 15(3.0) 25(4.6) 54(3.3) Myocardial 13(1.3) 6(1.5) 7(1.4) 15(2.8) 28(1.1) Infarction Stroke 95(9.4) 37(9.2) 46(9.2) 61(11.3) 144(10.0) MACCE 155(15.3) 65(16.1) 77(15.5) 126(23.2)a 268(18.6)a Angina Pectoris 376(37.0) 154(38.2) 179(36.1) 240(44.3)a 573(39.8)a Note: CABG: Coronary artery bypass grafting, MACCE: Major adverse cardiovascular and cerebrovascular events; a compared with never smokers, p<0.05 [1] Sun HN, Hu SS, Zheng Z, et al. Impact of smoking and smoking cessation on long-term outcome of patients after coronary artery bypass grafting. Chinese Journal of Cardiology, 2011, (39)9: 805-809. 55 Report on Cardiovascular Diseases in China (2013) 2.2.3.2 Effect of SHS on Cardiovascular Morbidity and Mortality Risk of cardiovascular morbidity and mortality increased in passive smokers as well. The result of a meta- analysis based on 18 epidemiological studies indicated that passive smokers were associated with a 25% higher risk of cardiovascular morbidity (RR: 1.25, 95% CI: 1.17-1.32). [1] Second-hand smoke exposure predicted COPD and other tobacco-related mortality: a 17-year (from Jan 1994 to July 2011) cohort study among 910 participants recruited in Xi’an city showed that those who were exposed to SHS had increased cause-specifi c mortality due to coronary heart disease (RR: 2.15, 95% CI: 1.00-4.61), ischemic stroke (RR: 2.88, 95% CI: 1.10-7.55), lung cancer, COPD as well as all-cause mortality, with signifi cant dose-response relationships between cumulative SHS exposure at home and work and the increased risk of cause-specifi c and total mortality (p for linear trend ranged from 0.045 to <0.001) (Table 2-2-6, Table 2-2-7). This study provided new evidence for causal relationship between SHS and COPD as well as ischemic stroke. [2] Table 2-2-6 Number of Deaths and Adjusted RRa of Major Causes of Death by Sources of SHS No. Exposure SHS at Home Only (n=131) SHS at Workplace Only (n=210) (n=299) Cause of Death No. No. No. RR RR(95%CI) P-value RR(95%CI) P-value Deaths Deaths Deaths All Cancers 18 1.00 12 2.16(1.01-4.64) .049 20 1.66(0.86-3.22) .132 Lung Cancer 4 1.00 2 1.64(0.28-9.68) .585 5 2.23(0.58-8.55) .243 Tobacco-related 9 1.00 4 1.48(0.43-5.09) .536 13 2.50(1.04-5.99) .040 All Vascular Diseases 24 1.00 12 1.63(0.79-3.37) .185 29 2.33(1.33-4.07) .003 CHD 9 1.00 4 1.16(0.35-3.92) .808 11 2.29(0.93-5.69) .073 Stroke 15 1.00 8 2.07(0.84-5.14) .115 18 2.34(1.15-4.76) .019 Hemorrhagic 9 1.00 5 2.63(0.83-8.39) .101 9 1.74(0.67-4.53) .256 Ischemic 6 1.00 3 1.71(0.40-7.37) .474 7 3.05(0.97-9.55) .056 All Respiratory 12 1.00 5 1.89(0.62-5.82) .264 13 2.53(1.09-5.85) .030 Diseases COPD 10 1.00 4 1.67(0.49-5.78) .415 10 2.52(1.00-6.38) .051 All Tobacco-related 36 1.00 16 1.47(0.79-2.73) .222 44 2.49(1.57-3.93) <.001 Diseases All-cause 70 1.00 37 1.75(1.15-2.66) .009 68 1.80(1.27-2.55) .001 a: Adjusted for age, sex, marital status, occupation, alcohol consumption, diastolic BP, triglyceride level, total cholesterol level, and BMI [1] 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. [2] Yal He, Bin Jiang, Liang Shou Li, et al. Secondhand smoke exposure predicted COPD and other tobacco-related mortality in a 17-year cohort study in China. Chest, 2012,142(4): 909-918. 56 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-2-7 Number of Deaths and Adjusted RR a of Major Causes of Death by Index of SHS a Index of Combined SHS Exposure from Home and Workplace b Cause of No Exposure Low Exposure Moderate Exposure High Exposure Death (n=299) (n=281) (n=275) (n=55) P for No. No. RR No. RR No. RR Regression RR p-value P-value P-value Deaths Deaths (95%CI) Deaths (95%CI) Deaths (95%CI) 1.51 1.50 3.70 All Cancers 18 1.00 21 .210 22 .211 8 .003 .019 (0.79-2.89) (0.79-2.86) (1.56-8.78) 1.42 1.83 7.55 Lung Cancer 4 1.00 4 .624 5 .382 3 .012 .045 (0.35-5.84) (0.47-7.03) (1.56-36.58) Tobacco- 1.45 1.85 4.10 related 9 1.00 9 .439 12 .178 4 .024 .036 (0.56-3.74) (0.76-4.52) (1.20-14.00) Cancers 2.14 2.20 2.49 All CVD 24 1.00 34 .006 36 .004 7 .038 .004 (1.14-3.67) (1.29-3.75) (1.05-5.89) 1.74 2.25 3.79 CHD 9 1.00 12 .222 15 .061 5 .021 .014 (0.72-4.20) (0.96-5.25) (1.23-11.73) 2.47 2.17 1.30 Stroke 15 1.00 22 .010 21 .028 2 .732 .732 (1.25-4.90) (1.09-4.33) (0.29-5.78) 2.65 1.49 Hemorrhagic 9 1.00 14 .029 9 .422 0 .920 (1.11-6.34) (0.57-3.90) 2.16 3.60 2.72 Ischemic 6 1.00 7 .190 12 .015 2 .230 .020 (0.68-6.81) (1.28-10.1) (0.53-13.89) All Respiratory 1.60 2.20 4.39 12 1.00 10 .297 15 .054 5 .007 .006 Diseases (0.66-3.88) (0.99-4.91) (1.49-12.91) 1.52 13 2.32 5.01 COPD 10 1.00 8 .396 .057 5 .005 .004 (0.57-4.04) (0.98-5.50) (1.65-15.24) All Tobacco- 1.65 2.23 3.74 related 36 1.00 38 .038 53 <.001 16 <.001 <.001 (1.03-2.64) (1.44-3.47) (2.03-6.87) Diseases 1.67 1.61 2.54 All-cause 70 1.00 79 .003 79 .005 21 <.001 <.001 (1.20-2.33) (1.16-2.25) (1.54-4.19) a: Adjusted for age, sex, marital status, occupation, alcohol consumption, diastolic BP, triglyceride level, total cholesterol level, and BMI b: Index of combined SHS: Cumulative SHS exposure at home (cigarettes/d×y) was divided into four categories (score 0, no exposure; score 1, <4 pack-years; score 2, 4 to <8 pack-years; score 3, ≥ 8 pack-years). Similarly, cumulative SHS exposure at workplace [(cigarettes/d×y×smokers×h/ d)÷100] was divided into four categories(score 0, no exposure; score 1, <5; score 2, 5 to <15; score 3, ≥ 15). The two scores were added (range 0-6) and matched into four levels (score 0, no exposure; score 1-2, low exposure; score 3-4, moderate exposure; score 5-6, high exposure) to obtain an index of combined SHS exposure from home and work. 57 Report on Cardiovascular Diseases in China (2013) 2.2.4 Disease Burden and Economic Cost of Tobacco Use in China 2.2.4.1 Disease Burden Attributed to Tobacco Use [1, 2] Disability Adjusted Life Years (DALY) Lost in Chinese people due to 8 smoking-related diseases (stroke, COPD, coronary heart disease, lung cancer, gastric cancer, esophageal cancer, tumors located in 5 local sites and tuberculosis) was 158.2/1 000 in individuals more than 40 years old. DALYs Lost among populations aged 40-69 years and more than 70 years was 118.1/1 000 and 445.4/1 000, respectively. Given the declined quality of life caused by diseases, the calculated Years lived with Disability (YLD) accounted for 32.3% of the overall disease burden. YLD was higher in younger adults. DALY Lost was the highest among males, especially those aged >70 years. The proportion of DALY Lost attributed to tobacco use varied among different diseases, COPD and lung cancer were the major contributors of total DALYs Lost (Figure 2-2-5). DALY/1 000 'HDWK$WWULEXWDEOHWR7REDFFO8VVH 'HDWK8QDWWULEXWDEOHWR7REDFFO8VVH 6WURN &23' &+ /XQJ&DQFHU*DVWULF&DQFHU(VRSKDJHDO&DQFHU2WKHU&DQFHU7XEHUFXORVL ' H V Figure 2-2-5 Disease Burden Related to Tobacco in Chinese Population 2.2.4.2 Cost of Tobacco Use [3] Base on the fact that smoking resulted in 1.4 million deaths in 2005 in China, the estimated direct economic cost due to tobacco was RMB 166.56 billion Yuan, indirect economic cost was RMB 86.111- 120.501 billion Yuan. The total cost was close to RMB 300 billion Yuan, accounting for 1.5% of Gross Domestic Product (GDP) of China in 2005 ( Table 2-2-8). [1] 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. [2] Li L, Chen QL, Jia RX, et al. Smoking mode and disease burden analysis. Chinese Health Economics, 2008,299(1):26-30. [3] Li L, Chen QL, Jia RX, et al. Smoking mode and disease burden analysis. Chinese Health Economics, 2008, 299(1): 26-30. 58 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-2-8 Direct Cost of Smoking Related Diseases Year Cost (0.1 billion) GDP(%) 2000 998.97 1.116 56 2005 1 665.60 0.913 55 Direct cost of smoking: total medical cost of smoking related diseases among population. 2.3 Dyslipidemia 2.3.1 Lipid Levels and Prevalence of Dyslipidemia in Adults Studies conducted in the 1980’s-1990’s showed [1, 2, 3, 4] that the serum total cholesterol (TC) level and low- density lipoprotein cholesterol (LDL-C) level were signifi cantly lower in Chinese than in Western countries’ populations. Moreover, marked differences existed in blood lipid levels and dyslipidemia prevalence rates among different populations in different regions. In two multi-center studies, the average of serum TC among middle-aged adults ranged from 137mg/dl (3.55mmol/L) to 203mg/dl (5.26mmol/L), and age-standardized prevalence of elevated total cholesterol (≥200mg/dl, 5.18mmol/L) was 4.8%-46.5%[5, 6]. The prevalence of dyslipidemia increased substantially in the past 30 years [7, 8, 9] . International collaborative survey of cardiovascular disease in Asia (InterAsia) [10] in 2000-2001 and China Diabetes Mellitus and Metabolic Disorder Study (CNDMDS) [11] in 2007-2008 investigated mean levels of major components of blood lipids (TC, TG, LDL-C, HDL-C) and the prevalence of dyslipidemia among populations aged 35 to 74 and over 20 respectively, the results is shown in Table 2-3-1. [1] 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. [2] 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. [3] Wu ZS, Yao CH, Zhao D, et al. Multiprovincial monitoring of the trends and determinants of cardiovascular diseases (China MONICA ). Chinese J of Cardiology, 1997,25(4):255-259. [4] Zhou BF, Zhang HY, Wu YF et al. Ecological analysis of the association between incidence and risk factors of coronary heart disease and stroke in Chinese populations.CVD Prevention. 1998, 1(3):207-216. [5] Wu ZS, Yao CH, Zhao D, et al. Multiprovincial monitoring of the trends and determinants of cardiovascular diseases (China MONICA ). Chinese J of Cardiology, 1997,25(4):255-259. [6] Zhou BF, Zhang HY, Wu YF et al. Ecological analysis of the association between incidence and risk factors of coronary heart disease and stroke in Chinese populations.CVD Prevention. 1998, 1(3):207-216. [7] The Collaborative Study Group on Trends of Cardiovascular Diseases in China and Preventive Strategy. Current status of major cardiovascular risk factors in Chinese population and their trend in the past two decades. Chinese Journal of Cardiology, 2001,29(2): 74-79. [8] He J, Gu D, Reynolds K et al. Serum total and lipoprotein cholesterol levels and awareness, treatment, and control of hypercholesterolemia in China. Circulation, 2004,110(4): 405-411. [9] Yang WY, Xiao JZ, Yang ZJ, et al. Serum lipids and lipoproteins in Chinese men and women. Circulation, 2012,125: 2212-2221. [10] He J, Gu D, Reynolds K et al. Serum total and lipoprotein cholesterol levels and awareness, treatment, and control of hypercholesterolemia in China. Circulation, 2004,110(4): 405-411. [11] Yang WY, Xiao JZ, Yang ZJ, et al. Serum lipids and lipoproteins in Chinese men and women. Circulation, 2012,125: 2212-2221. 59 Report on Cardiovascular Diseases in China (2013) Table 2-3-1 Age-standardized Mean Level of Blood Lipid and Age-standardized Prevalence of Dyslipidemia in Multi-center Cross-sectional Surveys in China Mean Blood Lipid Level Prevalence of Study and Dyslipidemia Year (mmol/L) Dyslipidemia(%) Population Items Men Women Classifi cations Men Women TC 4.76 4.86 Borderline TC 23.5 24.1 InterASIA LDL-C 2.80 2.86 High TC 7.9 10.2 10 provinces and HDL-C 1.32 1.36 Borderline LDL-C 16.4 17.5 2000-2001 cities, urban/rural TG 1.46 1.43 High LDL-C 4.9 5.4 areas, 35-74 y Severely high LDL-C 2.3 3.2 Low HDL-C 22.1 16.2 TC 4.70 4.73 Borderline TC 22.6 22.4 CNDMDS LDL-C 2.68 2.69 High TC 8.7 9.3 2007-2008 14 provinces and HDL-C 1.25 1.35 Borderline LDL-C 13.6 14.2 cities, urban/rural TG 1.71 1.42 High LDL-C 3.5 3.5 areas, over 20 y Severely high LDL-C 3.1 3.0 Low HDL-C 27.1 17.5 Note: Classifi cations of dyslipidemia: borderline TC (5.18-6.21mmol/L), high TC (≥6.22mmol/L); borderline LDL-C (3.37-4.13mmol/L), high LDL-C (4.14-4.91mmol/L), severely high LDL-C (≥4.92mmol/L). Data from the China National Nutrition and Health survey, [1] which conducted in 31 provinces and cities in 2002, demonstrated that the prevalence of dyslipidemia (defi ned as met at least one of following: TC≥ 5.72mmol/L, TG≥ 1.70mmol/L, HDL-C<1.04mmol/L) was 18.6%. The number of individuals with dyslipidemia reached 200 million, according to the China census in 2007. The prevalence of borderline high TC (5.20-5.71mmol/L) and high TC (≥5.72mmol/L) was substantially higher in people aged > 45 years than in those 18-44 years of age; It was also markedly higher in urban residents than in rural residents (Figure 2-3-1). 7& PPRO/ 0- 7&ıPPRO/ 3UHYDOHQFH˄˅ ı ı $JH 8UEDQ5XUDO Figure 2-3-1 Prevalence (%) of Borderline High TC (5.20-5.71mmol/L) and High TC ( ≥ 5.72mmol/L) by Region and Age (China). [1] Zhao WH, 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. 60 Chapter 2 Risk Factors of Cardiovascular Diseases According to 2010 survey among 97 409 residents aged 18 and over from 162 surveillance points of 31 provinces, [1] the prevalence of high TC (TC≥ 6.22mmol/L) was signifi cantly higher in urban than in rural areas, in areas of east than in areas of west and center, in people aged 45 and over than aged 18 to 44. Prevalence of high TG (TG≥ 2.26mmol/L) was signifi cantly higher in males than in females, and higher in females aged 45 and over than in females aged 18 to 44. (Table 2-3-2) Table 2-3-2 Prevalence of Dyslipidemia among Adults (China: 2010) (%) TC ≥ 6.22mmol/L TG ≥ 2.26mmol/L Men Women Men Women In Total 3.4 3.2 13.8 8.6 Urban/Rural Areas Urban 4.1 4.3 15.7 8.5 Rural 3.0 2.7 13.0 8.7 Geography East 4.2 4.3 13.8 8.1 Center 2.5 2.2 14.1 9.3 West 3.4 2.8 13.6 8.6 Age Groups 18-44 3.0 1.3 14.1 5.8 45-59 4.5 5.0 16.1 12.2 ≥60 2.9 6.9 8.7 12.9 Note: The numbers in this fi gure had been complex weighted. Results of two national surveys in 2002 [2] and 2010 [3] about mean serum TC levels of Chinese adults by gender, urban/rural areas, and age were displayed in table 2-3-3. Mean TC levels of all groups in 2010 were higher than those in 2002. Table 2-3-3 Mean TC Levels (mmol/L) among Adults (China: 2002, 2010) Men Women 2002 2010 2002 2010 In total 3.81 4.06 3.82 4.03 Urban areas 3.96 4.09 3.96 4.07 Rural areas 3.75 4.04 3.76 4.01 Ages (years) 18-44 3.77 3.95 3.64 3.78 45-59 4.03 4.24 4.14 4.34 ≥60 4.06 4.17 4.36 4.49 Note: The numbers in this fi gure had been complex weighted. [1] Li JH, Wang LM, Li YC, et al. Epidemiologic characteristics of dyslipidemia in Chinese adults in 2010. Chinese Journal of Preventive Medicine, 2012, 46(5): 414-418. [2] Zhang J, Man QQ, Wang CR, et al. Level and distribution characteristics of blood lipid among Chinese aged more than 18. Chinese Journal of Preventive Medicine, 2005, 39(5): 302-305. [3] Li JH, Mi SQ, Li YC, et al. The levels and distribution of serum lipids in Chinese adults, 2010. Chinese Journal of Preventive Medicine, 2012, 46(7): 607-612. 61 Report on Cardiovascular Diseases in China (2013) 2009 CHNS investigated the prevalence of high TC (≥ 5.18mmol/L), high LDL-C (≥ 3.37mmol/L), high TG (≥ 1.70mmol/L) and low HDL-C (<1.04mmol/L for males, <1.30mmol/L for females, <1.04mmol/ L for children) among 9 244 individuals aged 7 and over in 228 sites, the results were shown in Figure 2-3-2. Women over 50 years of age suffered a signifi cantly higher prevalence of high TC and high LDL-C than men of the same age group, and the prevalence increased with age [1] . \\\\ \\>\ 0DOH )HPDOH 3UHYDOHQFH˄˅ +L7* +L/'/ /R+'/ +L7& +L7* +L/'/ /R+'/ +L7& Figure 2-3-2 Prevalence of Dyslipidemia by Gender and Age In 2012, a sampling survey was conducted in seven cities of Xinjiang district, involving 14 046 subjects aged over 35. [2] Table 2-3-4 showed the age-standardized prevalence of dyslipidemia of 3 ethnic groups base on the population data of Xinjiang from a national census in 2002. Table 2-3-4 Age-standardized Prevalence of Dyslipidemia of 3 Ethnic Groups in Xinjiang (%) Number of Subjects Ethnic Group High TC High TG Low HDL-C (men/women) Han 5 544(2 675/2 869) 27.8 35.1 32.7 Wei 4 587(1 955/2 632) 17.0 32.6 31.7 Ha 3 915(1 984/2 021) 33.4 16.4 28.7 High TC: TC≥5.18 mmol/L; High TG: TG≥1.76mmol/L; Low HDL-C: HDL-C<1.04mmol/L [1] Yan S, Li J, Li S, et al. The expanding burden of cardiometabolic risk in China: the China Health and Nutrition Survey. Obes Rev, 2012,13(9): 810-821. [2] Li Y, Ma YT, Yu ZY, et al. Epidemiologic characteristics of dyslipidemia in Han, Uighur and Kazak in Xinjiang district. Chinese Journal of Preventive Medicine, 2012, 33(6): 567-571. 62 Chapter 2 Risk Factors of Cardiovascular Diseases 2.3.2 Prevalence of Dyslipidemia among Children and Adolescents Data from 2002 China National Nutrition and Health Survey [1] revealed that the prevalence of high cholesterol (TC≥ 220mg/dl or 5.72mmol/L) and the prevalence of high triglycerides (TG≥ 150mg/dl or 1.70mmol/L) was 0.8% (1.4% in urban area, 0.6% in rural area) and 2.8% (2.5% in urban area, 2.9% in rural area), respectively among children and adolescents 3 to 17.9 years of age. The results of dyslipidemia prevalence survey in Beijing and Guangzhou from 1987 to 2007 are summarized in Table 2-3-5 [2, 3, 4]. Of which, the 2007 survey in Beijing among 19 037 children aged 6 to 18 demonstrated the prevalence of dyslipidemia (TC≥ 5.20mmol/L or TG≥ 1.70mmol/L) was about 30% in obese children, signifi cantly higher than that in non-obese children [5] (Figure 2-3-3). Table 2-3-5 Prevalence of Dyslipidemia (%) among Children and Adolescents by District and Year District Publish Year Age(y) Sample Size High TC High TG Beijing City[6] 1987 7-19 1 201 1.3 4.2 Guangdong Province# [7] 2005 3-14 6 188 2.1 2.2 # [8] City 9978, 1.6 9.5 Beijing City 2007 6-18 Suburb 9523 0.8 8.1 Note: High TC: TC≥ 200mg/dl(5.17mmol/L), High TG: TG≥ 150mg/dl(1.70mmol/L); # Fasting peripheral blood test. [1] Zhang WH, Zhang J, Li Y. Report of Chinese nutrition and health status: blood lipid, 2002. [2] Li JZ, Niu QT, Li PY, et al. Study of blood lipid and lipoprotein among infants and adolescents. Peking Medicine, 1987, 9(6): 346-349. [3] Ma WJ, Xu YJ, Fu CX, et al. A cross sectional survey on serum lipid level and its infl uencing factors in children aged 3-14 years in Guangdong province. Chinese Journal of Cardiology, 2005,33(10):950-955. [4] Liu Y, Mi J, Du JB, et al. A survey on dyslipidemia of 6-18-year old children in Beijing area. Chinese Journal of Practical Pediatrics, 2007,22(2): 101-102. [5] Yan H, Mi J, Liu Y, et al. Association of family history and BMI and dyslipidemia in children. Beijing Da Xue Xue Bao. 2007, 39(6): 591-594. [6] Li JZ, Niu QT, Li PY, et al. Study of blood lipid and lipoprotein among infants and adolescents. Peking Medicine, 1987, 9(6): 346-349. [7] Ma WJ, Xu YJ, Fu CX, et al. A cross sectional survey on serum lipid level and its infl uencing factors in children aged 3-14 years in Guangdong province. Chinese Journal of Cardiology, 2005,33(10):950-955. [8] Liu Y, Mi J, Du JB, et al. A survey on dyslipidemia of 6-18-year old children in Beijing area. Chinese Journal of Practical Pediatrics, 2007,22(2): 101-102. 63 Report on Cardiovascular Diseases in China (2013) 3UHYDOHQFH˄˅ Non-obese No Non-obese with Obese No Obese with Family Historyᰐ㛕㜆ᰐᇦ᯿Family Historyᰐ㛕㜆ᴹᇦ᯿Family History㛕㜆ᰐᇦFamily History㛕㜆ᴹᇦ Figure 2-3-3 Prevalence of Dyslipidemia in Children by Obesity᯿ and Family History᯿ ਢ ਢ ਢ ਢ The prevalence of high TC (≥5.18mmol/L), high LDL-C (≥3.37mmol/L), high TG (≥1.70mmol/L) and low HDL-C (<1.04mmol/L) among males and females aged 7 to 18 in CHNS of 2009 [1] was shown in Figure 2-3-2. A 2010 sampling survey of 20 191 children and adolescents of ages 7-16 years from Beijing, Tianjin, Hangzhou, Shanghai, Chongqing, and Nanning (10 669 males, 9 522 females) revealed that 95th percentile values were 5.15 mmol/L and 5.25 mmol/L for TC; 2.97 mmol/L and 3.09 mmol/L for LDL-C; 1.68 mmol/L and 1.73 mmol/L for TG; 3.68 mmol/L and 3.77 mmol/L for non-HDL-C; and 5th percentile values were 0.94 mmol/L and 0.97 mmol/L for HDL-C, for males and females respectively. The prevalence of dyslipidemia in the obese group was clearly higher than the non-obese group (p < 0.01). [2] 2.3.3 Effect of Dyslipidemia on Cardiovascular Diseases Multiple prospective cohort studies in China have shown that elevated blood serum TC/LDL-C or decreased HDL-C can increase the risk of cardiovascular diseases. At the same time, studies have shown a predicted value of non-HDL-C, VLDL-C, and TG for cardiovascular diseases. The results of two cohort studies, Sino-USA collaborative study on epidemiology of cardiovascular diseases and the Chinese Multi-Provincial Cohort Study [3] revealed that in comparison with subjects whose TC below 5.18 mmol/L, the relative risk of ischemic cardiovascular diseases among those with borderline high TC and high TC is 1.6 (96% CI: 1.2-2.1) and 1.7 (95% CI: 1.2-2.3), respectively; The relative risks [1] Yan S, Li J, Li S, et al. The expanding burden of cardiometabolic risk in China: the China Health and Nutrition Survey. Obes Rev, 2012,13(9):810-821. [2] Zhu JF, Liang L, Fu JF, et al. Survey on the levels of lipids in school-aged children of Beijing, Tianjin, Hangzhou, Shanghai, Chongqing and Nanning cities. Chinese Journal of Epidemiology, 2012, 33(10): 1005-1009. [3] Wu Y, Zhao D, Zhou B, et al. Cut offs and stratifi cation of dyslipidemia in Chinese adults. Chinese Journal of Cardiology, 2007; 35(5): 428-433. 64 Chapter 2 Risk Factors of Cardiovascular Diseases of elevated LDL-C (4.13mmol/L) for ischemic cardiovascular diseases at these two studies were 1.4 (95% CI: 1.0-2.0) and 2.0 (95% CI: 1.4-2.9), respectively compared with LDL-C < 3.37 mmol/L. One multi- center epidemiological study found that in comparison with serum TC <5.7 mmol/L, the relative risk and attributable risk of developing ischemic cardiovascular diseases among those with TC5.7 mmol/L was 2.0 (1.5-3.7) and 11.4%, respectively. [1] A study on male employees of Capital Iron and Steel Company (more than 5,000 men, follow-up of 20 years) found that in comparison to people with serum TC levels <4.7 mmol/ L, those with TC levels of 4.7-5.1 mmol/L, 5.2-5.6 mmol/L, 5.7-6.1 mmol/L, and≥6.2 mmol/L had linearly increased relative risk of myocardial infarction, it was 1.7 (1.03-2.82), 1.95 (1.14-3.32), 2.76 (1.54-4.95), and 3.69 (2.18-6.24), respectively. [2] Among patients with hypertension, the relative risk of myocardial infarction gradually increases with blood serum TC elevation. [3] One cohort study among elderly population (1 211 subjects, follow-up of 11.2 years) reported that elevated LDL-C levels signifi cantly increased the risk of coronary heart disease with an odds ratio of 1.55 (95% CI: 1.32-1.81). [4] Several cohort studies have shown that in comparison with individuals whose HDL-C>1.0 mmol/ L, the relative risks of developing acute coronary syndrome and ischemic stroke in those whose HDL-C <1.0mmol/L were 1.39 (95% CI: 1.00-1.92) and 1.45 (95% CI: 1.15-1.83), respectively. [5] Elevated HDL-C signifi cantly decreased the risk of coronary heart disease in the elderly population, with an odds ratio of 0.69 (95% CI: 0.57-0.82). [6] The relative risks of acute coronary events at TG levels of 1.15-1.59 mmol/L and 1.60 mmol/L compared to TG < 0.81 mmol/L were 1.81 (95% CI: 1.18-2.78) and 1.58 (95% CI: 1.03-2.45), respectively. [7] The relative risks of ischemic cardiovascular diseases increased at non-HDL-C levels of 3.88-4.38 mmol/ L, 4.39-4.90 mmol/L and ≥ 4.91 mmol/L compared to levels of <3.88 mmol/L, with values of 1.44 (95% CI: 1.07-1.94), 1.81 (95% CI: 1.26-2.60), and 1.53 (95% CI: 1.06-2.22) respectively. [8] Using non-HDL-C [1] Zhou BF. Prospective study for characters of risk factors of cardiovascular diseases in Chinese population. Chinese Journal of Epidemiology, 2005,26(1): 58-61. [2] Yue H, Gu D, Wu Y, et al. A 20-year prospective study on risk factor of myocardial infarction of 5137 men in Capital Steel and Iron Company. Chinese Journal of Preventive Medicine, 2004, 38(1): 43-46. [3] Li JX, Cao J, Lu XF, et al. The effect of total cholesterol on myocardial infarction in Chinese male Hypertension population. Biomedical and Environmental Sciences, 2010, 37-41. [4] Li J, Chen M, Wang Yu, et al. A long-term follow-up study of serum lipids and cardiovascular disease in the elderly. Chinese Journal of Cardiology, 2002, 30(11): 647-650. [5] Wang W, Zhao D, Sun GY, et al. Risk factors comparison in Chinese patients developing acute coronary syndrome, ischemic or hemorrhagic stroke: A multi-provincial study. Chinese Journal of Cardiology, 2006. 34(12): 1133-1137. [6] Wang M, Zhao D, Wang W, et al. Serum triglyceride is an independent risk factor for acute coronary heart disease events in 35- 64 years old Chinese-Chinese provincial cohort study. Chinese Journal of Cardiology, 2008, 36(10): 940-943. [7] Li Y, Chen ZH, Zhou BF, et al. The predictive effects of lipids and lipoproteins on the incidence of ischemic cardiovascular diease in middle-aged Chinese population. Chinese Journal of Cardiology, 2004, 32(7): 643-647. [8] Ren J, Zhao D, Liu J, et al.Relationship between serum non-high-density lipoprotein cholesterol and incidence of cardiovascular disease. Chinese J of Cardiology, 2010, 38(10):934-938. 65 Report on Cardiovascular Diseases in China (2013) levels of <3.37 mmol/L as reference, relative risks of acute coronary events gradually increased at non- HDL-C levels of 3.37-4.13 mmol/L, 4.14-4.91 mmol/L and≥4.92 mmol/L, with values of 1.24 (95% CI: 0.91-1.70), 1.78 (95% CI: 1.25-2.53), and 2.23 (95% CI: 1.48-3.35), respectively. The relative risks of ischemic stroke also increased, at values of 1.34 (95% CI: 1.07-1.68), 1.38 (95% CI: 1.04-1.83), and 1.38 (95% CI: 0.97-1.94), respectively. [1] 2.3.4 Prevention and Control of Dyslipidemia (1) Communities Data from the 2002 China Community Nutrition and Health Survey showed that the awareness rate among adults (18 years of age) with dyslipidemia (at least met one of the following disorders: TC≥5.72 mmol/L and/or TC≥1.70 mmol/L and/or HDL-C <0.91 mmol/L) was only 3.2% (3.4% among males, 2.7% among females). The rate of ever taking lipid examination was 6.4%. [2] Awareness rate and examination rate among middle-aged and elderly populations were clearly higher than among younger groups and higher in cities than in rural areas. (Figures 2-3-4 and 2-3-5). 20.0 \ 18.0 16.0 \ 14.0 ı\ 12.0 10.0 8.0 6.0 $ZDUHQHVV5DWH 4.0 2.0 0.0 0DOHV )HPDOHV 0DOHV )HPDOHV 8UEDQ 5XUDO Figure 2-3-4 Awareness Rate of Dyslipidemia among Chinese Adults. \ \ ı\ ([DPLQDWLRQ5DWH 0DOHV )HPDOHV 0DOHV )HPDOHV ⭧ᙗ ྣᙗ ⭧ᙗ ྣᙗ 8UEDQ 5XUDO Figure 2-3-5 Examination Rates of Blood Lipid Levels among Chinese Adults. [1] Ren J, Zhao D, Liu J, et al. Correlation between non-HDL-C level and risk of cardiovascular disease of Chinese population. Chinese Journal of Cardiology, 2010. 38(10): 934-938. [2] Zhang WH, Zhang J, Li Y. Survey Report on the Status of Nutrition and Health of the Chinese People: Series Four. 2002, Blood lipid. 66 Chapter 2 Risk Factors of Cardiovascular Diseases Based on the InterAsia [1] and CNDMDS [2] studies, the proportion of men and women over the age of 35 and 20 years who were aware, treated, and controlled of hypercholesterolemia was relatively low (Table 2-3-6). Table 2-3-6 Awareness, Treatment, and Control Rates of Hypercholesterolemia Program and Study Males Females Survey Group TC ≥ 6.22mmol/L TC ≥ 5.18mmol/L TC ≥ 6.22 TC ≥ 5.18mmol/L Awareness Rate 21.3 8.8 18.1 7.5 InterASIA, 10 Provinces, 2000-2001 Urban / Rural, Ages Treatment Rate 14.0 3.5 11.6 3.4 35-74 Control Rate 11.3 1.9 9.5 1.5 Awareness Rate 27.6 12.8 20.7 9.3 CNDMDS, 14 Treatment Rate 21.4 6.1 14.0 4.1 2007-2008 Provinces, Urban / Rural, Ages >20 Control Rate 18.3 3.3 11.2 2.2 Treatment-control 88.1 52.1 78.4 55.4 Rate (2) Inpatients Two national surveys on clinic control of blood lipid levels in 2000 [3] and 2006 [4] included more than 20 provincial and community hospitals from more than 10 cities. The 2000 survey included 2 136 patients with dyslipidemia and found a 26.5% control rate of dyslipidemia (based on guidelines from the 1997 “Recommendations for Prevention and Treatment of Dyslipidemia”). The control rate in 2006 among 2 237 patients was 34% according to the criteria of 2004 American NCEP-ATP III guidelines and 50% according to the criteria of 2007 China Adult Dyslipidemia Prevention and Control Guidelines. An analysis of 539 patients from the 2006 survey based on the same guidelines used in the 2000 survey (“Recommendations for Prevention and Treatment of Dyslipidemia for Chinese Adults, 1997”) showed the control rate was 39.9%, markedly higher than that reported in the year of 2000. [5] The 2008 China Cholesterol Education Program (CCEP) included 4 778 patients with coronary heart disease in 52 medical centers across 6 provinces and cities in China, found treatment rates based on [1] 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, 110(4): 405-411. [2] Yang WY, Xiao JZ, Yang ZJ, et al. Serum lipids and lipoproteins and Chinese men and women. Circulation, 2012, 125: 2212- 2221. [3] The current status on clinical control of hypercholesterolemia in China collaborative research group. A multi-center study of current status on clinical control of hypercholesterolemia in China: success rate and related factors. Chinese Journal of Cardiology, 2002, 30(2): 109-104. [4] 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, 2007; 35(5): 420-427. [5] Zhao LC, Liang LR, Chen Z, et al. The trends of clinical management of hyperlipidemia and goal attainment rate from 2000 to 2004-2006 in China. Chinese Journal of Cardiology, 2007; 35(9): 861-864. 67 Report on Cardiovascular Diseases in China (2013) therapeutic lifestyle changes (TLC) and statins were 82.8% and 82.2%, respectively. Only 36.2% of the high- risk patients achieved the target LDL-C level (<2.6mmol/L); 10.9% of the very high-risk patients achieved the optimal LDL-C level (<1.82mmol/L) suggested by NCEP ATP III. The rate of achieving the target level was only 42.2%. [1] A national survey of 51 hospitals in 2009 reported that statin treatment rates in patients with acute coronary syndrome at discharge, at 6 months, and at 12 months gradually decreased, 80.4%, 65.8%, and 59.4% respectively. [2] A 2009 survey among 1 151 patients with type 2 diabetes at 6 tertiary hospitals in Beijing reported that, based on the 2007 Chinese Guidelines for Type 2 Diabetes (CGT2D), control rates for blood serum levels of TG, HDL-C, LDL-C, and TC were 48.8%, 59.2%, 34.0%, and 42.0%, respectively. [3] Among outpatients and inpatients with coronary heart diseases from 6 large cardiovascular disease centers in 2010, 2 436 patients received lipid-lowering therapy for at least six weeks. [4] 96.7% of patients received statin-based therapy. Among them, those who reached LDL-C target levels of <100 mg/dl and <70 mg/dl were 67% and 38%, respectively. Among patients with LDL-C levels < 100 mg/dl, 38% used atorvastatin (average dose 24 mg/d) and 22% used simvastatin (average dose 30 mg/d). Among patients with LDL-C levels < 70 mg/dl, 22% used atorvastatin (average dose 28 mg/d) and 10% used simvastatin (average dose 35 mg/d). In both groups, less than 1% and 0.2% patients used combined lipid-lowering agent therapy, with the majority being statins plus ezetimibe. With regard to non-HDL-C, 66% of patients reached target levels of < 130 mg/dl, but only 40% reached levels of < 100 mg/dl. With regard to HDL-C, 94% of males and 75% of females reached normal HDL-C levels. In 2013, 12 040 patients with dyslipidemia were admitted at 84 hospitals in 19 different provinces. Among them, 50% had hypertension, 37.5% had coronary heart disease, and more than 30% had peripheral arterial disease. 39% received lipid-lowering therapy, the majority among them receiving statins (42.5% used atorvastatin, 29.0% used simvastatin, and 15.2% used rosuvastatin). The results showed that only 25.8% reached target LDL-C levels (based on American NCEP ATP III cardiovascular disease comprehensive risk stratifi cation guidelines). Control rates among women and patients with elevated BMI (≥ 30 kg/m2) were even lower, 22.2% and 17.4% respectively. Control rates among high-risk patients and very high-risk patients based on risk stratifi cation criteria were only 19.9% and 21.1% respectively. [5] [1] 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. [2] 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. [3] Li MZ, Ji LN, Meng ZL, et al. Management status of type 2 diabetes mellitus in tertiary hospitals in Beijing: gap between guideline and reality. Chin Med J (Engl version), 2012, 125 (23): 4185-4189. [4] Guo Y, Liu J, Li J, et al. A multi-center survey of achieving recommended lipid goals in Chinese patients with coronary artery disease in real world cardiovascular practice. Int J Cardiol, 2011, 153 (2): 211-212. [5] Gao F, Zhou YJ, Hu DY, et al. Contemporary management and attainment of cholesterol targets for patients with dyslipidemia in China. PLoS One, 2013. 8(4): e47681. 68 Chapter 2 Risk Factors of Cardiovascular Diseases Researches from the past 30 years have clearly revealed that dyslipidemia is one of the most important risk factors for cardiovascular diseases in the Chinese population. Blood lipid levels and dyslipidemia prevalence rate are quickly increasing, particularly in urban developed areas and among middle-aged and elderly populations. Currently, whether in the community or in the hospital, the state of management and control of dyslipidemia is not optimistic. Effective strategies must be employed to increase the management and control rates for dyslipidemia, and to decrease the risk of cardiovascular diseases. 2.4 Diabetes The 2010 China Chronic Disease Survey (CCDS), published in September 2013, reported the prevalence of diabetes and prediabetes, as well as the control rate of diabetes in China [1] . Its results were based on the data from 162 local disease control centers scattered throughout the 31 provinces in 2010, with a sample size of 98,658 Chinese adults aged over 18 years, for whom HbA1c, fasting blood glucose (FBG), and 2-hour postprandial blood glucose were measured. Diabetes was defi ned as (1) self-reported diabetes with a confi rmed diagnosis by the professionals; (2) the FBG equal to or greater than 126 mg/dl; (3) 2 hours postprandial blood glucose is equal to or greater than 200 mg/dl; (4) the HbA1c is equal to or greater than 6.5%. Prediabetes was defi ned as (1) FBG 100-125 mg/dl; (2) 2 hours postprandial blood glucose 140-199 mg/ dl; or (3) HbA1c 5.7%-6.4%; and no previous history of diabetes mellitus. This survey investigated the status of diabetes prevention and control, which included the awareness, treatment, and control rates of diabetes. Awareness rate was defi ned as the proportion of patients who reported having been diagnosed with diabetes by physicians among those with diabetes. Treatment rate was defi ned as the proportion of diabetes patients under hypoglycemic treatments. Control rate was defi ned as the proportion of treated diabetic patients with HbA1c of less than 7.0% among those under treatment. Table 2-4-1 shows the prevalence rate of diabetes in Chinese adults. The prevalence rate of diabetes was estimated to be 11.6% in Chinese adults (12.1% in males, and 11.0% in females); the prevalence rate of newly diagnosed diabetes was 8.1% (8.5% in males, and 7.7% in females); and the prevalence rate of previous diabetes was estimated to be 3.5% (3.6% in males, and 3.4% in females). The prevalence rate of diabetes in urban areas was higher than that in rural areas in both males and females (Table 2-4-1, Figure 2-4-1A). The prevalence rate increased with age. Higher percentage of men than women have diabetes until 60 years of age, after that, a higher percentage of women have diabetes than men. The prevalence of diabetes was higher in persons living economically developed regions and among obesity people. The study estimated that the prevalence of prediabetes was 50.1% in Chinese adults (52.1% in males, and 48.1% in females). It was slightly higher in rural than in urban areas, especially for men. The prevalence rate of prediabetes increased with age. In those under the age of 50, males have a higher prevalence than females. [1] Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA, 2013, 310 (9):948-959. 69 Report on Cardiovascular Diseases in China (2013) The prevalence rate of prediabetes was higher in underdeveloped areas, as well as among overweight and obese persons (Table 2-4-2, Figure 2-4-1B). The awareness rate of diabetes was 30.1% (29.7% in males, 30.5% in females). Among patients with diabetes, only 25.8% (25.5% in males, 26.2% in females) received treatment for diabetes, and only 39.7% (40.7% in males, 38.6% in females) of those treated had adequate glycemic control. The proportions of those who were aware of, treated for, and managed their glucose levels were higher in urban than in rural residents and higher in economically developed and intermediately developed regions than in underdeveloped regions. Women living in rural areas had a substantially lower proportion of controlled diabetes than did their male counterparts or than did women living in urban areas. Similarly, women living in underdeveloped regions had a much lower control rate than men living in the same regions or women living in intermediately developed or developed regions. In the multivariable, multinomial, logit models, male sex; older age; urban residency; parental history of diabetes; overweight; obesity; central obesity; elevated systolic blood pressure; and elevated serum total cholesterol, LDL-cholesterol, and triglyceride levels were all signifi cantly associated with a higher risk of diabetes (Table 2-4-3). In addition, male sex, older age, parental history of diabetes, overweight, obesity, central obesity, physical activity, elevated systolic blood pressure, and elevated serum total cholesterol were positively associated with a higher risk of prediabetes. Higher education level, higher serum HDL-cholesterol and triglycerides levels, and living in intermediately developed and developed regions were inversely associated with prediabetes. Table 2-4-1 Prevalence of Diabetes among Chinese Adults Prevalence Rate (95% CI)，%a FBG≥126 2HPBS≥200 FBG≥126, Previously 2HPBS FBG≥126 FBG≥126 HbA1c mg/dL and/or mg/dl 2HPBS≥200 Diagnosed Total ≥200 mg/dL and/or mg/dL ≥6.5% 2HPBS≥200 and/or mg/dl and/or with mg/dl HbA1c≥6.5% mg/dl HbA1c≥6.5% HbA1c≥6.5% Diabetes. Overall 11.6 4.5 3.5 4.6 6.2 6.9 6.2 8.1 3.5 (11.3-11.8) (4.4-4.7) (3.4-3.7) (4.4-4.7) (6.0-6.4) (6.7-7.2) (6.0-6.4) (7.9-8.3) (3.4-3.6) Gender Male 12.1 5.0 3.8 4.6 6.6 7.3 6.4 8.5 3.6 (11.7-12.5) (4.7-5.2) (3.5-4.0) (4.4-4.9) (6.4-6.9) （7.0-7.6) (6.1-6.7) (8.2-8.8) (3.4-3.8) Female 11.0 4.0 3.3 4.5 5.7 6.6 6.0 7.7 3.4 (10.7-11.4) (3.8-4.3) (3.1-3.5) (4.3-4.7) (5.4-6.0) (6.3-6.9) (5.7-6.2) (7.4-8.0) (3.2-3.5) Region City 14.3 5.0 4.1 5.3 6.8 7.7 7.0 8.8 5.6 (13.9-14.8) (4 .8-5.3) (3.8-4.3) (5.0-5.5) (6.5-7.1) (7.3-8.0) (6.7-7.3) (8.5-9.1) (5.3-5.8) Country 10.3 4.3 3.3 4.3 5.9 6.6 5.8 7.8 2.5 (10.0-10.6) (4.1-4.5) (3.1-3.5) (4.0-4.5) (5.7-6.2) (6.4-6.9) (5.6-6.1) (7.5-8.1) (2.4-2.7) 70 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-4-1 Prevalence of Diabetes among Chinese Adults Continue Prevalence Rate (95% CI)，%a FBG≥126 2HPBS≥200 FBG≥126, Previously 2HPBS FBG≥126 FBG≥126 HbA1c mg/dL and/or mg/dl 2HPBS≥200 Diagnosed Total ≥200 mg/dL and/or mg/dL ≥6.5% 2HPBS≥200 and/or mg/dl and/or With mg/dl HbA1c≥6.5% mg/dl HbA1c≥6.5% HbA1c≥6.5% Diabetes. Age Cohorts, Years Old 18-29 4.5 2.1 1.3 2.1 2.7 3.4 2.7 3.8 0.7 (4.1-5.0) (1.8-2.5) (1.0-1.6) (1.8-2.4) （2.3-3.1） (3.0-3.9) (2.3-3.1) （3.4-4.2) (0.6-0.9) 30-39 6.6 3.2 2.0 2.6 4.0 4.4 3.6 5.1 1.5 (6.1-7.1) (2.9-3.6) (1.8-2.3) (2.4-3.0) (3.6-4.4) (4.0-4.8) (3.2-3.9) (4.7-5.5) (1.3-1.8) 40-49 11.3 5.0 3.4 4.4 6.5 7.1 5.9 8.1 3.2 (10.8-11.8) (4.7-5.4) (3. 1-3.7) (4.1-4.8) (6.1-6.9) (6.7-7.5) (5.5-6.3) (7.7-8.6) (2.9-3.4) 50-59 17.6 6.4 5.1 7.1 8.7 10.3 9.3 11.8 5.9 (17.0-18.3) (6.0-6.9) (4.7-55) (6.7-7.5) (8.2-9.2) (9.7-10.8) (8.8-9.8) (11.2-12.3) (5.5-6.2) 60-69 22.5 7.0 6.9 8.6 10.5 11.8 11.6 14.1 8.3 (21.6-23.4) (6.4-7.5) (6.4-7.5) (8.0-9.3) (9.9-11.2) (11.1-12.6) (10.9-12.3) (13.4-14.9) (7.8-8.9) ≥70 23.5 7.7 8.2 8.3 12.4 12.2 12.7 15.5 8.0 (22.3-24.7) (6.9-8.5) (7 .4-9.0) (7.5-9.2) (11.5-13.4) (11.2-13.2) (11.7-13.7) (14.4-16.6) (7.3-8.8) Economic Development Under 9.9 4.2 3.3 4.5 5.8 6.7 6.1 7.9 2.1 Developed (9.5-10.4) (3.9-4.5) (3.0-3.6) (4.2-4.9) (5.4-6.1) (6.3-7.0) (5.7-6.4) (7.5-8.3) (1.9-2.3) Intermediate 10.5 3.9 3.2 4.1 5.6 6.2 5.6 7.3 3.2 Developed (10.1-11.0) (3.7-4.2) (3.0-3.5) (3.8-4.3) (5.3-5.9) (5.9-6.5) (5.3-5.9) (7.0-7.7) (3.0-3.4) Developed 14.3 5.5 4.1 5.1 7.2 8.0 6.9 9.1 5.2 (13.9-14.7) (5.2-5.8) (3.8-4.3) (4.9-5.4) (6.8-7.5) (7.6-8.4) (6.6-7.2) (8.7-9.5) (4.9-5.5) BMI <25.0 8.3 3.2 2.4 2.9 4.5 4.9 4.2 5.9 2.4 (8.0-8.6) (3.1-3.4) (2.2-2.5) (2.7-3.1) (4.3-4.7) (4.7-5.1) (4.0-4.4) (5.6-6.1) (2.3-2.5) 25.0-29.9 17.0 6.6 5.3 7.1 8.8 10.1 9.2 11.5 5.5 (16.5-17.6) (6.2-6.9) (5.0-5.7) (6.7-7.5) (8.4-9.2) (9.7-10.6) (8.8-9.6) (11.1-12.0) (5.2-5.8) ≥30.0 24.5 9.9 8.4 12.8 13.3 16.6 15.2 18.1 6.3 (23.1-26.0) (9.0-11.0) (7.5-9.4) (11.7-13.9) (12.1-14.5) (15.4-17.9) (14.0-16.5) (16.9-19.5) (5.6-7.1) Waist, cm <90, Male 7.9 3.2 2.2 2.7 4.4 4.7 4.0 5.7 2.2 <80, Female (7.6-8.2) (3.0-3.3) (2.1-2.4) (2.5-2.8) (4.2-4.6) (4.5-4.9) (3.8-4.1) (5.4-5.9) (2.1-2.4) ≥90, Male 19.1 7.3 6.2 8.5 9.8 11.6 10.7 13.0 6.0 ≥80, Female (18.6-19.6) (7.0-7.7) (5.8-6.5) (8.1-8.9) (9.4-10.2) (11.1-12.0) (10.3-11.2) (12.6-13.5) (5.8-6.3) Note: *BMI, body mass index; HbA1c, glycosylated hemoglobin; unit conversion: 1mg/dL =0.0555mmol/L; data in a are weighted averages in percentages. 71 Report on Cardiovascular Diseases in China (2013) $'LDEHWHV 0DOH)HPDOH 3UHYDOHQFH˄˅ . . . . . ı 8UEDQ 5XUDO 8QGHU 0RGHUDWHO\ 'HYHORSHG $JH GHYHORSHG 'HYHORSHG 3DUWLFLSDQW 0DOH )HPDOH %3UHGLDEHWHV 'HWHFWLRQUDWH˄˅ . . . . . ı 8UEDQ 5XUDO 8QGHU 0RGHUDWHO\ 'HYHORSHG $JH GHYHORSHG 'HYHORSHG 3DUWLFLSDQW 0DOH )HPDOH (UURUEDUVLQGLFDWH FRQILGHQFHLQWHUYDOV Figure 2-4-1 Age-standardized Prevalence of Diabetes and Prediabetes in Chinese Adults Aged 18 Years or Old in 2010 Table 2-4-2 Prevalence Rate of Prediabetes in Chinese Adults Prevalence Rate (95% CI)，%a FBG FBG 2HPBS 2HPBS 100-125 100-125 140-199 Total of FBG 100-125 HbA1c 140-199 mg/dL and/or mg/dL and/or mg/dl and/or Pre-diabetes mg/dL 5.7%-6.4% mg/dl 2HPBS 140-199 HbA1c HbA1c mg/dl 5.7%-6.4% 5.7%-6.4% Overall 50.1 27.2 8.3 35.4 31.0 48.3 38.7 (49.7-50.6) (26.8-27.6) (8.1-8.5) (35.0-35.8) (30.6-31.4) (47.9-48.7) (38.3-39.1) Gender Male 52.1 29.0 7.9 36.3 32.5 50.4 39.7 (51.5-52.7) (28.5-29.6) (7.6-8.2) (35.8-36.9) (32.0-33.1) (49.7-51.0) (39.1-40.3) Female 48.1 25.3 8.7 34.4 29.4 46.2 37.6 (47.6-48.7) (24.8-25.8) (8.4-9.1) (33.8-34.9) (28.9-29.9) (45.7-46.8) (37.1-38.2) Male 48.4 28.0 8.3 33.6 31.4 46.9 36.8 (47.8-49.1) (27.5-28.6) (7.9-8.6) (33.1-34.2) (30.8-31.9) (46.3-47.5) (36.2-37.3) Female 50.9 26.8 8.3 36.2 30.8 49.0 39.5 72 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-4-2 Prevalence Rate of Prediabetes in Chinese Adults Continue Prevalence Rate (95% CI)，%a FBG FBG 2HPBS 2HPBS - - - Total of FBG 100-125 HbA1c 100 125 100 125 140 199 140-199 mg/dL and/or mg/dL and/or mg/dl and/or Pre-diabetes mg/dL 5.7%-6.4% mg/dl 2HPBS 140-199 HbA1c HbA1c mg/dl 5.7%-6.4% 5.7%-6.4% (50.4-51.4) (26.4-27.3) (8.0-8.6) (35.7-36.7) (30.4-31.3) (48.4-49.5) (39.0-40.1) Age Group 18-29 40.1 21.4 4.4 25.1 23.8 38.6 27.4 (39.0-41.1) (20.5-22.3) (4.0-4.9) (24.2-26.0) (22.9-24.7) (37.6-39.7) (26.5-28.4) 30-39 47.1 26.0 6.2 30.6 28.9 45.3 33.7 (46.2-48.0) (25.2-26.8) (5.7-6.6) (29.7-31.4) (28.1-29.8) (44.4-46.2) (32.8-34.6) 40-49 52.6 29.8 8.9 36.7 33.8 50.7 40.4 (51.9-53.4) (29.1-30.6) (8.4-9.3) (35.9-37.4) (33.0-34.5) (49.9-51.5) (39.6-41.2) 50-59 58.2 31.7 10.2 44.8 35.8 56.5 48.3 (57.4-59.1) (30.9-32.5) (9.7-10.8) (44.0-45.6) (35.0-36.6) (55.6-57.3) (47.5-49.2) 60-69 57.7 29.6 12.9 45.5 35.3 55.5 49.6 (56.6-58.8) (28.6-30.6) (12.2-13.7) (44.4-46.6) (34.3-36.4) (54.4-56.6) (48.5-50.6) ≥70 58.1 29.6 16.1 46.5 37.4 55.7 50.8 (56.7-59.5) (28.3-31.0) (15.1-17.3) (45.0-47.9) (36.0-38.8) (54.2-57.2) (49.4-52.3) Economic Development Under 53.2 26.1 8.5 39.5 30.2 51.2 42.9 Developed (52.4-53.9) (25.4-26.7) (8.1-8.9) (38.8-40.3) (29.6-30.9) (50.4-52.0) (42.1-43.6) Intermediate 47.7 25.3 7.8 33.3 29.2 45.9 36.5 Developed (47.0-48.4) (24.7-25.9) (7.4-8.1) (32.7-34.0) (28.6-29.8) (45.2-46.6) (35.9-37.2) Developed 49.5 30.3 8.6 33.2 33.6 47.9 36.5 (48.8-50.2) (29.7-30.9) (8.3-9.0) (32.6-33.8) (33.0-34.2) (47.2-48.5) (35.9-37.2) BMI <25.0 48.1 25.3 6.9 33.2 28.7 46.3 36.3 (47.6-48.6) (24.8-25.7) (6.7-7.2) (32.7-33.7) (28.1-29.1) (45.8-46.8) (35.8-36.8) 25.0-29.9 54.3 31.1 10.6 39.5 35.5 52.4 43.2 (53.5-55.0) (30.4-31.8) (10.2-11.1) (38.7-40.2) (34.8-36.2) (51.6-53.1) (42.5-44.0) ≥30.0 54.6 31.3 13.4 41.0 36.8 52.5 45.0 (52.8-56.3) (29.7-32.9) (12.3-14.7) (39.3-42.7) (35.1-38.5) (50.7-54.2) (43.2-46.7) Waist, cm <90, Male 48.5 25.7 6.9 33.2 29.0 46.7 36.4 <80, Female (47.9-49.0) (25.2-26.1) (6.6-7.1) (32.8-33.7) (28.6-295) (46.1-47.2) (35.9-36.9) ≥90, Male 53.6 30.3 11.3 39.7 35.0 51.7 43.4 ≥80, Female (51.9-54.2) (29.7-31.0) (10.9-11.7) (39.1-40.4) (34.4-35.7) (51.0-52.4) (42.7-44.1) Note: *BMI, body mass index; HbA1c, glycosylated hemoglobin; unit conversion: 1mg/dL =0.0555mmol/L; data in a are weighted averages in percentages. 73 Report on Cardiovascular Diseases in China (2013) Table 2-4-3 Risk Factors for Diabetes and Prediabetes in Chinese Adults a Diabetes, OR Pre Diabetes, OR Risk Factorsb P value P value (95% CI) (95% CI) Male 1.52(1.40-1.64) <0.001 1.23(1.16-1.29) <0.001 Every Additional Ten Years of Age 1.55(1.51-1.59) <0.001 1.16 (1.24-1.28) <0.001 Inhabitance in Cities and Towns 1.15(1.08-1.23) <0.001 0.99(0.94-1.03) 0.56 Parent(s) With Diabetes 2.59(2.32-2.88) <0.001 1.11(1.02-1.21) 0.01 Educational Level above Junior High 1.02 (0.95-1.09) 0.55 0.91 (0.87-0.95) <0.001 Weight C Overweight 1.31(1.21-1.41) <0.001 1.19(1.12-1.25) <0.001 Obesity 2.03(1.78-2.32) <0.001 1.52(1.37-1.70) <0.001 Central Obesity 1.64(1.51-1.77) <0.001 1.17(1.11-1.24) <0.001 Physical Exercise 0.99 (0.96-1.02) 0.53 1.06(1.04-1.08) <0.001 Every 22 mmHg Increased in Systolic - - Blood Pressure 1.47 (1.42 1.52) <0.001 1.17(1.14 1.20) <0.001 Cholesterol Total Cholesterol Increase Every 43 mg/dL 1.65(1.47-1.85) <0.001 1.61 (1.46-1.76) <0.001 Low Density Lipoprotein Cholesterol - - Increase Every 31 mg/dL 1.10 (1.01 1.20) 0.03 0.97 (0.91 1.04) 0.46 High Density Lipoprotein Cholesterol - - Increase Every 12 mg/dL 0.70 (0.66 0.73) <0.001 0.79 (0.76 0.82 ) <0.001 Triglyceride Increase Every 118 mg/dL 1.12 (1.07-1.18) <0.001 0.93 (0.89-0.97) <0.002 Intermediate Developed Area Compared to - - Underdeveloped Area 0.80 (0.74 0.87) <0.001 0.77 (0.74 0.81) <0.001 Developed Area Compared to - - Underdeveloped Area 1.00 (0.92 1.09) 0.93 0.89 (0.84 0.94) <0.001 a: 1 596 cases excluded due to lack of information: 1 432 cases lacked condition of blood glucose control, 4 cases lacked current smoking status, 85 cases lacked body mass index, and 75 cases lacked waist circumference. b: Continuous variables are measured with standard deviation; c: Overweight: BMI between 25.0 and 29.9, obesity: BMI ≥ 30.0; central obesity: male, waist ≥ 90cm\female, waist ≥ 80cm. Conducted in a large nationally representative sample of the general population in China, CCDS provided a comprehensive estimation of diabetes awareness, treatment and control in the Chinese population. The study confi rmed that diabetes and prediabetes were strongly related to other cardiovascular risk factors, such as dyslipidemia and hypertension. It also showed that one third of Chinese adults were obese or centrally obese. Half of the patients with obesity were at the stage of prediabetes, and one fi fth of them were with diabetes. This study suggested that a higher diagnosis rate for diabetes could be obtained by using both FBG and HbA1c, while the prevalence estimated by 2-hour plasma glucose alone was much lower than by either fasting plasma glucose or HbA1c alone, which was different from fi ndings in prior surveys. 74 Chapter 2 Risk Factors of Cardiovascular Diseases The prevalence of diabetes in China (11.6%) in the survey was much higher than that reported in 2010 [1] (9.7%). The main reason is that all 3 indicators, FBG, 2HPBS and HbA1c, were used for diabetes diagnosis in the latter. The latest ADA [2] includes HbA1c concentration of 6.5% or higher for the diagnosis of diabetes and may have partly contributed the increased prevalence . The prevalence was also 9.7% if using the same diagnostic criteria of FBG and/or 2HPBS. The prevalence of diabetes was more or less the same compared to a few years ago. However, it is a serious problem that the prevalence of prediabetes was high while the control rate of diabetes is low, and that signifi cant disparities existed across regions. Recently, the 3B Research Study assessed the level of control of blood glucose, blood pressure, and blood lipids (3Bs) among patients with type 2 diabetes. An additional objective of 3Bs was to investigate the impact of hospital type, physician specialty, treatment pattern, and patient profi le on clinical outcomes.[3] In this cross-sectional, multi-center observational study, 25 817 diabetic patients from 104 hospitals were recruited, with an average age of 62.6. 47% of them were male, and 72% of them reported hypertension, dyslipidemia, or both. Patients with concurrent type 2 diabetes, hypertension, and dyslipidemia were 6 times more likely to report a prior history of cardiovascular diseases compared with those with type 2 diabetes alone. The mean HbA1c level was 7.6%. While 47.7%, 28.4%, and 36.1% of patients achieved the individual target goals for control of blood glucose (HbA1c <7%), blood pressure (systolic blood pressure <130 mmHg, diastolic blood pressure <80 mmHg), and blood lipids (total cholesterol <4.5mmol/L), respectively, only 5.6% achieved all 3 target goals. Lower body mass index (<24 kg/m2), no active smoking or drinking, higher education, and diabetes duration <5 years were independent predictors of better cardiovascular disease risk control. The China Chronic Disease Survey was a nationwide study of patients in the community, while 3B Study was a study conducted among diabetic patients in endocrinology departments. Both studies showed that the blood glucose control rate (HbA1c<7%) in diabetic patients was less than 50%. The 3B Study further confi rmed that the integrated control rate of blood glucose, lipid and pressure is lower, only 5.6%. Unhealthy lifestyles are signifi cantly associated with cardiovascular risk factors. The China National Chronic Kidney Disease Work Group investigated the clustering of four cardiovascular disease (CVD) risk factors (defi ned as two or more of the following: hypertension, diabetes, dyslipidemia and overweight) and their association with unhealthy lifestyles (habitual drinking, physical inactivity, chronic use of non-steroidal anti-infl ammatory drugs (NSAIDs) and a low modifi ed Dietary Approaches to Stop Hypertension (DASH) score). Among the 46 683 participants enrolled in this study, only 31.1% were free of any pre-defi ned CVD risk factor. A total of 20 292 subjects (43.5%) had clustering of CVD risk factors, and the adjusted prevalence of CVD risk factor clustering was 36.2%, and the prevalence was higher among males than among females (37.9% vs 34.5%). Habitual drinking, physical inactivity, and chronic use of NSAIDs were positively associated with the clustering of CVD risk factors, with ORs of 1.60 (95% CI 1.40-1.85), 1.20 (95%CI 1.11-1.30) and 2.17 [1] Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Eng J Med, 2010, 362(12): 1090-1101. [2] American Diabetes Association. Diagnosis and classifi cation of diabetes mellitus. Diabetes Care, 2010, 33(suppl 1): S62-S69. [3] Ji L, Hu D, Pan C, et al. Primacy of the 3B Approach to control risk factors for cardiovascular disease among type 2 diabetes. Am J Med, 2013, 126 (10), 925: e11-e22. 75 Report on Cardiovascular Diseases in China (2013) (95%CI 1.84-2.55), respectively. The modifi ed DASH score was inversely associated with the clustering of CVD risk factors, with an OR of 0.73 (95%CI 0.67-0.78). The lifestyle risk factors were more prominent among participants with low socioeconomic status. [1] 2.5 Overweight and Obesity 2.5.1 The Current State of Obesity in China With economic development and changes in lifestyle in the past 30 years, the prevalence of obesity has shown continued growth and has become a major public health problem. According to 2012 China Health and Nutrition Survey (CHNS), it was estimated that the number of overweight (BMI: 24-27.9kg/m2) and obese (BMI≥28kg/m2) people > 18 years of age might be as high as 200 million and 60 million. These numbers will be reached up to 240 million and 70 million, respectively based on the national standard population composition in 2006. [2] (Figure 2-5-1). 25 20 15 10 Prevalence (%) 5 0 Overweight Obesity Overweight + Obesity Figure 2-5-1 Prevalence of Overweight and Obesity in China in 1992 and 2002 After long-term monitoring of diet and health status in nine provinces, many cross-sectional studies showed that in the past 20 years the prevalence of overweight and obesity in China was in an upward trend. [3] In 2009, the prevalence of overweight, obesity, and both already reached as high as 30.0%, 8.7%, and 38.7%, respectively (Figure 2-5-2), and the prevalence of central obesity (defi ned as waist circumference 85cm for males, 80cm for females) was up to 45.3% (Figure 2-5-3). [1] Gao B, Zhang L, Wang H. Clustering of major cardiovascular risk factors and the association with unhealthy lifestyles in the Chinese adult population. PLoS One, 2013; 8(6): e66780. [2] Ma GS, Li YP, Wu YF, et al.The Prevalence of body overweight and obesity and itschanges among Chinese people during 1992- 2002. Chin J Prev Med, 2005,39(5):311-315. [3] Xi B, Liang Y, He T, et al. Secular trends in the prevalence of general and abdominal obesity among Chinese adults,1993-2009. Obes Rer, 2012,13(3):287-296. 76 Chapter 2 Risk Factors of Cardiovascular Diseases 40 30 20 Prevalence (%) 10 0 Overweight Obesity Overweight or Obesity Figure 2-5-2 Temporal Trends of Overweight rate and Obesity Rate among Adults in China 9 Provinces and Cities 50 40 30 20 Prevalence（%) 10 0 Figure 2-5-3 Temporal Trends of Central Contol Obesity Rate among Adults in China 9 Provinces and Cities In 2010, China’s chronic disease surveillance program surveyed close to 100 000 people at 162 monitoring sites in 31 provinces, municipalities or autonomous regions using cluster randomization. The results [1] showed that the prevalence of overweight, obesity, and both had already reached 30.6%, 12.0%, and 42.6%, respectively (Figure 2-5-4), which increased signifi cantly from 2002, indicating an increasing trend in overweight and obesity over the last decade. [1] Li XY, Jiang Y, Hu N, et al. Prevalence and characteristic of overweight and obesity among adults in China, 2010. Chin J Prev Med, 2012, 46(8): 683-686. 77 Report on Cardiovascular Diseases in China (2013) 50 40 Urban 30 Rural Total Prevalence (%) 20 10 0 Overweight Obesity Overweight or Obesity Figure 2-5-4 Overweight rate and Obesity Rate among Chinese Adults in 2010 There were fi ve national surveys on the health status of Chinese students from 1985 to 2010. These studies targeted students aged 7-18 years, with sample sizes larger than 200 000 per study. The results showed an increasing trend in overweight and obesity [1] (Figure 2-5-5), the prevalence of overweight, obesity and overweight + obesity was 8.7, 38.1, and 11.8 times as much as that in 1985. 15.0 12.5 10.0 7.5 Prevalence (%) 5.0 2.5 0.0 Overweight Obesity Overweight or Obesity Figure 2-5-5 Temporal Trends of Overweight rate and Obesity Rate among Chinese Students Three national epidemiology investigations on childhood obesity were conducted between 1986 and 2006 in 8 cities. The results indicated a signifi cant increasing trend in the prevalence of childhood obesity[2] (Figure 2-5-6), the prevalence increased with age. [1] Ma J, Cai CH, Wang HJ, et al. The trend analysis of overweight and obesity in Chinese students during 1989-2010.Chin J Prev Med, 2012,46(9):776-780. [2] Zong XN, Li H. Secular trends in prevalence and risk factors of obesity in infants and preschool children in 9 Chinese cities, 1986-2006. PLoS One, 2012, 7(10): e46942. 78 Chapter 2 Risk Factors of Cardiovascular Diseases 8.0 \ \ 6.0 \ 4.0 Prevalence (%) 2.0 0 1 2 3 4 5 6.7 (Age) Figure 2-5-6 Temporal Trends of Obesity Rate among Chinese Children 2.5.2 Diseases Related to Overweight and Obesity Diabetes has been a growing health problem in recent decades, overweight or obesity subjects are at increased risk for future diabetes. Results of a study conducted among 58 426 coal miners in Kailuan showed that with increased waist circumference at baseline, the risk of diabetes increased signifi cantly after a 4-year follow-up. The association still existed after adjusting for several confounding factors [1] (Table 2-5-1). Table 2-5-1 Relationship between Baseline Waist Circumference and New-onset Diabetes in the Kailuan Study New onset DM Risk of new onset DM* WC (cm) N N % OR(95% CI) P <80 13 230 307 2.32 1.00 - 80- 15 208 547 3.60 1.17 (1.00-1.36) <0.05 86- 13 912 760 5.46 1.47 (1.26-1.70) <0.01 ≥92 16 078 1 429 8.89 1.95 (1.67-2.28) <0.01 *: Logistic regression analysis adjusted for gender, baseline age, BMI, blood pressure, blood lipid and blood glucose levels, and family history of diabetes. An 11-year follow-up study among 10 704 workers (aged 35-59 years without diabetes at baseline) in Qingdao Port found the risk of diabetes signifi cantly increased among those who were overweight and obesity [2] (Table 2-5-2). [1] Liu XR, Li JJ, Zhou YR, et al. On the relationship between the change in waist circumference and new onset of diabetes: Study on a population of Northern China. Chin J End Met, 2012, 28(9): 710-714. [2] Shang X, Li J, Tao Q, et al. Educational Level, obesity and Incidence of diabetes among Chinese adult men and women aged 18- 59 years old: An 11-year follow-up study. PLoS One, 2013, 8(6): e66479. 79 Report on Cardiovascular Diseases in China (2013) Table 2-5-2 Relationship between Baseline BMI and New onset Diabetes in Qingdao Port Study [RR (95% CI)] BMI Male (n=8 238) Female (n=2 466) <24 1.00 1.00 24-27.9 1.69(1.38-2.09) 1.81(1.12-2.92) ≥28 2.24(1.66-3.02) 2.58(1.37-4.86) P for trend 0.0015 0.0082 *: Cox regression analysis, adjusted for baseline age, marital status, occupation, educational attainment, smoking status, alcohol use, working intensity, leisure-time physical activity, diet pattern, WC, heart rate, blood pressure, blood lipid, uric acid, blood glucose, and family history of diabetes. A large-scale prospective study followed more than 26 000 subjects aged≥ 35 years for 11 years and showed that overweight and obesity were risk factors for ischemic stroke [1] (Table 2-5-3). Evidence also showed an escalating trend of the risk of ischemic stroke, which could be related with the growing prevalence of obesity. Thus, control of overweight and obesity will be a great help to the prevention of cardiovascular diseases. Table 2-5-3 Baseline BMI and Relative Risk of Different Types of Stroke [RR (95% CI)] BMI P for Trend <18.5 18.5-24.9 25.0-29.9 ≥ 30.0 Male (n=12 560) Ischemic Stroke 0.59(0.30-0.89) 1.00 1.64(1.30-2.10) 2.71(1.76-4.21) <0.001 Hemorrhagic Stroke 1.12(0.73-1.73) 1.00 1.01(0.73-1.41) 0.35(0.09-1.42) 0.365 Female (n=14 047) Ischemic Stroke 1.09(0.70-1.71) 1.00 1.54(1.16-2.04) 1.68(1.02-2.74) <0.001 Hemorrhagic Stroke 0.83(0.52-1.33) 1.00 0.78(0.56-1.08) 0.54(0.25-1.16) 0.731 Cox regression analysis, adjusted for baseline age, education attainment, smoking status, alcohol use, history of diabetes, high blood pressure and heart diseases. Besides increasing the budget for chronic disease prevention, the National Health and Family Planning Commission also developed the “Chronic Disease Prevention and Control Work Plan (2012-2015)” and the “Nationwide Fitness Program (2011-2015)” to halt the epidemic of obesity and other chronic disease risk factors. Intervention programs targeting chronic diseases, like “Healthy lifestyle” and “Community- based physical activity promotion”, were also implemented nationwide to facilitate the prevention of chronic diseases. More efforts should be made on multi-sector cooperation to prevent chronic disease and to promote health, which will in return reverse the increasing trend of obesity. [1] Wang C, Liu Y, Yang Q, et al. Body mass index and risk of total and type-specific stroke in Chinese adults: results from a longitudinal study in China. Int J Stroke, 2013, 8(4): 245-250. 80 Chapter 2 Risk Factors of Cardiovascular Diseases 2.6 Physical Inactivity Physical inactivity is a major risk factor for cardiovascular diseases and contributes to the development of obesity, high blood pressure, dyslipidemia, and hyperglycemia which increase the incidence of CVD. 2.6.1 Current Status, Trends, and Infl uence Factors of Physical Activity Work-related physical activity decreased signifi cantly with social and economic development. Results from CHNS [1] showed that the major component of daily physical activity among Chinese adults aged 18- 55 years is work-related physical activity. Except for a limited increase in leisure-time physical activity, all other types of physical activity have decreased considerably in the past two decades, especially work-related physical activity. Compared with the data of 1997, total physical activity decreased by 27.8% in male and by 36.9% in female in 2006 (Table 2-6-1). Table 2-6-1 Changes in physical activity (PA, MET-h/week) among Chinese adults aged 18-55 years Male Female 1991 1997 2006 1991 1997 2006 Work related PA 370.6 334.4 241.5 399.7 340.1 217.1 Housework related PA 19.1 11.7 5.6 61.3 46.8 25.3 Leisure time PA 1.4 3.6 0.6 2.3 Transport related PA 2.6 1.9 2.5 1.3 Total PA 350.0 252.7 390.0 246.1 Physical activity levels among children and adolescents are also not optimistic. A survey on physical activity among 1 846 fi rst-grade primary students in Shanghai in 2011 showed that a quarter of all students did not meet activity recommendations of 60 minutes of moderate-intensity physical activity per day, and that this proportion increased during weekends (Table 2-6-2). [2] Another study conducted among 4 549 junior high school students in 2009 showed that only 7.5% of all students reached the recommended level of physical activity. [3] [1] 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. [2] Yuan DG, Yi MM, Zhang LL, et al. Analysis of the fi rst grade pupils' physical activity type and level of Shanghai City. Chinese Journal of School Health, 2012, 33(3): 290-292. [3] Ren YJ, Liu QM, Lu Y, et al. Behavior and knowledge on physical activity among urban junior students in Hangzhou. Chinese Journal of Epidemiology, 2012, 33(7): 672-675. 81 Report on Cardiovascular Diseases in China (2013) Table 2-6-2 Proportion of First-grade Primary Students Reaching the Recommended Levels of Physical Activity (PA)* in Shanghai Proportion reaching the recommended level of PA(%) Number School days Weekends Boy students 973 75.4 65.7 Girl students 873 77.3 66.0 Total 1846 76.4 65.8 * Children and adolescents should have at least 60 minutes of moderate to high-intensity level of physical activity per day according to WHO recommendations. Active exercise is the main approach to increase physical activity. The 3rd Chinese National Physical Activity Survey (2007) showed that the proportion of people who were physically active was only 28.2% (including school students), and that this proportion was much lower among younger adults in the age group of 20-49 years (Figure 2-6-1). [1] 15 10 5 Physical Activity Rate（%） 0 . . . . . . .! $JH Figure 2-6-1 Regular Physical Activity Rate in Different Age Groups in 2007 The 2010 Report on Chronic Diseases Risk Factors Surveillance in China showed that the proportion of the adult population that were physically active(3 times/week, at least 10 minutes of moderate-intensity physical activity each time) was only 11.9%. Although the defi nition of physically active is slightly different from the 3rd Chinese national physical activity survey, the results still suggested a lower rate of physically active adults within age group of 25-44 years (Figure 2-6-2). [2] Thus, more attention should be paid on younger adults with regard to health education and promotion to improve their motivation to be more physically active. [1] State Physical Culture Administration. The third national populace sports present situation investigation report. Beijing: People's Sports Press, 2010. [2] Cheng XR, Jiang Y, Wang LM, et al. Leisure-time physical activity and sedentary behaviors among Chinese adults in 2010. Chinese Journal of Preventive Medicine, 2012, 46(5): 399-403. 82 Chapter 2 Risk Factors of Cardiovascular Diseases 15 10 5 Physical Activity Rate（%） 0 .......!! $JH Figure 2-6-2 Regular Physical Activity Rate in Different Age Groups in 2010 Analysis of comparable data from the years 1997 to 2007 showed a slightly increasing trend of the proportion of residents aged >16 years (not including school students) engaging in regular exercise (Figure 2-6-3) [1] . A survey on physical activity levels among Chinese adults aged 20-69 years in 10 cities in 2013 [2] showed a 4.5% increase in the proportion of regular exercising in Chinese adults. This indicated that the “Nationwide Fitness Program” has achieved a certain effect on physical activity. Physical Activity Rate（%） \HDU Figure 2-6-3 Regular Physical Activity Rate in Different Years The 3rd Chinese National Survey on Physical Activity reported that the main reasons for participation in physical activity were “to increase physical activity level” (34.8%), “for leisure purposes” (26.8%), and “to prevent disease” (18.9%) (Figure 2-6-4). Teenagers (ages 16-19) made up the largest proportion of people [1] General Administration of Sports of China. Report on the 3rd Chinese national physical activity survey. Beijing: Peoples Sports Publishing House, 2010. [2] General Administration of Sports of China. Survey of the physical activity level among Chinese adult aged 20-69 years, 2013. 83 Report on Cardiovascular Diseases in China (2013) involved in physical activity for leisure purposes (37.2%), while older adults (aged >70 years) comprised the largest proportion of people doing physical activity to prevent disease (46%). [1] ,QFUHDVH3K\VLFDO$FWLYLW\/HYHO /HLVXUH3XUSRVHV 3UHYHQW'LVHDVH 5HOD[ :HLJKW/RVV )LWQHVV 2WKHUV Figure 2-6-4 Main Purposes of Physical Activity (%) Main reasons for not participating in physical activity were “having no time” (33.8%), “not interested” (20.4%), “limited access to sport grounds and facilities” (12.9%), and “not necessary” (12.6%). 1RWLPH 1RW,QWHUHVWHG /DFN6SRUW*URXQGVDQG)DFLOLWLHV 1RW1HFHVVDU\ :HDNQHVV ,QHUW 2WKHUV Figure 2-6-5 Main Reasons for not Participating in Physical Activity (%) Two studies explored the factors affecting physical activity participation among older adults in Hong Kong. One cross-sectional study showed that better neighborhood environments (safer, better aesthetic quality, lower pollution) and accessibility (parks, playgrounds, community centers) were positively associated with more physical activity. [2] The other interventional study showed that the use of pedometry and “peer [1] State Physical Culture Administration. The third national populace sports present situation investigation report. Beijing: People's Sports Press, 2010. [2] Cerin E, Lee KY, Barnett A, et al. Objectively measured neighborhood environments and leisure-time physical activity in Chinese urban elders. Prev Med, 2013, 56(1): 86-89. 84 Chapter 2 Risk Factors of Cardiovascular Diseases support” could promote physical activity among older adults. [1] 2.6.2 Physical Inactivity and Cardiovascular Diseases A large-scale cross-sectional study was conducted across 10 regions in China in 2004-2008 to explore a possible relationship between physical activity/sedentary time and BMI/waist circumstance among 460,000 residents aged 30-79 without non-communicable diseases (CHD, stroke, TB, COPD, and cancer). Results of the study [2] showed that physical activity was negatively associated with BMI, WC, and percent body fat (PBF) (Table 2-6-3), while sedentary time was positively associated with BMI, WC, and PBF (Table 2-6-4). Moreover, the proportion of obesity (BMI≥ 28.0kg/m2) increased signifi cantly with increases in sedentary time and decreases in physical activity (Figure 2-6-6). Table 2-6-3 Changes of BMI (kg/m2), WC (cm) and Percent Body Fat (PBF, %) for Every 14 MET-h/day Increase in Physical Activity Change in BMI Change in WC Change in PBF N (95% CI) (95% CI) (95% CI) Male* Rural 108 347 -0.16 (-0.18-0.14) -0.63 (-0.69-0.58) -0.45 (-0.49-0.42) Urban 80 300 -0.16 (-0.19-0.13) -0.93 (-1.01-0.85) -0.56 (-0.61-0.51) Female* Rural 157 557 -0.16 (-0.18-0.14) -0.36 (-0.42-0.30) -0.49 (-0.53-0.45) Urban 120 401 -0.09 (-0.12-0.07) -0.54 (-0.61-0.47) -0.40 (-0.45-0.35) Total** 466 605 -0.15 (-0.16-0.14) -0.58 (-0.61-0.55) -0.48 (-0.50-0.45) *, Multivariate linear regression model was used to explore the association between physical activity and BMI/WC/PBF after adjusting for age, region, education attainment, and annual family income. **, Regression coeffi cients were estimated according to the inverse of the variance. [1] Thomas GN, Macfarlane DJ, Guo B, et al. Health promotion in older Chinese: a 12-month cluster randomized controlled trial of pedometry and "peer support". Med Sci Sports Exerc, 2012, 44(6): 1157-1166. [2] Du H, Bennett D, Li L, et al. Physical activity and sedentary leisure time and their associations with BMI, waist circumference, and percentage body fat in 0.5million adults: the China Kadoorie Biobank study. Am J Clin Nutr 2013, 97(3): 487-496. 85 Report on Cardiovascular Diseases in China (2013) Table 2-6-4 Changes in BMI (kg/m2), WC (cm) and PBF (%) for Every 1.5 Hour/day Increase in Sedentary Time Change in BMI Change in WC Change in PBF N (95% CI) (95% CI) (95% CI) Male* Rural 108 347 0.20 (0.18-0.22) 0.76 (0.70-0.83) 0.50 (0.46-0.54) Urban 80 300 0.12 (0.09-0.14) 0.49 (0.43-0.55) 0.26 (0.22-0.30) Female* Rural 157 557 0.21 (0.19-0.23) 0.52 (0.46-0.57) 0.57 (0.53-0.61) Urban 120 401 0.21 (0.19-0.22) 0.54 (0.49-0.59) 0.46 (0.42-0.50) Total** 466 605 0.19 (0.18-0.20) 0.57 (0.54-0.59) 0.44 (0.42-0.46) *, Multivariate linear regression model was used to explore the association between sedentary time and BMI/WC/PBF after adjusting for age, region, education attainment, and annual family income. **, Regression coeffi cients were estimated according to the inverse of the variance. 0DOH )HPDOH /RZ3K\VLFDO$FWLYLW\ 0RGHUDWH3K\VLFDO$FWLYLW\ +LJK3K\VLFDO$FWLYLW\ 3UHYDOHQFHRI2EHVLW\ 3UHYDOHQFHRI2EHVLW\ 6HGHQWDU\/HLVXUH7LPH KG 6HGHQWDU\/HLVXUH7LPH KG Figure 2-6-6 Relationship between the Prevalence of Obesity (BMI ≥ 28kg/m2) and Physical Activity Note: 466 605 residents with no major diseases were classifi ed into three groups (low, mid, high level) based on their total physical activity level. The adjusted prevalence of obesity was calculated by using logistic regression models with adjustment for age (in 5-y intervals), study area, education, and annual household income. In men, the cutoff values for defi ning low, moderate, and high levels of physical activity were 17.8 and 28.8 MET-h/d, whereas in women, the corresponding cutoff values were 12.6 and 24.4 MET-h/d. MET: metabolic equivalent task. Two prospective studies explored the possible relationship between physical activity and type 2 diabetes. The multiple metabolic disorder and metabolic syndrome prevention study conducted in Jiangsu province, followed 3 461 subjects aged 35-74 who were non-diabetic at baseline for an average of 6.3 years. Its results showed an inverse association between work-related physical activity and the risk of incident diabetes. 86 Chapter 2 Risk Factors of Cardiovascular Diseases Compared with high-intensity physical activity, the risk of developing diabetes increased signifi cantly in people performing low or moderate-intensity physical activity (Table 2-6-5). [1] Table 2-6-5 Baseline Work-related Physical Activity and Risk of Type 2 Diabetes Intensity of Work-related Cumulative incident diabetes N Physical Activity * n Cumulative incidence (%) OR (95% CI) † High-intensity 627 16 2.6 1.00 Moderate-intensity 2 585 133 5.1 2.15 (1.26-3.68) Low-intensity 249 13 5.2 2.39 (1.12-4.87) *, Low-intensity: jobs which require sitting most of the time (secretary, etc.); moderate-intensity: jobs which require standing and walking most of the time (shop assistant); high-intensity: jobs require walking or heavy manual labor most of the time (industrial or agricultural labor). †, Age, gender, family history of diabetes, and blood pressure, blood lipid, and fasting blood glucose at baseline were adjusted in the logistic regression model. 4 550 non-diabetic residents at baseline were re-examined after 3 years in another prospective study conducted in Nanjing. The results showed that the risk of developing type 2 diabetes decreased by 57% among those who were physically active at baseline (Table 2-6-6). [2] Table 2-6-6 Baseline Physical Activity and the Risk of Type 2 Diabetes Cumulative incident diabetes in 3 years of follow-up Baseline Physical Activity* N n Cumulative incidence (%) OR (95% CI) † Physically Active 3 797 211 5.6 1.00 Physically Inactive 753 21 2.8 0.43 (0.27-0.69) *, Physically active was defi ned as doing moderate-intensity physical activity for a minimum of 30 minutes on 5 days each week, or high- intensity physical activity for a minimum of 20 minutes on 3 days each week. Otherwise was defi ned as physically inactive; †, Age, gender, educational attainment, family history of diabetes, BMI, smoking status, alcohol use, time spent watching TV, high blood pressure, and intake of meat and vegetables were adjusted in the logistic regression model. Shanghai Male Health Study explored the association between physical activity and death. Baseline data was collected in more than 60 000 males aged 40-74 years in 2002-2006, and the follow-up was fi nished by the end of 2009. Study results showed that baseline physical activity level was reversely associated with total death and cardiovascular death. When physical activity level reached≥ 13.9MET-h/week, the risk of total death and cardiovascular death decreased 21%, and 24% respectively (Table 2-6-7). [3] [1] Jing-chao L, Zhi-rong G, Xiao-shu H, et al. Impact of lifestyle and obesity on the type 2 diabetes: a prospective study in Jiangsu province. Chin J Prev Med, 2012, 46(4): 311-315. [2] Chao L, Zhi-yong W, Xin H, et al. Relationship between physical activity and risk of type-2 diabetes in urban adults of Nanjing: a pool study from two 3-year community-based prospective cohorts. Modern Preventive Medicine, 2012, 39(15): 3879-3881. [3] Wang N, Zhang X, Xiang YB, et al. Associations of tai chi, walking, and jogging with mortality in Chinese men. Am J Epidemiol, 2013, 178(5): 791-796. 87 Report on Cardiovascular Diseases in China (2013) Table 2-6-7 Hazard Ratios for Total and CVD Mortality and Physical Exercise Total Death Cardiovascular Death Frequency of Exercise N n RR(95%CI) n RR(95%CI) No regular exercise 39 630 1 306 1.00 419 1.00 <13.9MET-h/week 10 365 424 0.81 (0.79-0.91) 147 0.82 (0.68-1.00) 13.9MET-h/week 11 482 691 0.79 (0.72-0.88) 234 0.76 (0.64-0.90) Adjusted for age; educational level; income; occupation; alcohol consumption; pack-years of smoking; daily intake of energy, red meat, fruits, and vegetables; daily physical activity other than exercise; body mass index; and history of cardiovascular disease, diabetes, hypertension, chronic liver disease, or pulmonary disease. The above studies show that the physical activity level of Chinese residents has signifi cantly decreased. Despite some improvement in adults, the proportion of physical activity was still low, especially in younger adults. Physical activity among primary and middle school students was insuffi cient. To improve this situation, action is needed throughout society to implement the “Nationwide Fitness Program (2011-2015)” developed by the National Health and Family Planning Commission, which in turn will curb the prevalence of chronic diseases and promote the health conditions of residents. 2.7 Diet and Nutrition 2.7.1 Current State and Trends of Nutritional Health The 2002 National Nutrition and Health Survey reported that there already has been signifi cant change in dietary patterns. Some were clearly disadvantageous for the prevention of cardiovascular diseases, including the decrease in whole-grain foods intake, the increase in fat intake, the decrease in energy contributions from carbohydrates and the excess from fat. [1] Moreover, fruit and vegetable intake was still relatively low. Although dietary salt intake level had somewhat decreased, it still exceeded the recommended standard (average intake of salt in Chinese population was about 15.9g/day according to 2002 National Nutrition and Health Survey). The Chinese Health and Nutrition Survey (CHNS) completed 8 investigations on the trends of nutrients intake of Chinese residents. [2] Studies demonstrated that the percentage of total energy from fat still showed an obvious increasing trend, much higher than the recommended level based on the dietary guidelines (20%-30%), while the percentage of total energy from carbohydrates was decreasing, lower than the level recommended by the guidelines (55%-65%). See Table 2-7-1. [3] The dietary cholesterol intake increased [1] Qu FY, Yang XG. Report on the status of Chinese nutrition and health 2002(Ⅱ): Diet and nutrients intake. People’s Medical Publishing House, Beijing, 2006, 7. [2] China Nutrition and Health Survey project group. The trends of nutrients intake of Chinese residents in nine Provinces from 1989 to 2009 (I): The China nutrition and health survey, Acta Nutrimenta Sinaca. 2011, 33(3): 234-236. [3] Zhang B, Wang HJ, Du WM, et al. The trends of nutrients intake of Chinese residents in nine Provinces from 1989 to 2009 (II): The general intake trend of Chinese adults aged 18-49 years, Acta Nutrimenta Sinaca, 2011, 33(3): 237-242. 88 Chapter 2 Risk Factors of Cardiovascular Diseases obviously. [1] Although the dietary calcium intake increased slightly, the average intake only reached about half of the recommended amount (800 mg/day). [2] Vitamin C intake (primarily from fresh fruits and vegetables) showed a decreasing trend, with average intakes of 85.2 mg/day and 83.1 mg/day in 2009 for males and females aged 18-44 years, respectively. [3] This was much lower than the level recommended by the guidelines (>100 mg/day). See Table 2-7-2. Table 2-7-1 Change in Proportion of Calories From Fat (>30%) and from Carbohydrates (<55%) among Participants ages 18–49 Years from 9 Different Provinces and Cities (China: 1989-2009) Survey Year Calorie Source 1989 1991 1993 1997 2000 2004 2006 2009 Fat Calories >30% 35.8 30.3 28.9 32.7 42.2 40.6 51.5 55.0 Carbohydrate Calories <55% 30.4 26.2 25.9 27.3 34.8 35.1 48.3 53.1 Table 2-7-2 Change in Dietary Consumption of Cholesterol, Calcium, and Vitamin C among Participants ages 18 – 49 Years from 9 Different Provinces and Cities (China: 1989-2009) Survey Year Calorie Source 1989 1991 1993 1997 2000 2004 2006 2009 Male Cholesterol (mg/d) 156 191 192 230 256 274 294 291 Calcium (mg/d) — 389 389 420 417 418 415 415 Vitamin C (mg/d) 117 100 102 94 95 94 89 85 Female Cholesterol (mg/d) 142 164 160 208 230 248 267 264 Calcium (mg/d) — 356 359 378 376 372 363 367 Vitamin C (mg/d) 111 93 95 87 87 87 84 83 The same situation is also seen among children and adolescents. Data from the CHNS showed that in the past 20 years, the percentage of population with > 30% of energy intake from dietary fat increased yearly and that with more than 55% of energy from carbohydrate decreased. [4] See Table 2-7-3. The absolute fat [1] Su C, Zhang B, Wang HJ, et al. The trends of nutrients intake of Chinese residents in nine Provinces from 1989 to 2009 (V): The fat and cholesterol intake trend of Chinese adults aged 18-49 years, Acta Nutrimenta Sinaca, 2011, 33(6): 546-550. [2] Liu AD, Zhang B, Wang HJ, et al. The trends of nutrients intake of Chinese residents in nine Provinces from 1991 to 2009 (VI): The calcium intake trend of Chinese adults aged 18-49 years. Acta Nutrimenta Sinaca, 2012, 34(1): 10-14. [3] Ma YX, Zhang B, Wang HJ, et al. The trends of nutrients intake of Chinese residents in nine Provinces from 1989 to 2009 (IX): The vitamin C intake trend of Chinese adults aged 18-49 years. Acta Nutrimenta Sinaca, 2012, 34(5): 427-431. [4] Zhang B, Wang HJ, Su C, et al. Trend of energy intake among Chinese children and adolescents in nine provinces from 1989 to 2009. Chinese Journal of Preventive Medicine, 2012, 46(12): 1064 – 1068. 89 Report on Cardiovascular Diseases in China (2013) intake, average energy from fat, and cholesterol intake all showed increasing trends, [1] while vitamin C intake showed a decreasing trend. [2] See Table 2-7-4. Table 2-7-3 Change in Proportion of Calories From Fat (>30%) and from Carbohydrates (<55%) among Participants Ages 6–17 Years from 9 Different Provinces and Cities (China: 1989-2009) Survey Year Calorie Source 1989 1991 1993 1997 2000 2004 2006 2009 Fat Calories >30% 25.4 24.8 25.1 30.2 42.7 41.6 51.5 58.1 Carbohydrate Calories <55% 19.1 19.1 21.0 23.7 34.1 32.9 47.1 55.1 Table 2-7-4 Change in Dietary Consumption of Cholesterol, Calcium, and Vitamin C among Participants Ages 7–17 Years from 9 Different Provinces and Cities (China: 1989-2009) Survey Year Calorie Source 1991 1993 1997 2000 2004 2006 2009 Male Fat (g/d) 54.4 51.9 58.2 67.4 64.5 67.3 70.6 Fat Contribution (%) 22.7 22.7 24.2 27.9 27.2 29.7 32.3 Cholesterol (mg/d) 149.8 162.1 195.3 221.0 232.4 253.0 258.7 Vitamin C (mg/d) * 72.8 72.6 64.3 64.7 66.9 57.6 54.0 Female Fat (g/d) 49.0 47.3 54.8 61.3 57.0 63.0 59.8 Fat Contribution (%) 22.2 22.3 24.9 28.6 27.3 30.7 31.6 Cholesterol (mg/d) 134.3 130.2 185.1 203.5 216.4 235.6 216.9 Vitamin C (mg/d) * 66.8 68.9 58.1 61.7 60.5 54.8 52.8 *, Participants ages 6-17 years. CHNS also analyzed 7 cross-sectional studies from 1989 to 2006 on primary dietary pattern changes among people aged 18-59 years. [3] Results showed the following trends: decrease in whole-grain intake; increases in meat, poultry, and dietary oil intake; decrease in vegetable intake; and increase in fruit intake (Table 2-7-5). Other trends in dietary pattern changes were essentially the same compared to the results of other three national nutrition surveys from 1982 to 2002. [1] Su C, Wang HJ, Wang ZH, et al. Current status and trends of both dietary fat and cholesterol intake among Chinese children and adolescents aged 7 to 17 years old in 9 provinces of China, from 1991 to 2009. Chinese Journal of Epidemiology, 2012, 33(12): 1208- 1212. [2] Wang ZH, Zhang B, Wang HJ, et al. Trend in dietary vitamin C intake among Chinese children and adolescents between 1991 and 2009. Chinese Journal of Preventive Medicine, 2012, 46(12): 1069-1073. [3] Zhang B, Wang H, Du WM, et al. Food consumption trend of Chinese adults in nine provinces (autonomous region) from 1989 to 2006. Chinese Journal of Preventive Medicine, 2011, 45(4): 330-334. 90 Chapter 2 Risk Factors of Cardiovascular Diseases Table 2-7-5 Dietary Intake Changes (age 18-59) in 9 Provinces and Cities (China: 1989-2006) Survey Year Food Type 1989 1991 1993 1997 2000 2004 2006 Male Whole-grain 552.8 537.0 529.2 535.8 477.9 490.7 466.3 Meat 97.0 102.9 113.4 114.2 125.2 131.1 141.5 Poultry 11.4 16.3 15.9 24.0 27.3 26.8 32.0 Dietary Oil 31.5 36.8 33.9 42.1 44.5 40.6 46.5 Vegetable 401.6 365.2 389.2 356.6 363.4 383.7 374.5 Fruit 124.6 92.9 126.4 145.9 137.4 133.8 229.1 Female Whole-grain 505.7 490.1 478.9 460.1 404.6 417.5 392.6 Meat 80.2 83.4 91.6 98.4 106.6 110.4 118.4 Poultry 10.8 14.7 14.0 23.2 25.8 25.1 29.9 Dietary Oil 29.5 32.8 30.2 37.1 38.7 36.0 39.5 Vegetable 385.3 338.37 363.5 336.5 337.1 354.7 346.4 Fruit 120.5 97.6 122.0 156.0 131.9 146.1 228.0 Beyond these results, a survey among adolescents aged 8-14 years in 4 major cities showed that the proportion of children consuming Western-style fast food had dramatically increased. [1] See Figure 2-7-1. This sort of dietary change is one of the major causes of unbalanced nutrition among youth. ≤1/mth 2~3/mth ≥4/mth Figure 2-7-1 Western Fast Food Frequency among Adolescents (age 8-14) in 4 Cities(%) [1] Ma GS, Zhang Q, Liu AL, et al. Changes in western fast food consumption in children and adolescents in four cities of China over 10 years. Chinese Journal of Health Education, 2011, 27(12): 887-889. 91 Report on Cardiovascular Diseases in China (2013) 2.7.2 Effects of Diet on CVD and Associated Risk Factors Analysis of data from 2002 National Nutrition and Health Survey found among 20 717 subjects aged 45-59 years without a history of diabetes, 1 332 were diagnosed with impaired glucose tolerance (fasting blood glucose≥6.1 mmol/L and/or post-prandial 2-hour blood glucose≥7.8 mmol/L). 662 subjects met the criteria of type 2 diabetes (fasting blood glucose≥7.0 mmol/L and/or post-prandial 2-hour blood glucose≥11.1 mmol/L). Multivariate adjusted analysis showed that the high-fat low-carbohydrate diets were associated with the high incidence of impaired glucose tolerance and type 2 diabetes in Chinese population. Table 2-7-6. [1] Table 2-7-6 Odds-ratios of New Diagnoses of Hyperglycemia and Diabetes Mellitus Based on High fat/low Carbohydrate Diet Scores (OR, 95% CI) High fat/low Carbohydrate Diet Score Hyperglycemia Diabetes mellitus 1 1.00 1.00 2 1.29 (1.04-1.61) 1.54 (1.11-2.14) 3 1.32 (1.06-1.64) 1.48 (1.05-2.96) 4 1.44 (1.15-1.81) 1.66 (1.18-2.33) 5 1.63 (1.29-2.45) 1.86 (1.32-2.61) p-value <0.0001 <0.0015 Note: During the logistic regression analysis, the following variables were adjusted: gender, age, drinking, sedentary time, family history of diabetes mellitus, socioeconomic status, educational level, BMI and TG, LDL-C, and HDL-C levels. Two cross-sectional studies separately investigated the relation between nutritional diets and obesity and hypertension in the youth population. One study in 2009 selected 5 267 primary school students from Beijing, Harbin, Jinan, Shanghai, and Guangzhou and used cluster analysis to sort their diets into healthy, transitional, and Western-style. Further analysis showed that the risk of obesity was clearly elevated among students who had transitional or Western-style diets compared to those with healthy diets (Table 2-7-7). [2] Table 2-7-7 Association between Obesity and Diet among Primary School Students (OR, 95% CI) Dietary Structure Obesity Central Obesity Healthy 1.00 1.00 Transitional 1.11 (0.89-1.38) 1.31 (1.09-1.56) Western 1.80 (1.15-2.81) 1.71 (1.13-2.56) Note: During the logistic regression analysis, the following variables were adjusted: region, gender, age, breastfeeding, birth weight, parental weights, family socioeconomic status, parental educational levels, total caloric intake and exercise amount. [1] He YN, Feskens, E, Li YP, et al. Association between high fat-low carbohydrate diet score and newly diagnosed type 2 diabetes in Chinese population. Biomed Environ Sci, 2012; 25(4): 373-382. [2] Shang X, Li Y, Liu A, et al. Dietary pattern and its association with the prevalence of obesity and related cardiometabolic risk factors among Chinese children. PLoS One, 2012. 7(8): e43183. 92 Chapter 2 Risk Factors of Cardiovascular Diseases Another survey on developmental health from Hong Kong in 2005-2006 selected 8 315 adolescents aged 12 to 18 years to elucidate the relationship between BP and exercise/eating habit. Questions about 11 different types of dietary habits were asked (e.g. consumption of sugary beverages and deep-fried foods). The results showed that among non-overweight and overweight adolescents, scores refl ecting unhealthy dietary habits was directly correlated with risk of hypertension. See Table 2-7-8. [1] Table 2-7-8 Association between HTN and Unhealthy Diet Scores among Adolescents in Hong Kong (OR, 95% CI) Non-overweight Youth Overweight Youth Unhealthy Diet Score* (n = 7 185) (n = 1 130) ≤6 1.00 1.00 7-9 1.33 (1.04-1.72) 1.88 (1.07-3.29) ≥10 1.52 (1.14-2.03) 2.11 (1.16-3.84) *, range 0-11. Logistic regression analysis adjusted for the following variables: gender, age, parental HTN, exercise frequency, and BMI. In order to investigate the effect of low-sodium salt consumption on blood pressure control, multiple large-scale interventional trials on low-sodium salt (substituted salt, compound ionized salt, low-sodium high-potassium salt) have been conducted over the past 10 years. [2, 3, 4, 5, 6] The results showed that lower salt intake appeared to decrease blood pressure levels among patients with cardiovascular diseases, patients with hypertension, and subjects with normal blood pressure (Table 2-7-9). [1] So HK, Li AM, Choi KC, et al. Regular exercise and a healthy dietary pattern are associated with lower resting blood pressure in non-obese adolescents: a population-based study. J Hum Hypertens, 2013; 27(5): 304-308. [2] China Salt Substitute Study Collaborative Group. Salt substitution: a low-cost strategy for blood pressure control among rural Chinese. A randomized, controlled trial. J Hypertens, 2007; 25(10): 2011-2018. [3] Zhou X, Liu JX, Shi R, et al. Compound ion salt, a novel low-sodium salt substitute: from animal study to community-based population trial. Am J Hypertens, 2009; 22(9): 934-942. [4] Zhou B, Wang HL, Wang WL, et al. Long-term effects of salt substitution on blood pressure in a rural north Chinese population. J Hum Hypertens, 2013; 27(7): 427-433. [5] Mu J, Liu Z, Liu F, et al. Family-based randomized trial to detect effects on blood pressure of a salt substitute containing potassinm and calcium in hypertensive adolescents. Am J Hypertens,2009, 22(9):943-947. [6] Zhang GH, Ma JX, Dun SL, et al. Field observation on the effect of low-sodium and high-potassium salt substitute on blood pressure in the rural community-based population in China. Chinese Journal of Epidemiology, 2011; 32(9): 859-863. 93 Report on Cardiovascular Diseases in China (2013) Table 2-7-9 Characteristics and Outcomes of Low-sodium Salt Intervention Trials Sodium use Follow-up Study name or Study percentage Study Sample Study subject percentage Main research Intervention outcome design in test group period size characteristics and type of unit (%) analysis High-risk males China Salt Randomized, NaCl: 65 1 and females plus 96, intention- SBP decreased by 5.4 mmHg [1] KCl: 25 608 ages > 55 with (P < 0.001), no change in DBP Substitute Study double-blind MgSO4: 10 year cardiovascular to-treat (ITT) compared to control group disease Males and Tianjin Wujing females of ages SBP decreased by 9.6 mmHg (P Randomized, NaCl: 65 6 50-80 with < 0.001), DBP decreased by 5.3 Medical School, KCl: 25 248 hypertension or 91, ITT mmHg (P < 0.001) compared to [2] single-blind MgSO4: 10 months Pingjin Hospital normal blood control group pressure NaCl: 65 Males and China Medical KCl: 30 females of SBP decreased by 3 mmHg (P Randomized, 2 University, No. 1 Calcium 462 ages > 18 with 81, ITT < 0.05), DBP decreased by 1 double-blind citrate: 4 years hypertension or mmHg (P < 0.05) compared to Hospital [3] Calcium normal blood control group carbonate: 1 pressure Xian Jiaotong No data, but Youth with SBP/DBP decrease of 5.9/2.8 University No. Simple daily sodium 2 elevated blood 90, per- mmHg in intervention group, and calcium 325 pressure, increase of 1.3/2.3 in control 1 Associated randomized intake of -400 years average age protocol (PP) group, P-value of difference Hospital[4] mg 20.8 between groups < 0.01 Males and SBP/DBP decrease of 7.4 / 3.8 Shandong females of ages mmHg in hypertension group; NaCl: 65 3 30-60 with decrease of 1.2 / 1.0 mmHg in University School No blinding KCl: 25 411 hypertension or 92, PP non-hypertensive group (P < [5] MgSO4: 10 months of Public Health normal blood 0.01). No comparison between pressure intervention and control groups A study from Pingjin Hospital, an affi liated unit of Tianjin Wujing Hospital, collected 24 hours urine samples before and after low-sodium salt interventions. Their results showed that low-sodium salt interventions signifi cantly decreased urinary sodium excretion and increased urinary potassium excretion compared to the control group (p < 0.001). [6] See Figure 2-7-2. [1] China Salt Substitute Study Collaborative Group. Salt substitution: a low-cost strategy for blood pressure control among rural Chinese. A randomized, controlled trial. J Hypertens, 2007, 25 (10): 2011-2018. [2] Zhou X, Liu JX, Shi R, et al. Compound ion salt, a novel low-sodium salt substitute: from animal study to community-based population trial. Am J Hypertens, 2009, 22(9): 934-942. [3] Zhou B, Wang HL, Wang WL, et al. Long-term effects of salt substitution on blood pressure in a rural north Chinese population. J Hum Hypertens, 2013, 27 (7): 427-433. [4] Mu J, Liu Z, Liu F, et al. Family-based randomized trial to detect effects on blood pressure of a salt substitute containing potassium and calcium in hypertensive adolescents. Am J Hypertens, 2009, 22(9): 943-947. [5] Zhang GH, Ma JX, Dun SL, et al. Field observation on the effect of low-sodium and high-potassium salt substitute on blood pressure in the rural community-based population in China. Chinese Journal of Epidemiology, 2011, 32(9): 859-863. [6] Zhou X, Liu JX, Shi R, et al. Compound ion salt, a novel low-sodium salt substitute: from animal study to community-based population trial. Am J Hypertens, 2009, 22(9): 934-942. 94 Chapter 2 Risk Factors of Cardiovascular Diseases 40 20 0 Urine sodium Urine potassium -20 -40 -60 Intervention Control -80 Changes in 24-hour urine sodium and potassium -100 Figure 2-7-2 Changes in 24-hour Urine Sodium and Potassium in Intervention and Control Groups Currently, some regions has already introduced low-sodium salt. For example, in 2009, the Beijing city government clearly stated in its 17th municipal report entitled “Healthy Beijing residents – 10-year plan to improve city-wide health (2009-2018)” to “encourage use of low-sodium salt in restaurants, cafeterias and homes.” Salt sold in city supermarkets are primarily low-sodium salt. While these kinds of strategies may decrease salt intake and thus decrease blood pressure levels in the community, their effects require scientifi c evaluation. Current interventional studies on low-sodium salt have generally excluded subjects that may not be suited to use low-sodium salt (e.g. those using potassium-sparing diuretics or those with abnormal renal function). Therefore, while encouraging the use of low-sodium salt, the right guidance must be provided and safety evaluations will be needed. Current researches show that the dietary patterns in the Chinese population are changing. Aside from the ongoing decreases in dietary salt intake (despite still exceeding recommended intake level by at least 100%) and increases in fruit intake, other dietary factors that are associated with cardiovascular or other chronic diseases still exist or show worsening trends (e.g. imbalance of nutritional sources, increases in cholesterol intake, decreases in vegetable intake, no change in calcium intake, etc.). The government’s public health departments and preventive medicine units, as well as the public should be aware of these changes. Spreading healthy dietary guidelines and improving population dietary patterns is an important step to prevent chronic illnesses including cardiovascular diseases. 2.8 Metabolic Syndrome (MS) The clinical defi nitions for MS was not consistence in different guidelines from the China Diabetes Society (CDS) for MS, the Chinese Cholesterol Prevention and Education Program’s Adult Treatment Panel (CCPEP-ATP), the National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III), and 95 Report on Cardiovascular Diseases in China (2013) the International Diabetes Federation (IDF). Studies on MS in China adopted different defi nitions, making their fi ndings diffi cult to compare. 2.8.1 Prevalence of MS 2.8.1.1 Prevalence of MS in Adults Data from the 2002 China Health and Nutrition Survey showed that the prevalence rates of MS in adults aged over 18 were 6.6% and 13.8%, respectively, based on criteria from the CDS and the NCEP-ATP III (Table 2-8-1). Table 2-8-1 Prevalence of MS in Selected Locations in China Criteria (%) Location Year Age Race/ethnicity N CDS IDF ATP III [1] Wei 4 688 40.56 Xinjiang* 2004-2007 ≥50 Han 3 596 41.06 [2] ≥ community Sichuan 2007 20 resident 3 511 22.4 [3] ≥ community Shanghai 2009 35 resident 22 001 29.69 [4] ≥ community Guizhou 2009 60 resident 5 182 16.96 [5] ≥ community Lanzhou 2010 15 resident 3 465 12.38 16.3 24.65 [6] community Qinhuangdao 2010 20-90 resident 3 567 5.72 Xinjiang[7] 2010 ≥18 Wei 3 442 21.2 Lianyungang[8] — 45-75 coastal farmers 11 089 37.0 44.3 *, Rate standardized by demography; others are estimated rates [1] Miao HJ, Zhou SH, Hong Y, et al. Epidemiological investigation of metabolic syndrome in Uygur and Han population in Xinjiang at the age of older than 50 people. Chinese Journal of Gerontology, 2013, 33: 889-892. [2] Fei YF, Wang C, Liu GJ, et al. Comparison of the application of different diagnosis criteria of metabolic syndrome in Sichuan population. Journal of Sichuan University (Medical Science Edition), 2012, 43: 547-552. [3] Zong WH, Liu YX, Gu JC. Study on the prevalence and risk factors of metabolic syndrome among residents in Zaibei district of Shanghai. Chinese General Practice, 2012, 15: 3103-3108. [4] Liu YX, Chu L, Liu WM, et al. Correlation analysis between hypertension and metabolic syndrome and the prevalence of stroke in community population. Chinese Journal of Geriatric Cardiovascular Diseases, 2012, 14: 961-964. [5] Liu YF, Tao YF, Che HX, et al. Comparison of the applications of three agnostic criteria of metabolic syndrome in Lanzhou community. Journal of Lanzhou University (Medical Sciences), 2012, 38: 31-34. [6] Zhang HB, Liu XS, Kang KY, et al. Epidemiological investigation and analysis of infl uence Factors of metabolic syndrome in adults of Beidaihe District, Qinhuangdao. Occupation and Health, 2012, 28: 211-212. [7] Li CH, Dun SX, Ma RL, et al. The epidemic status of metabolic syndrome among Uighur population in Kashi district, Xinjiang in 2010. Chinese Journal of Preventive medicine, 2012, 46: 419-423. [8] Zhao CX, Zhou Y, Wen JT, et al. Correlation study between hypertension status and the prevalence of metabolic syndrome in costal rural residents. Chinese Journal of Primary Medicine and Pharmacy, 2012, 19: 3710-3711. 96 Chapter 2 Risk Factors of Cardiovascular Diseases 2.8.1.2 Prevalence of MS among Children In 2010, the Chinese Children and Adolescent Metabolic Syndrome Association (CCAMSA) conducted an epidemiological study in Beijing, Tianjin, Hangzhou, Shanghai, Chongqing and Nanning (Table 2-8-2). In this cross-sectional study, 22 071 (11 638 males and 10 433 females) children and adolescent aged 7-16 were included. Based on the 2012 Chinese criteria for metabolic syndrome for Chinese children and teenagers (MS-CHN 2012) and the International Diabetes Federation (MS-IDF 2007), the prevalence rates of MS were 2.4% and 1.4%, respectively. Another study found that the prevalence of MS in 2 752 children aged 7-17 was 3.2% based on NCEP-ATP III. Table 2-8-2 Prevalence of MS among Children and Adolescence Aged 6-17 prevalence (%) Area Age (n) Diagnosis criteria Normal weight Overweight Obese MS-CHN2012 — — 28.8 6 cities[1] 7-16(22 071) MS-IDF2007 — — 16.8 8 provinces[2] 7-17(2 752) Cook guidelines 0.7 8.0 23.9 MS-CHN2012 0 9.57 19.64 Xinjiang[3] 6-13(5 360) ATP III 0.64 2.61 16.07 Note: Cook et al. (2003) defi ned MS as the presence of any 3 of the following 5 risk factors: TG ≥ 1.24mmol/L, HDL-C ≤ 1.03 mmol/L , waist circumference (WC) at or above the 90th percentile, fasting glucose ≥ 110 mg/dL, and blood pressure (BP) at or above the 90th percentile. 2.8.2 Risk Factors of MS 2.8.2.1 Alcohol and MS A longitudinal 8-year follow-up study of 14 572 adults aged 35-74 reported that MS is associated with amount of alcohol consumption, frequency of alcohol consumption, and the type of alcohol consumed in men after adjusting for age, location, smoking status, rural/urban resident, education level, physical activity and BMI (Table 2-8-3). However, only the amount of alcohol consumption was associated with MS for women after adjusting for covariates. [4] [1] Chinese Work Group of Pediatric Metabolic Syndrome. Prevalence of metabolic syndrome of children and adolescent students in Chinese six cities. Chinese Journal of Pediatrics, 2013, 51: 409-413. [2] Yu DM, Zhao LY, Ma GS, et al. Prevalence of Metabolic Syndrome among 7-17 Years Old Overweight and Obesity Children and Adolescents. Journal of Hygiene Research, 2012, 41: 359-362. [3] Li M, Zhang T, Xu PR. Epidemiological characteristics of metabolic syndrome among Kazakh children aged from 6 to 13 in Xinjiang, China. Chinese Journal of Epidemiology, 2013, 34(4): 336-341. [4] Wei WM, Huang JF, Li JX, et al. Alcohol consumption and the incidence of metabolic syndrome in Chinese population. Chinese Journal of Health Management, 2012, 6: 75-80. 97 Report on Cardiovascular Diseases in China (2013) Table 2-8-3 Alcohol and MS Male Female Area OR (95% CI) OR (95% CI) Amount of Alcohol Consumption None 1 1 Very low (0.1-10g/d) 1.200(0.884-1.629) 0.838(0.559-1.254) Low (10.1-20g/d) 1.364(1.024-1.738) 2.668(1.259-5.633) Moderate (20.1-40g/d) 1.335(1.026-1.738) 2.383(1.346-4.215) Heavy≥40g/d 1.412(1.129-1.767) Frequency of Alcohol Consumption ( per week) 0 1 1 1 1.3936(0.797-2.435) 1.046(0.325-3.371) 2-5 1.250(1.006-1.553) 0.941(0.629-1.407) ≥6 1.256(1.041-1.517) 1.524(0.989-2.349) Type of Alcohol None 1 1 Beer Only 1.600(1.046-2.445) 0.729(0.378-1.404) Chinese Spirit Only 1.298(1.018-1.654) 1.310(0.781-2.197) Rice Wine or Yellow Wine 0.606(0.345-1.063) 1.207(0.569-2.558) Mixed Type 1.266(1.055-1.520) 1.142(0.736-1.771) 2.8.2.2 Physical Activity and MS In a study involving 11 512 adults aged 35-74 for a follow-up period of 8.1 years, compared to a group with MET-h/d <32.00 (metabolic equivalent of task, per hour, per day), the relative risk for MS in groups with MET-h/d in ranges 32.00 to 37.85, 37.86 to 52.29, and ≥ 52.30 was 1.05 (0.92-1.19), 0.98 (0.86-1.12), and 0.68 (0.59-0.80) (Chi square = 34.23, P < 0.05), respectively. [1] Participants involved in high, moderate, and low physical activity had lower odds of developing MS when compared to participants with very low physical activity levels (OR [95%CI], 0.80 [0.69-0.92], 0.70 [0.59-0.82], 0.54 [0.45-0.65]) (Chi square = 42.34, P < 0.05). In a 2008-2010 cross-sectional study among 15 514 adults aged 50-70 years conducted at the Dongfeng Motor Corporation Shiyan, Hubei Province, low physical activity was reported as a risk factor for MS (Figure 2-8-1). [2] The participants were categorized into fi ve groups based on their physical activity levels, which [1] Meng DJ, Cheng JC, Huang JF, et al. Physical activity and the incidence of metabolic syndrome in Chinese population: A prospective cohort study. Chinese Journal of Preventive Medicine, 2013, 47: 312-317. [2] Chen M, He M, Min X, et al. Different physical activity subtypes and risk of metabolic syndrome in middle-aged and older Chinese people. PLoS One, 2013; 8(1):e53258. 98 Chapter 2 Risk Factors of Cardiovascular Diseases were measured by MET-h/d. After adjusted for covariates (age, gender, education level, smoking, alcohol, family history for CVD and diabetes, intake of meat, vegetables, fruits, and nuts, and antihypertensive, hypoglycemic, lipid lowering, and antiplatelet treatments), the risk of MS in top quintile was lower than in the bottom quintile by about one-fourth (OR: 95% CI, 0.75: 0.66, 0.86). 2GGVUDWLR )LYHJURXSVGLYLGHGE\0(7KG Figure 2-8-1 Odd-ratio of developing MS at different physical activity levels 2.8.3 MS and CVD MS is associated with stroke recurrence. In the ACROSS-China study, a 1-year follow-up study in 2 639 patients with ischemic stroke, patients with MS had a higher risk for ischemic stroke recurrence with an OR of 1.94 (95% CI: 1.39-2.73). [1] [1] Mi D, Jia Q, Zheng H. Metabolic syndrome and stroke recurrence in Chinese ischemic stroke patients – the ACROSS-China study. PLoS One, 2012, 7(12): e51406. 99 Chapter 3 Cardiovascular Diseases 3.1 Stroke (Cerebrovascular Disease) 3.1.1 Stroke Prevalence, Mortality and Trend in Chinese Population (1) Stroke Prevalence The Ministry of Health has been conducting a national health service survey every fi ve years since 1993 [1] . Based on the results of the four surveys thus far, the prevalence of stroke is on the rise with a higher prevalence in the urban population than in the rural population (Figure 3-1-1). Total Rural Urban 3UHYDOHQFH˄ă˅ Figure 3-1-1 Stroke Prevalence in Urban and Rural Populations (China: 1993-2008) (2) Global Burden of Disease Study 2010 [2] The Global Burden of Disease Study 2010 (GBD 2010) described the trends in several metrics including mortality, disability-adjusted life-years (DALYs) in 19 countries between the years of 1990 and 2010. Stroke was the leading cause of death in China. The number of deaths with stroke as the underlying cause increased from 1.340 6 million in 1990 to 1.726 7 million in 2010. The number of deaths due to ischemic stroke were 426 400 in 1990 and 609 600 in 2010, respectively. [1] Statistics Information Centre of Ministry of Health. China Health Service Survey. Peking Union Medical College Press. [2] Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990-2010: fi ndings from the Global Burden of Disease Study 2010. Lancet, 2013, 381(9882):1987-2015. 100 Chapter 3 Cardiovascular Diseases (3) Stroke Mortality in 2011 [1] According to data from China Health Statistics Yearbook 2012, the mortality rate of stroke was 125.37 per 100 000 in 2011 in urban populations and 136.68 per 100 000 in rural populations. Based on the 6th Census data, 834 500 urban residents and 921 100 rural residents died from stroke in 2011 by estimation. Overall, the mortality rate was higher in rural than in urban population, and higher in men than in women (Figure 3-1-2). Men Women Total Mortality（1/100 000） 8UEDQ 5XUDO Figure 3-1-2 Stroke Mortality by Gender and Region (China: 2011) (4) Stroke Mortality Rate in Urban Population by Gender and Age in 2011 The mortality rate of stroke increased exponentially with age in urban population. Mortality rates were higher in men than in women across all age groups (Figure 3-1-3 and Table 3-1-1) 0DQ :RPDQ 0RUWDOLW\᷊᷉ aaaaaaaaaaaaaa $JH Figure 3-1-3 Stroke Mortality in Urban Population by Gender and Age (China: 2011) [1] China Health Statistics Yearbook 2002-2012. Peking Union Medical College Press. 101 Report on Cardiovascular Diseases in China (2013) Table 3-1-1 Stroke Mortality in Urban Population by Gender and Age (China: 2011) (per 100 000 ) 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- Men 1.20 2.19 4.73 9.89 23.68 49.51 80.42 123.49 204.57 362.00 685.67 1284.43 2167.34 3259.52 Women 0.84 1.07 1.36 4.11 8.33 17.11 28.19 49.79 107.29 210.58 459.56 935.57 1787.59 3076.25 (5) Stroke Mortality Rate in Rural Population by Gender and Age in 2011 The stroke mortality rate also increased exponentially with age in rural population. Mortality rates were higher in men than in women across all age groups (Figure 3-1-4). The overall mortality rate was higher in rural than in urban population (Table 3-1-2). 0DQ :RPDQ 0RUWDOLW\᷊᷉ aaaaaaaaaaaaaa $JH Figure 3-1-4 Stroke Mortality in Rural Population by Gender and Age (China: 2011) Table 3-1-2 Stroke Mortality in Rural Population by Gender and Age (China: 2011) (per 100 000) 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- Men 2.22 2.66 4.27 10.50 28.54 49.03 79.61 164.49 289.62 475.50 868.46 1 618.24 3 290.04 6 031.32 Women 0.84 0.96 1.86 4.07 14.57 25.47 44.70 93.74 170.24 273.19 563.46 1 056.59 2 151.77 4 579.36 (6) Trends in Stroke Mortality from 2003 to 2011 [1] Overall, stroke mortality rate was higher in rural than in urban population from 2003 to 2011. Stroke mortality rates in 2009 increased by a ratio of 1.41 in urban and 1.44 in rural populations, respectively when compared to the rates in 2006. However, stroke mortality has been decreasing since 2009 and this decrease [1] China Health Statistics Yearbook 2002-2012. Peking Union Medical College Press. 102 Chapter 3 Cardiovascular Diseases was relatively more signifi cant in rural population (Figure 3-1-5). 8UEDQ 5XUDO 0RUWDOLW\᷊᷉ Figure 3-1-5 Trends in Stroke Mortality (China: 2003-2011) 3.1.2 Stroke Incidence 3.1.2.1 Comparison of Stroke Incidence in Different Regions [1] All studies of stroke incidence in China between 1980 and 2010 were systematically reviewed, 9 eligible studies with data on the incidence of stroke in 32 of 34 provincial regions of China (with Hong Kong and Macao as exceptions) were included in the fi nal analysis. Nine provincial regions (Heilongjiang, Tibet, Jilin, Liaoning, Xinjiang, Hebei, Inner Mongolia, Beijing, and Ningxia) met the criteria for a region of high stroke incidence and constitute a stroke belt in China. The incidence of stroke in the stroke belt (236.2 per 100 000 population) was signifi cantly higher than the regions outside the belt (109.7 per 100 000 ). 3.1.2.2 Stroke incidence in Fuxin County, Liaoning Province A population-based sample of 38 949 rural Chinese adults, aged ≥ 35 years and free from stroke at baseline, were followed from 2004-2006 to 2010 in Fuxin County, Liaoning Province [2] . The study demonstrated that the age-adjusted incidence of fi rst stroke per 100 000 person-years was 601.9 (95% CI: 528.3-675.5). The age-adjusted incidence rate was higher in men (775.9 per 100 000 person-years) than in women (435.5 per 100 000 person-years). Among 858 stroke events that occurred during the follow- up, 56.3% were ischemic strokes, 40.6% were hemorrhagic strokes, and 3.1% were undetermined strokes. [1] Xu G, Ma M, Liu X, Hankey GJ. Is there a stroke belt in China and why? Stroke, 2013, 44(7): 1775-1783. [2] Sun Z, Zheng L, Detrano R, et al. An epidemiological survey of stroke among rural Chinese adults results from the Liaoning province. Int J Stroke, 2013, 8(8): 701-706. 103 Report on Cardiovascular Diseases in China (2013) Hypertension and dyslipidemia were the main risk factors. Table 3-1-3 Age-adjusted Incidence (per 100 000) of All Strokes and Stroke Subtypes IS Incidence ICH Incidence SAH Incidence US Incidence Total Incidence Gender Case (95% CI) Case (95% CI) Case (95% CI) Case (95% CI) Case (95% CI) 454.1 299.5 20.0 775.9 Men 314 209 2 2.3(0-6.7) 15 540 (362.8-545.4) (224.8-374.1) (3.1-37.4) (656.5-895.3) 231.6 184.9 14.1 435.6 Women 169 133 4 5.0(0-13.5) 12 318 (168.3-294.9) (127.9-141.9) (1.4-28.2) (348.3-522.9) 340.3 299.8 17.0 601.9 Total 483 342 6 3.7(0-8.8) 27 858 (285.1-395.6) (248.9-350.7) (5.8-28.2) (528.3-675.5) CI, confi dence interval; IS, ischemic stroke; ICH, intracerebral hemorrhage; SAH, sub-arachnoid hemorrhage; US, undetermined stroke 3.1.3 Clinical Characteristics of Hospitalized Patients with Stroke in China 3.1.3.1 China National Stroke Registry (1) Overall Characteristics [1] China National Stroke Registry (CNSR) conducted by Beijing Tiantan Hospital was a prospective registry study funded by the 11th Five-Year National Science & Technology Support Program. Between September 2007 and August 2008, the CNSR recruited 22 216 patients with diagnoses of acute cerebrovascular events from 132 hospitals covering 31 provinces and municipalities (including Hong Kong) in China, and monitored their baseline characteristics, medical management and functional outcomes. These patients were 63.8 years of age on average, and 39% were females. Percentage breakdown was as follows: Ischemic stroke (66.4%), intracerebral hemorrhage (23.4%), subarachnoid hemorrhage (3.4%), and transient ischemic attack (6.3%). (2) Intracerebral Hemorrhage (ICH) CNSR followed 3 255 ICH patients aged≥ 18 years for 1 year. [2] Table 3-1-4 shows the cumulative mortality and functional outcome. Table 3-1-4 Intracerebral Hemorrhage Cumulative Mortality and Outcome (%) Period Cumulative Mortality (%) Poor Outcome*(%) 3-month 20.0 49.1 6-month 22.5 47.1 12-month 26.1 46.0 *, Poor outcome was defi ned as a revised Rankin score (mRS) between 3 and 6. [1] Wang Y, Cui L, Ji X, et al. The China National Stroke Registry for patients with acute cerebrovascular events: design, rationale, and baseline patient characteristics. Int J Stroke, 2011, 6(4): 355-361. [2] Wang WJ, Lu JJ, Wang YJ, et al. Clinical characteristics, management, and functional outcomes in Chinese patients within the first year after intracerebral hemorrhage: Analysis from China National Stroke Registry. CNS neuroscience & therapeutics, 2012,18(9): 773-780. 104 Chapter 3 Cardiovascular Diseases (3) Subarachnoid Hemorrhage (SAH) There were 651 patients with spontaneous subarachnoid hemorrhage in CNSR study. The mortality rate breakdown is shown in Table 3-1-5. Aneurysmal rupture was the most common cause of SAH (Figure 3-1-6) [1] . Table 3-1-5 Spontaneous Subarachnoid Hemorrhage Cumulative Mortality Non-aneurysmal SAH Period Aneurysmal SAH (%) and Uncertain Etiology (%) 28-day 16.9 10.2 3-month 21.2 12.2 6-month 23.6 12.9 12-month 24.6 13.6 SAH, subarachnoid hemorrhage $QHXU\VPDO5XSWXUH 3HULPHVHQFHSKDOLF1RQDQHXU\VPDO6$+ &DYHUQRXV+HPDQJLRPD $UWHULRYHQRXV0DOIRUPDWLRQ +\SHUWHQVLYH 0R\DPR\D'LVHDVH 8QNQRZQ Figure 3-1-6 Percentage Breakdown of Spontaneous Subarachnoid Hemorrhage Etiologies (%) (4) Effect of Age on Ischemic Stroke CNSR categorized patients into four age groups: ≤ 45, 46-65, 66-79, and≥80 years and showed that the rates of disability, mortality and recurrent stroke all increase with age [2] (Figure 3-1-7). [1] Bian LH, Liu YF, Nichols LT, et al. Epidemiology of subarachnoid hemorrhage, patterns of management, and outcomes in China: A hospital-based multicenter prospective study. CNS neuroscience & therapeutics, 2012,18(11): 895-902. [2] Deng YX, Wang YL, Gao BQ, et al. Age differences in clinical characteristics, health care, and outome after ischemic stroke in China.CNS neuroscience and therapeutics, 2012,18(10):819-826. 105 Report on Cardiovascular Diseases in China (2013) ≤45 46.65 66.79 ≥80 &XPXODWLYH,QFLGHQFH5DWHVLQPRQWK˄ˁ˅ Disability Death Recurrent Figure 3-1-7 12-month Cumulative Rates in Patients with Ischemic Stroke by Age and Outcome There are signifi cant differences in terms of demographics and socioeconomic characteristics between the very elderly (>80 years) and the elderly (66-80 years). Hypertension is the primary risk factor in both groups. Non-metabolic risk factors, such as atrial fi brillation, are more prominent in the very elderly (P=0.0002). However, metabolic risk factors (such as obesity, diabetes, and dyslipidemia) and behavioral risk factors (such as smoking and heavy drinking) play a lesser role in the very elderly population (P<0.01). Table 3-1- 6 shows the percentage breakdown of ischemic stroke etiologies for both the very elderly and the elderly. The most common cause was large-artery atherosclerosis (60.9%), followed by cardioembolism (19%) and small-vessel disease (17.3%), and rarely other cause or unknown etiologies. In the elderly population, the most common subtype was also large-artery atherosclerosis. However, the proportion of small-vessel disease was higher than cardioembolism. There were signifi cant differences in TOAST (Trial of Org 10172 in Acute Stroke Treatment) type between the very elderly and elderly (Table 3-1-7) [1] . Table 3-1-6 Percentage Breakdown of Ischemic Stroke Risk Factors between the Very Elderly and the Elderly Risk Factors Very Elderly (n=858),% Elderly (n=3818),% Hypertension 57.46 60.29 * Obesity 29.68 35.03 ** Coronary Heart Disease 21.10 16.76 *** Diabetes Mellitus 13.75 21.48 [1] Ma AJ, Dong Z, Li G. Prevalence rates and risk factors of stroke among 50-79 years old people in Beijing. Epidemiology, China. 2012, 33 (7): 645-648. 106 Chapter 3 Cardiovascular Diseases Table 3-1-6 Percentage Breakdown of Ischemic Stroke Risk Factors between the Very Elderly and the Elderly Continue Risk Factors Very Elderly (n=858),% Elderly (n=3818),% *** Atrial Fibrillation 12.35 8.30 *** Smoking 10.51 20.26 *** Family History of Stroke 3.86 7.91 *** Hyperlipidemia 3.38 7.52 *** Heavy Drinking 2.68 5.66 Valvular Heart Disease 1.30 2.05 Peripheral Vascular Disease 0.58 0.55 Notes：compared with the elderly group, *P<0.05，**P<0.01，***P<0.001 Table 3-1-7 TOAST Type between the Very Elderly and the Elderly Type Very elderly (n=585), % Elderly (n=2767), % *** Large-artery Atherosclerosis 60.85 62.27 *** Small-vessel Disease 17.26 23.85 *** Cardioembolism 18.97 10.12 *** Other Etiology 1.03 1.30 *** Unknown Etiology 1.88 2.46 Notes：compared with the elderly group, ***P<0.001 (5) Effect of Complications on Ischemic Stroke CNSR showed that six medical complications (pneumonia, pulmonary embolism, deep vein thrombosis, urinary tract infection, gastrointestinal bleeding, and decubitus ulcer) strongly increased the death risk of patients with ischemic stroke (Table 3-1-8). [1] Table 3-1-8 Effect of Complications on Mortality of Patients with Ischemic Stroke Any Complication Without Complication Variables Total (n=11 560) P values (n=1 826, %) (n=9 734, %) Baseline NIHSS Median (IQR) 7.5(2.0-10.0) 14.2(5.0-19.0) 6.2(2.0-8.0) <0.0001 Death During Hospital 352 (3.05) 227 (12.43) 125 (1.28) <0.0001 Death at 3-month 1 037 (8.97) 523 (28.64) 514 (5.28) <0.0001 Death at 6-month 1 324 (11.45) 639 (34.99) 685 (7.04) <0.0001 Death at 12-month 1 664 (14.39) 765 (41.89) 899 (9.24) <0.0001 NIHSS: National Institutes of Health Stroke Scale. IQR: interquartile range. [1] Wang PL, Zhao XQ, Yang ZH, et al. Effect of in-hospital medical complications on case fatality post-acute ischemia stroke: Data from the China National Stroke Registry. Chinese Medical Journal, 2012, 125(14): 2449-2454. 107 Report on Cardiovascular Diseases in China (2013) 3.1.3.2 Smoking as a Risk Factor for Stroke in Chinese Men A multicenter prospective cohort study, conducted by Chinese University of Hong Kong, enrolled 26 607 mainland participants ≥ 35 years with no previous stroke between 1986 and 2000. After an average of 9.5 years of follow-up, 1 108 participants developed stroke. A signifi cantly increased risk for all types of strokes and ischemic stroke was observed among men who smoked >15 cigarettes/day and men who had smoked for >25 years (Table 3-1-9). The rate of smoking cessation was very low among Chinese men (7.2%) and women (1.5%). Smoking cessation does not reduce the risk of hemorrhagic stroke, but may reduce the risk of ischemic stroke. [1] Table 3-1-9 Incidence and Hazard Ratio (HR) of Stroke Based on the Status, Amount and Duration of Smoking among Chinese Men, Using Cox’s Proportional Hazards Models. All Strokes Ischemic Stroke Hemorrhagic Stroke No. of Crude b No. of Crude b No. of Crude b a HR(95%CI) a HR (95%CI) a HR (95%CI) Cases Rate Cases Rate Cases Rate Smoking Habit Never Smokers 229 5.9 1 137 3.5 1 85 2.2 1 Former - - - Smokers 68 10.2 1.35(1.00 1.81) 35 5.3 1.17(0.78 1.76) 32 4.8 1.77(1.14 2.73) Current - - - Smokers 305 5.4 1.39(1.15 1.67) 183 3.2 1.49(1.17 1.90) 118 2.1 1.29(0.95 1.76) Cigarettes Per Day ≤15 132 5.2 1.20(0.96-1.51) 75 2.9 1.14(0.85-1.53) 55 2.2 1.36(0.95-1.95) >15 173 5.5 1.61(1.29-2.01) 108 3.5 1.99(1.50-2.64) 63 2.0 1.22(0.85-1.76) Duration of Smoking in Yearsc ≤25 81 2.4 1.01(0.76-1.34) 49 1.5 1.00(0.70-1.43) 32 1.0 1.11(0.71-1.75) >25 224 9.5 1.57(1.28-1.92) 134 5.7 1.77(1.36-2.29) 86 3.6 1.37(0.98-1.90) Time Since Smoking Cessation in Yearsc <20 27 7.7 1.08(0.72-1.64) 15 4.3 0.86(0.49-1.51) 12 3.4 1.59(0.86-2.92) ≥20 41 13.0 0.86(0.60-1.22) 20 6.4 0.65(0.39-1.08) 20 6.4 1.27(0.76-2.10) CI, confi dence interval a: Crude incidence rate (per 1000 person-years). b: Adjusted for age (years), study center, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption, systolic blood pressure, years of education and treatment status. c: Adjusted for age (years), study center, history of heart disease or diabetes, body mass index, alcohol drinking habits, alcohol consumption, systolic blood pressure, years of education, treatment status, number of cigarettes smoked per day and age at smoking initiation, using current smokers as the reference group. [1] Tse LA, Fang XH, Wang WZ, et al. Incidence of ischemic and hemorrhagic stroke and the association with smoking and smoking cessation: A 10-year multicentre prospective study in China. Public Health, 2012, 126(11):960-966. 108 Chapter 3 Cardiovascular Diseases 3.1.4 Clinical Trials 3.1.4.1 Antiplatelet Therapy The Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) study demonstrated that the combination of clopidogrel and aspirin was superior to aspirin alone for reducing the risk of stroke in the fi rst 90 days and did not increase the risk of hemorrhage among patients with transient ischemic attack (TIA) or minor stroke within 24 hours after the onset of symptoms [1] . The study was conducted at 114 centers in China. 5 170 patients within 24 hours after the onset of minor ischemic stroke or high-risk TIA were randomly assigned to combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300 mg, followed by 75 mg per day for 90 days, plus aspirin at a dose of 75 mg per day for the fi rst 21 days) or to placebo plus aspirin (75 mg per day for 90 days). All participants received open-label aspirin at a clinician-determined dose of 75 to 300 mg on the fi rst day. The primary outcome was stroke (ischemic or hemorrhagic) at 90-day follow-up. Treatment differences were assessed with the use of a Cox proportional-hazards model, with study center as a random effect. Stroke occurred in 8.2% of patients in the clopidogrel-aspirin group, a 32% decrease as compared with 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confi dence interval, 0.57 to 0.81; P<0.001). Moderate or severe hemorrhage occurred in seven patients (0.3%) in the clopidogrel-aspirin group and in eight (0.3%) in the aspirin group (P=0.73); the rate of hemorrhagic stroke was 0.3% in each group. 3.1.4.2 Antihypertensive Therapy The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) study demonstrated that blood pressure reduction with antihypertensive medications could not reduce the likelihood of death and major disability at day 14 or hospital discharge. [2] 4 071 patients with ischemic stroke that had elevated systolic blood pressured but did not receive thrombolysis were recruited from 26 hospitals across China with 48 hours of stroke onset. Patients were randomly assigned to receive antihypertensive treatment (n = 2 038) or to discontinue all antihypertensive medications during hospitalization (n = 2 033). The study showed that mean systolic blood pressure was reduced from 166.7 mmHg to 144.7 mmHg in the antihypertensive treatment group and from 165.6 mmHg to 152.9 mmHg in the control group within 24 hours after randomization. Mean systolic blood pressure was 137.3 mmHg in the antihypertensive treatment group and 146.5 mmHg in the control group at day 7 after randomization. The primary outcome did not differ between the two groups (683 events in antihypertensive treatment group vs 681 events in control group; odds ratio, 1.00 (95% CI: 0.88 to 1.14; P =0 .98) at day 14 or hospital discharge. The secondary composite outcome of death and major disability at 3-month post treatment follow-up also did not differ signifi cantly between the two groups (500 events in antihypertensive treatment group vs 502 events in control group ) . [1] Wang YJ, Wang YL, Zhao XQ, et al.Clopidogrel with aspirin in acute minor stroke or transient ischemic attach. N Engl J Med, 2013, 369(1): 11-19. [2] He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: The CATIS randomized clinical trial. JAMA, 2014.311(5):479-489. 109 Report on Cardiovascular Diseases in China (2013) 3.2 Coronary Heart Disease (CHD) 3.2.1 Epidemiological Studies of Coronary Heart Disease 3.2.1.1 Mortality and Trends [1] (1) Coronary Heart Disease Mortality in 2011 According to data from the China Health Statistics Yearbook 2012, coronary heart disease mortality in 2011 was 95.97 per 100 000 in the urban and 75.72 per 100 000 in the rural population, respectively; both showed increases compared to the mortality rates in 2010 (urban: 86.34 per 100 000 ; rural: 69.24 per 100 000 ). Overall, coronary heart disease mortality was higher in the urban than in the rural population, and higher in males than in females (Table 3-2-1). 0DOHV)HPDOHV7RWDO 0RUWDOLW\˄ 8UEDQ5XUDO Figure 3-2-1 Coronary Heart Disease Mortality in Urban and Rural Population by Gender (China: 2011) Table 3-2-1 Coronary Heart Disease Mortality (1/100 000) in Urban and Rural Populations by Gender (China: 2011) Urban Rural Total Male Female Total Male Female AMI 47.36 51.87 42.78 48.53 52.73 44.15 Other CHD 48.61 47.19 50.04 27.19 26.57 27.84 Total CHD 95.97 99.06 92.82 75.72 79.30 71.99 AMI, acute myocardial infarction; CHD, coronary heart disease. (2) Coronary Heart Disease and Acute Myocardial Infarction Mortality Trends between 2002 and 2011 The mortality rates of coronary heart disease and acute myocardial infarction trended upwards from 2002 to 2011, higher rates in the urban population than in the rural population. Since 2005, acute myocardial infarction mortality in the rural population increased rapidly. From 2009-2011, acute myocardial infarction mortality in rural areas exceeded that of urban areas. (Figure 3-2-2, Figure 3-2-3) [1] China Health Statistics Yearbook 2012. Ministry of Health of the PRC. Peking Union Medical College Press 110 Chapter 3 Cardiovascular Diseases 8UEDQ5XUDO Mortality （1/100 000) Mortality （1/100 ˄ Figure 3-2-2 Coronary Heart Disease Mortality Trends (China: 2002-2011) 8UEDQ5XUDO Mortality （1/100 000) Mortality （1/100 ˄ Figure 3-2-3 Acute Myocardial Infarction Mortality Trends (China: 2002-2011) (3) Age Specifi c Death Rates of Acute Myocardial Infarction The acute myocardial infarction mortality increased exponentially with age since 40 years old. This held true for every year between the years of 2002 and 2011, regardless of location (i.e, rural/urban) or sex (Figures 3-2-4 to Figure3-2-7). 111 Report on Cardiovascular Diseases in China (2013) Mortality （ 1/100 000) Figure 3-2-4 Acute Myocardial Infarction Mortality Trends for Men in Urban Areas by Age (China: 2002-2011) Mortality （ 1/100 000) Figure 3-2-4 Acute Myocardial Infarction Mortality Trends for Women in Urban Areas by Age (China: 2002-2011) 112 Chapter 3 Cardiovascular Diseases Mortality （ 1/100 000) Figure 3-2-6 Acute Myocardial Infarction Mortality Trends for Men in Rural Areas by Age (China: 2002-2011) Mortality （ 1/100 000) Figure 3-2-7 Acute Myocardial Infarction Mortality Trends for Women in Rural Areas by Age (China: 2002-2011) 113 Report on Cardiovascular Diseases in China (2013) 3.2.1.2 Coronary Heart Disease Prevalence [1] Based on the data from the Fourth Family Health Survey in 2008 in China Health Services Survey, the overall prevalence of ischemic heart disease was 7.7 ‰, 15.9 ‰ in urban areas and 4.8 ‰ in rural areas. Compared with the data of the 3rd Family Health Survey in 2003 (4.6 ‰, 12.4 ‰ for urban residents and 2.0 ‰ for rural residents), the prevalence of ischemic heart disease increased considerably. 3.2.1.3 The Incidence and Trends of Acute Coronary Events in Beijing Residents Over the Age of 25 From 2007 to 2009 [2] By incorporating data from the Hospital Discharge Information System in Beijing Public Health Information Center and the Cause of Death Register System in Beijing Center for Diseases Prevention and Control, the incidence of acute coronary events among permanent residents of Beijing more than 25 years of age from 2007 to 2009 was analyzed. A total of 68 390 acute coronary events were identifi ed. The age- adjusted incidence was 166.4 per 100 000 overall, 218.5 per 100 000 in males and 115.2 per 100 000 in females. The age-adjusted incidence was 158.4, 169.4, and 171.2 per 100 000 in 2007, 2008, and 2009, respectively. The age-adjusted incidence increased by 8.1% in 2009 compared with 2007, the increase in males (11.1%) was greater than in females (2.5%) . The most signifi cant change was in the group of males aged 35-44 years, in which an increase of 30.3% was noted. The incidence of acute coronary events increased with age for all years between 2007 and 2009, especially in men and young adults. 3.2.1.4 Status and Trends of Ischemic Cardiovascular Disease Mortality [3] The mortality data from National Disease Surveillance System in 2004 and 2008 (161 disease surveillance points, 64 in urban and 97 in rural areas) demonstrated that mortality of ischemic cardiovascular disease and AMI in 2008 was 71 per 100 000 and 45.7 per 100 000 , respectively. The standardized mortality rates were lower in 2008 than in 2004. The mortality rates of ischemic cardiovascular disease decreased in 40-59 and 60-79 age groups. However, the overall mortality in individuals more than 80 years of age increased by 4.9 per 100 000 from 2004 to 2008, mainly due to the high mortality of ischemic cardiovascular disease in rural population. 3.2.1.5 Studies on Coronary Heart Disease Risk Factors (1) Body Mass Index (BMI) and Mortality in Men [4] A prospective cohort study of 142 214 men (40-79 years with no major disease history at baseline) were followed for more than 15 years (1990-2006). The study showed that the association between BMI and all- [1] Ministry of Health Statistics Center. 2008 China Health Services Survey – 4th Family Health Survey. 2009. [2] Sun JY, Liu J, Xie XQ, et al. Acute coronary events incidence in Beijing residents≥25 years of age from 2007 to 2009. Chinese Journal of Cardiology, 2012, 40(3):1 94-198. [3] Zhang XF, Hu DY, Ding RJ, et al. Status and trends of cardio-cerebrovascular disease mortality. Chinese Journal of Cardiology, 2012, 40(3): 179-187. [4] Chen Z, Yang G, Offer A, et al. Body mass index and mortality in China: a 15-year prospective study of 220 000 men. International Journal of Epidemiology, 2012, 41(2): 472-481. 114 Chapter 3 Cardiovascular Diseases cause mortality was U-shaped with the lowest mortality at BMI 22.5-25 kg/m2. In the left lower portion of the U-curve, a BMI decrease of 5 kg/m2 was associated with a 14% increase in mortality (HR 0.86, 95% CI 0.82-0.91); in the right upper portion of the U-curve, a BMI increase of 5 kg/m2 was associated with a 27% increase in mortality (HR 1.27, 95% CI 1.15-1.40). (2) Infl uence of Dietary Patterns on the Risk of Acute Myocardial Infarction[1] INTER-HEART China Study, a case-control study, enrolled 1 312 cases of fi rst AMI and 2 235 control subjects who did not have previous angina, diabetes mellitus, hypertension or stroke. Dietary patterns were measured with a 19-item food frequency questionnaire. Multivariable analysis showed that higher score in terms of vitamin and microelement (i.e., high intake of vegetables, fruits and tofu) was associated with reduced AMI risk. The highest quartile score of fat and protein (high in animal foods and fried foods) was associated with increased AMI risk. (Table 3-2-2) Table 3-2-2 Odds Ratio (95% CI) for Acute Myocardial Infarction for Different Dietary Pattern Scores Dietary Patterns Scores Vitamin and Microelement Dietary Scores Fat and Protein Dietary Scores Quartile 1 1.00 1.00 Quartile 2 0.81 (0.66-1.00) 0.96 (0.78-1.19) Quartile 3 0.67 (0.54-0.82) 0.94 (0.75-1.17) Quartile 4 0.70 (0.56-0.88) 1.36 (1.09-1.69) Notes：logistic model adjusted for region, sex, age, education, household income, marital status, smoking, alcohol, body mass index, waist to hip ratio, physical activity status and psychosocial factors. (3) Physical Activity Levels, Sport Activities, and Risk of Acute Myocardial Infarction [2] INTER-HEART China Study, a hospital-based case-control study, evaluated the amount of physical activity at work and during leisure time in relation to acute myocardial infarction (AMI) in Chinese population. The case group included 2 909 individuals with fi rst AMI. The controls (n = 2 947) were matched to the cases on age and gender. Compared to a sedentary lifestyle, individuals who perform strenuous physical activities during leisure-time had lower risk of AMI. The odds ratios (ORs) of leisure-time physical activity for strenuous exercise compared to mainly sedentary was 0.74 (95% confi dence interval [CI]: 0.61- 0.90) and for moderate exercise it was 0.96 (95% CI: 0.85-1.08). In addition, there was a reverse relationship between exercise duration per week and AMI incidence (Table 3-2-3). AMI risk of work-related heavy physical activity was higher compared to mainly sedentary with an OR of 1.44 (95% CI: 1.06-1.94); for climbing and lifting it was 0.90 (95%CI: 0.75-1.07). [1] Guo J, Li W, Wang Y, et al. Infl uence of dietary patterns on the risk of acute myocardial infarction in China population: the INTERHEART China study. Chinese Medical Journal, 2013, 126(3): 464-470. [2] Cheng X, Li W, Guo J, et al. Physical activity levels, sport activities, and risk of acute myocardial infarction: Results of the INTERHEART study in China. Angiology, 2014, 65(2): 113-121. 115 Report on Cardiovascular Diseases in China (2013) Table 3-2-3 Exercise Duration and AMI Risk (OR) Cases (%) Control (%) Exercise Duration (Hours Per Week) OR(95% CI)* (n=2 909) (n=2 947) <1 81.2 81.2 1.00 1-3 4.6 4.7 1.01 (0.76-1.10) 4-6 3.4 5.1 0.65 (0.49-0.88) 7 6.7 9.0 0.70 (0.56-0.87) Notes：logistic model adjusted for sex, age, body mass index, waist to hip ratio, hypertension, diabetes, stroke, smoking, alcohol, education, household income, marital status, psychosocial factors, dietary factors and residential region. 3.2.2 Intervention Treatment for Coronary Heart Disease 3.2.2.1 A New Generation of Biodegradable Polymer-coated Sirolimus-eluting Stents (EXCEL Stents) for Treatment of Coronary Artery Disease: 5-year Clinical Outcomes from the CREAT Study [1] The multicenter CREATE study enrolled 2 077 patients treated with EXCEL stents to evaluate the fi ve- year safety and effi cacy of the EXCEL stents with six months of dual antiplatelet therapy. In this study, more than 80% of the patients took antiplatelet therapy for six months, and then aspirin without clopidogrel. Up until December 2012, Clinical follow-up was completed in 1,982 patients (95.4%) at fi ve-year follow- up. The rates of defi nite or probable stent thrombosis (ST) at fi ve years and defi nite ST from one to fi ve years were 1.1% and 0.3%, respectively. The rates of major adverse cardiac events, cardiac death, non-fatal myocardial infarction (MI) and target lesion revascularization at fi ve-year were 7.4%, 3.0%, 1.5%, and 3.7%, respectively. Prior history of heart failure and myocardial infarction were independent predictors of stent thrombosis. Landmark analysis of a propensity score matched patient cohort showed that patients with or without dual antiplatelet treatment after six months had similar clinical outcomes. This study demonstrated satisfactory long-term safety and effi cacy profi les for EXCEL stents with six months dual antiplatelet therapy. 3.2.2.2 Inpatient Prognosis and 3-year Outcomes of STEMI (ST Elevation Myocardial Infarction) in Beijing [2] This multicenter study enrolled 808 STEMI patients within 24 hours of symptom onset between Jan. 1, 2006 and Dec. 31, 2006 at 19 hospitals in Beijing. According to the treatment strategy, patients were divided into three groups: conservative therapy group (n=184), thrombolytic therapy group (n=106), and emergent PCI group (n=518). Patients were followed up for 3 years. Patients’ clinical characteristics and the effect of different treatment strategies on the 3-year follow-up prognosis were shown in Table 3-2-4 and Table 3-2-5. The result showed that the baseline age of patients in the conservative treatment group (64.5 years) [1] Han YL, Zhang L, Yang LX, et al. A new generation of biodegradable polymer-coated sirolimus-eluting stents for the treatment of coronary artery disease: fi nal 5-year clinical outcomes from the CREATE study. Euro Intervention. 2012;22;8(7):815-822. [2] Yang JG, Pi L, Song L, et al. Inpatient prognosis and 3-year follow-up outcome of STEMI (ST elevation myocardial infarction) in Beijing. Chinese Journal of Cardiology, 2013, 41(6): 474-479. 116 Chapter 3 Cardiovascular Diseases was signifi cantly higher than those in the thrombolytic therapy group (57.9 years) and in the PCI group (60.4 years). The median time from symptom onset to hospital in the conservative treatment group (207 min) was also signifi cantly longer than those in the thrombolytic therapy group (130 min) and in the PCI group (130 min). Emergency department admission was signifi cantly higher in the PCI group than the other two groups. Number of patients with health insurance coverage in the PCI group was signifi cantly higher than the other two groups. PCI was performed less frequently than thrombolytic therapy [66.6% (345/518) vs 80.2% (85/106), P=0.02] during off-hours and more frequently performed in tertiary hospitals than in secondary hospitals (66.8% vs 52.6%, P<0.01). The inpatient mortality and cardiovascular mortality 3-year post-discharge were signifi cantly higher in the conservative treatment group (9.2% and 9.4%) than in the PCI group (3.5% and 4.5%) and the thrombolytic therapy group (6.6% and 2.3%). Patients in the PCI group had the highest medication compliance level at 3-year. Table 3-2-4 Baseline Characteristics by Treatment [Num. of Cases (%)] Conservative Thrombolytic Emergent PCI Variables treatment P value (n=184) （n=106） （n=518） * * Age (years) 64.5±13.5 57.9±11.0 60.4±12.3 <0.01 ** * >70 68(37.0) 16(15.1) 124(23.9) <0.01 ** * Male 124(68.9) 85(80.9) 404(78.9) 0.01 Conditions at Admission Time from Symptom Onset to Hospital * * 207(106 407） 130(70 260) 130(70 270) <0.01 Arrival [min, M(Q1,Q3)] * * Hospital Arrival Within 6 Hours 126(68.5) 89(84.0) 428(82.6) <0.01 EMS Called 46(25.0) 29(27.3) 184(35.5) 0.02 Hospital Level <0.01 *** Secondary 46(29.8) 27(17.5) 81(52.6) *** Tertiary 138(21.1) 79(12.1) 437(66.8) *** Arriving Hospital at Off-Hours 129(70.1) 85(80.2) 345(66.6) 0.02 ** **** Patients with Medical Insurance 119(64.7) 64(60.4) 396(76.4) <0.01 Notes：compared to the conservative group, * P<0.01,** P<0.05; compared to the thrombolytic group, *** P<0.05, **** P<0.01. 117 Report on Cardiovascular Diseases in China (2013) Table 3-2-5 Inpatient and 3-year Mortality by Treatment [Num. of cases (%)] Treatment Variables Total Conservative Thrombolytic Emergent PCI P value Inpatient Events Cases 184 106 518 808 Death 17(9.2) 7(6.6) 18(3.5) <0.01 42(5.2) 3-year Follow-up Events Cases 159 86 446 691 All-cause Death 20(12.6) 4(4.7) 35(7.8) <0.01 59(8.5) Cardiovascular Death 15(9.4) 2(2.3) 20(4.5) <0.01 37(5.4) The study suggested that socioeconomic factors such as medical insurance coverage and hospital level, age, time of arrival at hospital, time from symptom onset to hospital arrival, etc. affected physicians’ decision to provide reperfusion therapy for STEMI. The study also found that patients receiving emergent PCI had the highest compliance for secondary prevention medication; they have lower cardiovascular mortality compared to the conservative treatment group. 3.2.2.3 Secondary Prevention of Coronary Heart Disease Cholesterol control in coronary heart disease in Beijing: a survey in the cardiology outpatient setting. [1] In this study, 903 patients with CHD were enrolled from 4 tertiary hospitals and 4 two-tier hospitals in Beijing between September 2014 and December 2014. All participants were instructed to fi nish a questionnaire and blood lipid examination to analyze the LDL-C control rate and related factors. Effective questionnaire was obtained from 876 patients [male 619 (70.7%), female 257 (29.3%), 65 ± 11 years of age]. The overall LDL-C control rate was 36.9% (262/709), 13.5% (27/173) in very high-risk CHD patients. Patients treated in tertiary hospitals had a higher LDL-C control rate than patients treated in two-tier hospitals (31.3% vs 43.7%). In addition, the control rate was lower in female patients than in male patients (27.1% vs 41.3%) and lower in diabetic patients than in non-diabetic patients (13.5% vs 44.7%), and signifi cantly lower in patients less than 60 years old and patients over 80 years old than that in 60-70 years old patients and 70 - 80 years old patients. LDL-C control rate was not affected by the history of hypertension, percutaneous coronary intervention or coronary artery bypass grafting, smoking, lipid examination frequency, knowledge on goal level of LDL-C, diet control and regularly physical exercises. There were 18.2% (129/709) patients not taking statins or not aware if they were taking statin or not. The main reason for not taking statin was statin [1] Ding RJ, Ma CS, Chen H, et al. Cholesterol control in coronary heart disease in Beijing – A survey in the cardiology outpatient setting. Chinese Journal of Cardiology, 2013, 41(3): 251-255. 118 Chapter 3 Cardiovascular Diseases was no prescribed by doctors (47.9%), followed by withdrawal by patients due to various reasons (27.1%). This study suggested that the LDL-C control rate was relatively low in patients with CHD in Beijing; there was still lack of knowledge regarding cholesterol among physicians and patients; health education needed to be reinforced to improve treatment compliance among CHD patients. The LDL-C control rates in different CHD patients were shown in Table 3-2-6. Factors affecting LDL-C control were shown in Table 3-2-7. Table 3-2-6 LDL-C Control Rates by Patient Population [Num. of Cases (%)] Variables LDL-C not controlled (n=447) LDL-C controlled (n=262) P value Risk Stratifi cation <0.01 Very High Risk 173(86.5) 27(13.5) High Risk 274(53.8) 235(46.1) Hospital Level <0.01 Two-tier 265(68.7) 121(31.3) Tertiary 182(56.3) 141(43.7) Gender <0.01 Male 285(58.6) 201(41.3) Female 161(72.9) 60(27.1) Age (years) <0.5 34- 156(67.5) 75(32.5) 60- 103(55.1) 84(44.9) 70- 147(65.0) 79(35.0) 80- 39(70.9) 16(29.1) Diabetes <0.01 No 244(55.3) 197(44.7) Yes 173(86.5) 27(13.5) Unaware 14(45.2) 17(54.8) Impaired Glucose Tolerance 16(43.2) 21(56.8) Table 3-2-7 Logistic Analysis of Factors Affecting LDL-C Control Variables β χ2 Odds Ratio 95% CI P Risk Stratifi cation a 1.670 51.695 5.312 3.369-8.734 <0.01 Hospital Level b -0.452 7.157 0.636 0.457-0.886 <0.01 Gender c 0.504 6.800 1.656 1.133-2.419 <0.01 Age (years) 8.452 <0.05 60-69 d -0.082 0.054 0.921 0.461-1.839 >0.05 70-79 d 0.532 2.226 1.702 0.846-3.421 >0.05 ≥80 0.133 0.144 1.143 0.574-2.273 >0.05 Note: a 1=high risk, 2=very high risk; b 1= two-tier level, 2=tertiary level; c1=male, 2=female; d compared to patients <60 years 119 Report on Cardiovascular Diseases in China (2013) 3.3 Arrhythmia 3.3.1 Pacemakers, Implantable Cardioverter-defi brillators (ICD) and Cardiac Resynchronization Therapy (CRT) The fi rst use of an artifi cial cardiac pacemaker in China was in 1962 in Shanghai.[1] Since then, pacemaker implant volume has been increasing annually, and the proportion of physiological pacemakers has also increased. [2, 3, 4, 5, 6] According to statistics from the Ministry of Health’s online enrollment system (reported at the Introduction to Cardiovascular Disease in China in March 2013; military hospitals not included), about 49 502 pacemakers were implanted in 2012 (this number is about 10% of the enrollment data), indicated a 15.2% increase compared with 2011. 42 986 pacemakers were implanted in 2011, an increase of 10.9% compared with 2010 (38 766) (Figure 3-3-1). According to the Sixth Population Census in 2010, 29 pacemakers were implanted per million people in 2010, 36 per million in 2011; and 35 per million in 2012, far below the numbers in Europe (951 implanted per million in 2010). Among the implanted pacemakers in 2011, 7 252 were replacements (16.87%), 15 588 were rate-responsive pacemakers (36.26%), and 1 756 were remote monitoring pacemakers (4.09%). The average age of patients with implanted pacemakers was 69.25 years, 22 108 patients (51.43%) were males. Among pacemakers implanted in 2012, the proportion of dual- chamber pacemakers was close to 60%. Provinces or cites with implantation numbers over 4 000 in 2012 were Zhejiang province and Shanghai city, over 3 000 were Beijing, Jiangsu province and Sichuan province, and over 2 000 were Guangdong, Shandong, Hubei, and Anhui provinces. There was only one hospital (Fu Wai Hospital) with annual implantation number more than 1 000 pacemakers, accounted for 2.7% of the national implantation volume. There were 53 hospitals with annual implantation number more than 200 pacemakers, accounted for 32.8% of the national volume. [1] Huo JQ, Fang ZP, Wang WN, et al. Experimental study and preliminary clinical application of two kinds of self-made pacemaker. Chinese Journal of Medicine, 1964, 50: 219-224. [2] Wang FZ, Hua W, Zhang S, et al. National survey on clinical application of peacemaker in 1998 and 1999. Chinese Journal of Cardiac Arrhythmias, 2001, 5(4): 229-230. [3] Wang FZ, Hua W, Zhang S, et al. National survey on clinical application of peacemaker in 2000 -2001. Chinese Journal of Cardiac Arrhythmias, 2003, 7(3): 189-191. [4] Wang FZ, Hua W, Zhang S, et al. National survey on clinical application of peacemaker in 2002-2005. Chinese Journal of Cardiac Arrhythmias, 2006, 10(6): 475-478. [5] Chen YH, Chen H, Wu Y, et al. Cardiac electrophysiology in China. Heart Rhythm, 2007,4(6):862. [6] Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defi brillators: Calendar year 2009 – A world society of arrhythmia’s project. Pacing Clin Electrophysiol, 2011, 34(8): 1013-1027. 120 Chapter 3 Cardiovascular Diseases Implantation Volume (10 000 units) ˄ Figure 3-3-1 Pacemaker Implantation Volume (China: 1995-2012) 666 $9EORFN 2WKHU Figure 3-3-2 Indications for Pacemaker Implantation (%, China: 2012) Statistical reports showed that in 2005 the proportion of dual-chamber pacemaker implants reached 51.5%. If uni-atrial pacemakers (AAI/R) and other physiologic pacemakers were included, the proportion is 52.9%, exceeding that of non-physiologic pacemakers. Among the indications for cardiac pacing in 2012, 50.5% were for the treatment of sick sinus syndrome (SSS) (23 995 cases), 38.7% for atrioventricular block (18 387 cases), and 10.8% for other causes (7 120 cases). See Figure 3-3-2. In 1996, the fi rst trans-jugular implantable cardioverter-defi brillator (ICD) placement was performed. A total of 285 such procedures have been recorded by 2001. 186 ICDs were implanted nationwide in 2005. From 2002 to 2005, ICD volumes have steadily increased. An analysis of the indications for ICD procedures at 31 domestic hospitals from January 2005 to December 2006 showed that 121 cases (85.2%) met the Class I indication for ICD implantation (secondary prevention) in 2002 ACC/AHA/NASPE guidelines. Only 15 121 Report on Cardiovascular Diseases in China (2013) cases (10.6%) fulfi lled the Class IIa indication for primary prevention[1] Subsequent analyses have shown that among 497 patients who met the Class I indication for ICD implantation, only 112 patients (22.5%) actually received ICDs. The remaining 77.5% of patients refused ICDs for various reasons. Follow-up for 11 ± 3 months showed that mortality rates was 1.8% among patients who received ICDs and 9.4% among those who did not receive ICDs. The incidence of sudden cardiac death was 6.7%. [2] By 2009, the total numbers of ICD implantation have reached to 1 316 (including military hospitals), 116 of which was for replacement, ICD volume was 116. Among them, 45 were uni-chamber ICDs, 19 were dual-chamber ICDs, and 36 were cardiac resynchronization therapy defi brillators (CRT-D). [3] The total ICD volume in 2011 was 1 228, with an increase of 19.6% compared with 1 027 cases in 2010. Among these, dual-chamber ICDs accounted for 14.7% (179). According to the 2010 Sixth Population Census, the ICD implantation volume in 2010 and 2011 was 1 per million, far below the numbers in Europe (158 per million). Average ages of ICD implantation was 59.33 years, 889 patients were male (72.4%). ICD used for secondary prevention accounted for 58.8% (722), and 41.2% for primary prevention (506). Among the implanted ICDs, 100 cases were used for replacement (8.14%), and 126 cases had remote monitoring function (10.26%). Figure 3-3-3. [4] Implantation Volume ˄ Figure 3-3-3 ICD Implantation Volumes by Year (China: 2000-2012) [1] Hua W, Zhang S, Niu HX, et al. Comparison study of defibrillator therapy for primary and secondary prevention of sudden cardiac death. Chinese Journal of Cardiac Arrhythmias, 2010, 14(1): 9-11. [2] Hua W, Niu H, Fan X, et al. Preventive effectiveness of implantable cardioverter defi brillator in reducing sudden cardiac death in the Chinese population: a multicenter trial of ICD therapy versus non-ICD therapy. J Cardiovasc Electrophysiol, 2012, 23 (Supp 1): S5-9. [3] Mond HG, Proclemer. The 11th world survey of cardiac pacing and implantable cardioverter-defi brillators: Calendar year 2009 – A world society of arrhythmia’s project Pacing Clin Electrophysiol, 2011, 34(8): 1013-1027. [4] Chen FR. Progress of China cardiac pacing therapy. China Continuing Medical Education, 2011, 11(3): 3-8. 122 Chapter 3 Cardiovascular Diseases Implantation Volume ˄ According to statistics from the Ministry of Health’s online enrollment system, about 1 553 ICDs were implanted in China in 2012, an increase of 23.5% compared with that in 2011 (1 228), and dual-chamber ICDs account for 33%. The number of total implants was 2 726 if CRT-D were included. This equivalents to a ratio of 2 implantations per million, much lower than that of European countries (158 per million in 2010). In 1999, China began to use biventricular pacing therapy to treat heart failure. From 2002 to 2007, the volume of CRT has increased by at least 30% every year. Based on responses from 193 hospitals in 2007, CRT implants totaled 541, including 59 CRT-Ds. 401 patients were male (74.12%) aged 20-90 (60 ± 12) years. [1] A total of 1 822 CRTs were performed in 2011, 19.3% higher than 2010 (1 573), including 987 CRT-P (54%) and 835 CRT-D (46%). According to the 2010 Sixth Population Census, CRTs were performed in less than 1 patient per million (0.68 per million in 2010, 0.74 per million in 2011), still far less than that of Europe (31 per million in 2010). The average age of patients receiving CRT transplantation was 62.37 years. 1 335 of these patients were male (71.16%). Among them, 160 CRTs (0.11%) were used for replacements, and 124 (8.17%) had remote monitoring function (Figure 3-3-4). [2] Statistics from the Ministry of Health’s online enrollment system reported about 2,210 CRT cases in 2012, 17.8% higher than 2011. CRT-D accounted for about 53%. CRT volume was still less than 1 per million, much lower than European countries (31 per million in 2010). 3.3.2 Radiofrequency Catheter Ablation The fi rst clinical application of radiofrequency catheter ablation (RFCA) was reported in 1991in [1] Hua W, Huang DJ, Chen FR, et al. National survey on application of cardiac resynchronization therapy in heart failure patients. Chinese Journal of Cardiac Arrhythmias, 2008, 12(6): 474-476. [2] Chen FR. Progress of China cardiac pacing therapy. China Continuing Medical Education, 2011, 11(3): 3-8. 123 Report on Cardiovascular Diseases in China (2013) China. [1] RFCA cases have increased rapidly since the mid-1990s (Figure 3-3-5). [2] Currently, the use of RFCA for pre-excitation syndromes and supraventricular tachycardia is already well accepted in over 600 Chinese hospitals. Statistics from the Ministry of Health’s online enrollment system showed that 63 355 ablations were performed in 2011, increased by16.1% compared with those in 2010 (54 559). According to the 2010 Population Survey, RFCA case volume was 41 per million in 2010, 47 per million in 2011. The average age of patients was 47.7 years. 32 274 patients were males (50.94%). [3] Case Volume (10 000 units) ˄ Figure 3-3-5 RFCA Case Volumes by Year (China: 1995-2012) Statistics from the Ministry of Health’s online enrollment system reported that about 74 410 RFCA procedures were done in 2012, 17.5% higher than 2011. The proportion of RFCA for atrial fi brillation was about 16.6%. In 2012, RFCAs in Beijing exceeded 7 000 cases, exceeded 5 000 cases in Zhejiang, Jiangsu, Guangdong provinces and Shanghai city. There was only one hospital (Fu Wai Hospital) that had annual RFCA cases exceeded 3 000, accounted for 5.2% of the total cases. 30 hospitals reported at least 500 RFCAs (4.1%) annually, accounted for 38.8% of the total cases. Of RFCAs performed in 2011, 20 876 (29.5%) were for AV nodal re-entry tachycardia (AVNRT), 18 805 (26.5%) were for AV re-entry tachycardia (AVRT), 18 805 (26.5%) were for atrial fl utter, 9 856 (13.9%) were for atrial fi brillation, 4 271 (6%) were for premature ventricular contractions, and 2 330 (3.3%) were for ventricular tachycardia. Of the remaining, 227 cases were for premature atrial beats and 1 982 for atrial tachycardia (Figure 3-3-6). [1] Li GS, Gao HN, Xu JL, et al. Methodological search of radiofrequency catheter ablation therapy for preexcitation syndrome. Chinese Journal of Cardiac Pacing and Electrophysiology, 1991, 5(2): 57-59. [2] Hu DY, Chen X, Ma CS, et al. National information summary of radiofrequency ablation in the treatment of rapid arrhythmia in 2000. National radiofrequency ablation in the treatment of rapid arrhythmia information, 2002, 6(2): 124-127. [3] Chen FR. Progress of China cardiac pacing therapy. China Continuing Medical Education, 2011, 11(3): 3-8. 124 Chapter 3 Cardiovascular Diseases 697 $) 97 2WKHU Figure 3-3-6 Diseases Treated by RFCA (China: 2011) (%) 3.3.3 Atrial Fibrillation An early survey on atrial fi brillation (AF) showed that the prevalence of AF among patients ≥ 35 years of age was 0.74% for males and 0.72% for females. 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%. [1] A recent published survey conducted in 2004 in 10 different regions (4 cities and 6 rural areas) showed that the prevalence of AF in people 35 to 59 years of age was 0.42% and 1.83% among people ≥ 60 years of age. After adjusting for age and gender, the prevalence of AF was 0.77% (0.78% in males, 0.76% in females). 19% of males and 30.9% of females with AF also had valvular heart conditions. After adjusting for age and gender, history of myocardial infarction, left ventricular hypertrophy, obesity, and alcoholism were identifi ed as risk factors for AF. [2] A study on anticoagulation for nonvalvular AF enrolled 988 AF patients with risk factors of thromboem- bolism and randomly divided patients into 3 groups: standard warfrin anticoagulation group (INR 2.1-2.5), low warfrin anticoagulation group (INR 1.6-2.0) and aspirin group (200 mg/d). [3] After an average follow- up period of 15 months, the annual incidence of thromboembolism was 2.3%, 2.6%, and 6.4%, respectively. The incidence in warfarin treatment groups was clearly lower than in the aspirin treatment group (P = 0.018 and P = 0.044), but there was no signifi cant difference between the standard and low warfarin anticoagulation groups. The incidence of excessive bleeding was 2.9%, 2.8%, and 1.0%, respectively, with no statistically signifi cant differences (P = 0.101). Low anticoagulation (INR 1.6-2.0) and standard anticoagulation (INR [1] Zhang S. Atrial fi brillation in mainland China: epidemiology and current management. Heart, 2009. 95(13): 1052-1055. [2] Li Y, Wu Y, Chen K, et al. Prevalence of atrial fi brillation in China and its risk factors. Biome Environ Sci, 2013. 26(9): 709-716. [3] Chen KP, Huang CX, Huang DJ, et al. Anticoagulation therapy in Chinese patients with non-valvular atrial fibrillation: a prospective, multi-center, randomized, controlled study. Chin Med J, 2012, 125(24): 4355-4360. 125 Report on Cardiovascular Diseases in China (2013) 2.1-2.5) with warfarin [Please check]were equally effective. In 2011, the Chinese Medical Association’s Geriatrics Expert Group published the fi rst Chinese Expert Opinion on Treatment of Atrial Fibrillation for Elderly Patients, [1] covering characteristics of elderly patients in stroke risk evaluation, control of ventricular rate or rhythm with medications, and antithrombotic therapies. New oral anticoagulation medications do not need regular monitoring during the course of treatment, allowing more convenience for the patients. Some examples include direct thrombin inhibitors like dabigatran and direct factor Xa inhibitors like rivaroxaban and apixaban. The RE-LY, ROCKET-AF, and ARISTOLE trials have proven that these kind of new anticoagulation medications can effectively lower the incidences of stroke and thromboembolism, and also reduce the risk of bleeding and all-cause mortality. [2, 3, 4] The clinical use of novel oral anticoagulants offers new options that are safe and effective for the prevention of thromboembolism and its complications in patients with atrial fi brillation. RE-LY study enrolled 569 patients from 11 medical centers in China, which provided evidence-based information for the clinical application of dabigatran in China. ROCKET-AF study included 496 patients from 37 medical centers in China. This study will provide evidence for the use of new anticoagulation medications in China. Analysis of registration data from 40 hospitals showed that from 1998 to 2007, the number of patients treated with catheter ablation for atrial fi brillation has quickly increased, from 11 cases in 1998 to 2 620 cases in 2007. The main techniques used were circumferential pulmonary vein ablation and segmental pulmonary vein ablation. The total success rate was 77.1%, recurrence rate was 22.9%, and complication rate was 5.3%. [5] Since 2008, China has begun building a national AF online platform for collecting and analyzing data in AF patients treated with RFCA. By 2010, the database has already received close to 20 000 patients’ data, but the real number of cases far exceeded the number recorded online. Registration data in 2010 showed that 4 253 RFCA cases were done for atrial fi brillation. Currently, circumferential pulmonary vein isolation is still the main technique of RFCA for AF, accounting for 65.1% of all cases. The proportions of pulmonary vein ablations with complex fractionated atrial electrograms and with stepwise ablation have increased to 11.3% and 13.6%, respectively. [6] [1] China Experts Opinion on the Treatment of AF in old People writing group. China Experts Opinion on the Treatment of AF in old People.Chinese J of Geriatrics, 2011, 30(11):894-908. [2] Ezekowitz MD, Connollys, Parekh A, et al. Rationale and design of RE-LY: Randomized evaluation of long-term anticoagulant therapy, warfarin, compared with dabigatran. Am Heart J, 2009, 157(5): 805-810. [3] Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med, 2011; 365(10): 883-891. [4] Granger GB, Alexander JH, McMurry JJ, et al. Apixaban versus warfarin in patients with atrial fi brillation. N Engl J Med, 2011; 365(11): 981-992. [5] Cao K, Chen X. Current situation and Prospect of catheter ablation for atrial fi brillation. Chinese Journal of Cardiac Arrhythmias, 2009, 13(3): 167-169. [6] Huang CX, Zhang H, Ma CS, et al. The registration study of catheter ablation in patients with atrial fi brillation in China-2006. Chinese Journal of Cardiac Arrhythmias, 2011. 15(4); 247-251. 126 Chapter 3 Cardiovascular Diseases 3.3.4 Other Arrhythmias Retrospective analysis of data in hospitalized patients in cardiology departments in 22 provincial hospitals revealed that 26.8% of all cardiology inpatients had cardiac arrhythmia. Among of all patients with arrhythmia, the proportion of atrial fi brillation ranked the fi rst (35.0%), followed by paroxysmal supraventricular tachycardia (28.0%), sick sinus syndrome (11.9%) and premature ventricular contractions (11.6%). [1] A study in Hubei, which enrolled 16 681 patients with chronic congestive heart failure, indicated that the incidence of atrial premature contraction, atrial tachycardia and AF was 35.39%, 23.57%, and 40.81% respectively. The incidence of atrial tachycardia and AF increased with age and the decrease of LVEF. [2] 3.4 Heart Failure 3.4.1 Prevalence of Heart Failure (HF) According to a survey in 15 518 participant from 20 urban and rural regions in 10 provinces and cities, the prevalence of chronic heart failure in adults between the ages of 35 and 74 in China was 0.9% (0.7% and 1.0% among males and females, respectively), indicating an estimated four million heart failure patients within this age group in China (Table 3-4-1 and Table 3-4-2). [3] Table 3-4-1 Prevalence (%) of Heart Failure in Adults (35-74 year) by Age Age Population 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：※Comparison between males and females, U=2.03, P<0.05; △ Comparison among different age groups χ2=28.37, P<0.01 [1] Wang ZW, Wang X, Shao L, et al. Arrhythmias among hospitalized patients in major parts of China. Chinese Journal of Cardiac Arrhythmias, 2009, 13(5): 395-398. [2] Yu SB, Huang H, Cui HY, et al. Distribution survey of atrial arrhythmias in patients with chronic systolic heart failure in Hubei. Chinese Journal of Cardiac Arrhythmias, 2011, 15(6): 405-408. [3] Gu DF, Huang GY, He J, et al. The epidemiology and prevalence of heart failure in China. Chinese Journal of Cardiology, 2003, 31(1): 3-6. 127 Report on Cardiovascular Diseases in China (2013) Table 3-4-2 Prevalence (%) of Heart Failure in Adults (35-74 year) by Region Region Population Male Female Total Northern 7 654 1.3 1.5 1.4△ Southern 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: △ Comparison between northern regions and southern regions, U=5.08, P ＜ 0.01; ※Comparison between urban regions and rural regions, U=1.92, P<0.054 3.4.2 Etiology and Pharmacotherapy of Heart Failure A study at the General Hospital of the People's Liberation Army among 6 949 patients with congestive heart failure concluded that the fi rst four common causes of HF were: CAD (45.0%), hypertension (38.7%), valvular disease (27.5%) and diabetes (18.3%). [1] Further analysis showed that for patients with a single disease, valvular disease (34.3%) was the most common cause; for patients with 5 or more co-morbidities, the three most common causes were: CAD (87.9%), hypertension (78.4%) and diabetes (66.3%). A recent retrospective study [2] among 16 681 cases of chronic systolic heart failure in 12 tertiary hospitals in Hubei province between Jan. 1st, 2000 and May 31st, 2010 analyzed the HF etiology for different age groups of both genders. The baseline characteristics is shown in Table 3-4-3. The study results showed that the proportion of dilated cardiomyopathy reduced gradually with age, but it was higher in males than in females; proportions of CAD and HTN-induced heart failures increased with age; 3) proportion of rheumatic heart disease decreased with age, it was greater in females than in males (Table 3-4-4). The medications used for heart failure are shown in Table 3-4-5. Table 3-4-3 Baseline Characteristics of 16 681 Cases with Heart Failure Variables Total(n=16 681) Living(n=10 228) Deceased(n=6 453) P-value Female 6 794(40.73) 4 668(45.64) 2 126(39.01) <0.001 Age(years) 63.42±11.16 61.75±11.75 65.37±13.90 <0.001 Hear rate(bpm) 85.31±20.14 83.57±22.60 87.49±23.11 <0.001 NYHA III-IV 12 668(75.94) 7 236(70.75) 5 432(84.18) <0.001 DM 2 700(16.19) 1 317(12.88) 1 383(21.43) 0.211 [1] Yin QX, Zhao YS, Li JY, et al. The Coexistence of Multiple Cardiovascular Diseases is an Independent Predictor of the 30-Day Mortality of Hospitalized Patients with Congestive Heart Failure: A Study in Beijing. Clin Cardiol, 2011, 34(7): 442-446. [2] Yu SB, Zhao QY, Cui HY, et al. Investigation on the prevalence and related factors of medicinal therapy in patients with chronic systolic heart failure. Chinese Journal of epidemiology, 2012, 33(2): 229-233. 128 Chapter 3 Cardiovascular Diseases Table 3-4-3 Baseline Characteristics of 16 681 Cases with Heart Failure Continue Variables Total(n=16 681) Living(n=10 228) Deceased(n=6 453) P-value HTN 7 939(47.59) 4 888(47.79) 3 051(47.28) 0.545 AF 6 807(40.81) 3 792(37.07) 3 015(46.72) <0.001 LVEDD(mm) 53.64±69.78 50.20±11.72 58.01±9.44 <0.001 LVEF(%) 37.96±10.41 40.31±7.02 30.82±8.02 <0.001 ACEI 8 607(51.60) 4 618(48.08) 3 689(57.17) <0.001 BB 7 770(46.58) 5 174(50.59) 2 596(40.23) <0.001 ARB 3 116(18.68) 1 890(18.48) 1 226(19.00) <0.001 Digoxin 7 713(46.24) 4 330(42.33) 3 383(52.43) <0.001 Diuretics 11 532(69.13) 6 744(65.94) 4 788(74.20) <0.001 Note：LVEDD，left ventricular end-diastolic dimension；LVEF，left ventricular ejection function；ACEI，angiotensin-converting-enzyme inhibitor；BB，βblocker； ARB，angiotensin II receptor blocker. Table 3-4-4 Causes of Heart Failure of 16 681 Cases in Hubei Province Age Diastolic HF(#/%) CAD(#/%) HTN(#/%) Rheumatic HD(#/%) (years) Male Female Male Female Male Female Male Female <30 154/66.38 61/29.33 5/2.16 3/1.44 10/4.31 5/2.4 48/20.69 79/37.98 30-39 206/52.69 56/20.29 22/5.63 1/0.36 45/11.51 21/7.61 88/22.51 133/48.19 40-49 529/50.43 158/21.44 136/12.96 42/5.7 173/16.49 82/11.13 174/16.59 413/56.04 50-59 742/40.33 344/26.56 446/24.24 170/13.13 422/22.93 292/22.55 243/13.21 505/39.00 60-69 687/31.70 344/19.49 710/32.76 486/27.54 625/28.84 579/32.80 144/6.65 370/20.96 70-79 459/15.72 175/7.90 1482/50.75 1017/45.93 988/33.84 934/42.19 91/3.12 142/6.41 ≥80 41/4.57 30/4.35 480/53.51 373/54.14 362/40.36 296/42.96 3/0.33 18/2.61 129 Report on Cardiovascular Diseases in China (2013) Table 3-4-5 Medications Usage by Drug Class NO.of Medication(%) Region Year Patients Nitrate Diuretic Digoxin ARB ACEI Spironolactone BB CCB 1973-1982 542 30.3 58.7 61.3 — — 5.9 9.0 14.8 Tianjin[1] 1983-1992 1 253 70.6 67.8 71.6 — 24.2 10.1 8.3 35.2 1993-2002 3 394 91.4 75.4 67.9 4.0 70.9 23.1 25.3 21.6 1980 1 756 44.7 63.7 51.7 0.4 14.0 10.0 8.5 6.1 42 Different Hospitals[2] 1990 2 181 36.0 70.2 45.5 1.4 26.4 8.4 9.5 16.4 2000 6 777 53.0 48.6 40.3 4.5 40.4 20.0 19.0 10.5 1980 2 178 74.4 77.1 60.0 — 0.6 — 6.8 — Shanghai[3] 1990 — — — — — 38.9 — 5.7 41.3 2000 — — — — 11.5 70.8 — 25.0 14.2 Primary Hospitals in [4] 2006 2 100 — 90.0 60.0 5.8 50.0 40.0 — 17 Different Regions Note: BB, βblocker; ACEI, angiotensin-converting-enzyme inhibitor; ARB, angiotensin II receptor blocker; CCB, calcium channel blocker. 3.4.3 Mortality of Hospitalized Patients A recent retrospective survey in patients hospitalized with CHF from 1993 to 2007 in General Hospital of the People's Liberation Army revealed that the 30-day mortality for CHF is 5.4%.[5] For women aged from 18 to 39 year-old and those aged more than 80 year-old, their mortality during hospitalization is approximately twice of their male counterparts (3.2% vs 1.8%, p=0.148; 16.1% vs 11.4%, p=0.086). With the increase of age and comorbidities, both men and women endured higher in-hospital mortality. (Figure 3-4-1 and 3-4-2) [1] Ma JP, Wang L, Dang Q, et al. Retrospective analysis of drug treatment on inpatients with chronic heart failure. Chinese Journal of epidemiology, 2007, 28(1): 78-82. [2] Chinese Society of Cardiology. Retrospective investigation of hospitalized patients with heart failure in some parts of China in 1980, 1990 and 2000. Chinese Journal of Cardiology, 2002, 30(8): 450-454. [3] Shanghai Cooperation of Heart Failure Investigation. The evolving trends in the epidemiologic factors and treatment of hospitalized patients with congestive heart failure in Shanghai during years of 1980, 1990, and2000. Chinese Journal of Cardiology, 2002, 30(1): 24-27. [4] Cao YM, Hu DY, Wang HY, et al. A survey of medical therapies for chronic heart failure in primary hospitals in China. Chinese Journal of internal medicine, 2006, 45 (11): 907-909. [5] Yin QX, Zhao YS, Li JY, et al. The coexistence of multiple cardiovascular diseases is an independent predictor of the 30-day mortality of hospitalized patients with congestive heart failure: A study in Beijing. Clin Cardiol, 2011, 34(7): 442-446. 130 Chapter 3 Cardiovascular Diseases 0DQ 0DQ :RPDQ :RPDQ 0RUWDOLW\˄˅ 0RUWDOLW\˄˅ ı $JH \HDUV &RPRUELGLWLHV Figure 3-4-1 In-hospital Mortality by Age Figure 3-4-2 In-hospital Mortality by and Gender Gender and Number of Co-morbidities 3.4.4 Research on Acute Coronary Syndrome and Acute Heart Failure Conducted in 2011 with a focus on the ACS patients with acute heart failure, [1] BRIG study analyzed the data of 3 168 patients admitted with defi nitive diagnosis of ACS in 65 hospitals from 31 provinces in mainland of China and Hong Kong from March to June in 2006. Among all of the patients, there were 1 329 patients with acute ST-elevation myocardial infarction, 348 patients with non ST-elevation myocardial infarction, and 1 491 patients with unstable angina. During hospitalization, 706 (22.3%) developed acute heart failure, 263 (8.3%) had a history of heart failure but did not have an episode of acute heart failure, and 2 200 (69.4%) did not have a history of heart failure and did not have heart failure. Compared with patients without heart failure, those with an episode of heart failure tended to be older and with higher percentage of having a history of stroke and atrial fi brillation. Those with an episode of heart failure also stayed longer in hospital (12.5 vs 9.9 days, p<0.01), endured higher in-hospital mortality (8.4% vs 0.8%, p<0.01) and composite end-point events (24.0% vs 8.3%, p<0.01). 3.4.5 Proprietary Pharmaceutical Development The phase II clinical trail of rhNRG-1, [2] a drug developed by the Chinese academics who owned complete intellectual property rights, suggested that rhNGR-1 (0.6 ug/kg) could improve the left ventricular [1] Wang N, Zhao D, Liu J, et al. Impact of heart failure on in-hospital outcomes of acute coronary syndrome patients in China — Results from the Bridging the Gap on CHD Secondary Prevention in China (BRIG) project. International Journal of Cardiology, 2012, 160(1):15-19. [2] Gao RL，Zhang J, Cheng L, et al. A Phase II, randomized, double-blind, multicenter, based on standard therapy, placebo- controlled study of the effi cacy and safety of recombinant human neuregulin-1 in patients with chronic heart failure. Journal of the American College of Cardiology, 2010, 55 (18): 1907-1914. 131 Report on Cardiovascular Diseases in China (2013) ejection fraction (LVEF) (27.11±31.12%, p=0.009 for rhNGR-1 group and 5.83±25.75%, p=0.49 for placebo group), and signifi cantly decreased the end-systolic volume (ESV) (-11.58 ±12.74%, p=0.002) and end- diastolic volume (EDV) (-5.64±10.03%, p=0.05). The research on heart failure treated by traditional Chinese medicine has also made remarkable progress. The multi-center clinical research on Qiliqiangxin (QLQX) suggested that the addition of QLQX to standard treatment could effectively decrease patients’ NT-proBNP level, increase their LVEF and shrink the dilated heart (Figure 3-4-3). [1] However, it was a study with surrogate endpoint, and could not serve as a solid clinical evidence. Large scale, long-term clinical research with mortality and worsening heart failure as primary endpoints are required to provide evidence for clinical practice. QLQX Group Placebo Group NYHA ዜ NYHA ዞ NYHA ዜ NYHA ዞ NYHA ዝ NYHA ዟ NYHA ዝ NYHA ዟ 100 100 50 50 Functional Grade（ % ） Functional Grade（ % ） NYHA NYHA 0 0 (GYKROTK ] ]] (GYKROTK ] ]] QLQX Placebo P-value NYHA Ė NYHA ė NYHA Ę NYHA ę NYHA Ė NYHA ė NYHA Ę NYHA ę (GYKROTK 0% 52.46% 41.80% 5.74% 0% 53.44% 41.70% 4.86% 0.904% ] 7.47% 65.15% 26.56% 0.83% 7.82% 59.26% 30.45% 2.47% 0.350% ] 16.45% 61.90% 21.21% 1.00% 8.51% 58.72% 31.06% 1.70% 0.005% ] 29.03% 55.76% 15.21% 0% 11.63% 61.40% 26.51% 0.47% <0.001% Figure 3-4-3 Results of Multi-center clinical Research on QLQX: Improved Cardiac Function (NYHA classifi cation). ˗ [1] Li X, Zhang J, et al. A multicenter, randomized, double-blind, parallel-group, placebo-controlled study of the effects of qili qiangxin capsules in patients with chronic heart failure. J Am Coll Cordiol, 2013, 62 (12): 1065-1072. 132 Chapter 3 Cardiovascular Diseases ABC QLQX QLQX QLQX 6RGIKHU 6RGIKHU 6RGIKHU m , mm , % VEF VEF Change in L Change in L Change in 6MWD, Baseline=KKQY Baseline=KKQY Baseline=KKQY Qili Qiangxin Capsule Placebo P\GR[K ͧ )/ͨ (GYKROTK=KKQY P\GR[K (GYKROTK=KKQY P\GR[K Fdipdbsejphsbqiz 2<+, r r " r r " 3KGT)NGTMK8GZKUL2<+, r r ͧͨ 2<+*SS r r " r r" 3KGT)NGTMK8GZKUL2<+,r r ͧͨ 7NXE-n!! r r " r r " 3KGT)NGTMK8GZKUL 3=*r r Figure 3-4-4 Results of Multi-center clinical Research on QLQX: Echocardiograph Measurements and 6MWD Changes. LVEF: Left ventricular ejection fraction; LVED：left ventricular end-diastolic diameter; 6MWD: 6-minute walking distance 3.5 Sudden Cardiac Death During a one-year follow-up of 678 718 people from July 2005 to June 2006, there were 2 983 cases of death, 284 of which was sudden cardiac death (SCD), accounted for 9.5%. The incidence of SCD is 41.8/ 100 000 with a higher rate in men compared with women (44.6/100 000 vs 39.0/100 000). Most of the death occurred among people older than 65 year-old, and only 2 cases of death occurred in people younger than 25 year-old. It is estimated that there are 544 000 cases of SCD annually in China. [1, 2] Another follow-up survey of 497 patients with class I recommendation of ICD implantation from 31 domestic hospitals between Jan. 2005 and Dec. 2006 demonstrated that the incidence of SCD was 5%, 7% and 8% at 3-month, 6-month and 12-months of follow-up, respectively. [3] [1] Hua W, Zhang LF, Wu YF, et al. Incidence of sudden cardiac death in China: analysis of 4 regional populations. J Am Coll Cardiol, 2009,54:1110-1118. [2] Zhang S. Sudden cardiac death in China. Pacing Clin Electrophysiol, 2009, 32(9):1159-1162. [3] Hua W, Niu H, Fan X, et al. Preventive effectiveness of implantable cardioverter defi brillator in reducing sudden cardiac death in the Chinese population: a multicenter trial of ICD therapy versus non-ICD therapy. J Cardiovasc Electrophysiol, 2012, 23 (Suppl 1): S5-9. 133 Report on Cardiovascular Diseases in China (2013) 3.6 Pulmonary Arterial Hypertension (PAH) Pulmonary arterial hypertension (PAH) is a clinically pathophysiological syndrome, which is characterized by elevated pulmonary arterial pressure, caused by pulmonary vascular functional change and (or) structure remolding, and will ultimately result in right heart failure and even death. [1, 2] 3.6.1 Screening for PAH in Patients with Congenital Heart Disease From May 2007 to December 2008, 692 patients with congenital heart disease (CHD) were examined with echocardiography during their hospitalization in Fuwai Hospital. A pulmonary arterial systolic pressure higher than 40 mmHg was used as the criteria for the diagnosis of PAH in patients with congenital heart disease (PAH-CHD). The results demonstrated that 187 (27.0%) patients suffered from atrial septal defect, 456 (65.9%) patients suffered from ventricular septal defect and 49 (7.1%) patients had patent ductus arteriosus. [3] The numbers of patients with PAH-CHD and Eisenmenger syndrome were 329 (47.5%) and 105 (15.2%), respectively. Among the PAH-CHD patients, 31.9% of them had Eisenmenger syndrome. In patients with congenital heart disease, the risk of developing PAH increased with age (OR=1.04, p<0.001) and the increased inner diameter of septal defect. Patients with ventricular septal defect (OR 2.78, p<0.001) or patent ductus arteriosus (OR=2.50, p<0.001) were more likely to develop PAH (Table 3-6-1). Table 3-6-1 Independent Factors of Developing PAH in Patients with Congenital Heart Disease Factors OR value 95%CI P-value One Year Increase of Age 1.04 1.02-1.06 <0.001 One kg/m2 Increase of BMI 0.90 0.85-0.96 0.001 One mmHg Increase of SBP 0.97 0.96-0.99 <0.001 One mmHg Increase of DBP 1.00 0.99-1.02 0.773 Type of Shunt VSD/ASD 2.78 1.77-4.38 <0.001 PDA/ASD 2.50 1.26-4.95 <0.001 BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; VSD, ventricular septal defect; ASD: atrial septal defect; PDA, patent ductus arteriosus. [1] Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J, 2009, 30(20): 2493-2537. [2] McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol, 2009, 53(17): 1573-1619. [3] Sun YJ, Feng KJ, He JG, et al. Screening of pulmonary arterial hypertension in patients with congenital heart diseases. National Medical Journal of China, 2012,92(16):1091-1094. 134 Chapter 3 Cardiovascular Diseases 3.6.2 Clinical Characteristics of Patients with PAH 551 WHO-I and WHO-IV PAH patients were enrolled in the Research for Improving diagnostic level of PAH from 31 tertiary hospitals across the country between May 2007 and October 2010. The project was funded by China’s 11th Five-Year plan of science and technology. The percentage breakdown of etiologies of PAH is shown in Figure 3-6-1. [1, 2] ,GLRSDWKLF 3$+&+' &RQQHFWLYHWLVVXHGLVHDVH UHODWHG3$+ &KURQLFWKURPERHPEROLF3$+ Figure 3-6-1 Percentage Breakdown of PAH Subtypes. 3.6.3 Prognosis of Idiopathic PAH (IPAH) Data were collected from 90 patients (age ≥ 18 year-old) who were newly diagnosed with IPAH in Fuwai Hospital from March 2006 to November 2009. The mean duration of follow-up was 16 months. The results showed that the 1-year, 2-year and 3-year survival rates for IPAH patients with sildenafi l therapy were 84.1%, 73.7% and 70.6%, respectively. For those who received conventional treatment, their 1-year, 2-year and 3-year survival rates were 67.7%, 55.9% and 47.0%, respectively. In conclusion, sildenafi l therapy could improve the prognosis of patient with IPAH. [3] Results of IPAH prognosis studies conducted in different medical centers are shown in Table 3-6-2. See Table 3-6-3 for factors affecting IPAH prognosis. [1] Dong L, He JG, Xiong CM, et al. Multicenter study of disease attributes in adult patients with pulmonary hypertension. National Medical Journal of China, 2012, 92: 1087-1090. [2] Dong L, He JG, Xiong CM, et al. Clinical analysis of 150 patients with idiopathic pulmonary arterial hypertension. Chinese Journal of Cardiology, 2012, 40(8): 657-661. [3] Zeng WJ, Sun YJ, He JG, et al. Impact of sildenafi l on survival of patients with idiopathic pulmonary arterial hypertension. Journal of Clinical Pharmacology, 2012, 52 (9): 1357-1364. 135 Report on Cardiovascular Diseases in China (2013) Table 3-6-2 Prognosis of IPAH Fuwai Hospital Fuwai Hospital United State NIH France Survival 5 Centers (Shanghai etc.) after 2006 before 2006 [1] 1980s [2] 2006 [4] Rate after 2006 [3](n=173) (n=90) (n=72) (n=162) (n=264) 1-year 84.1% 68% 68% 92.1% 85.7% 2-year 73.7% 56.9% - - 69.6% 3-year 70.6% 38.9% 48% 75% 54.9% Table 3-6-3 Factors Affecting IPAH Prognosis Factors HR 95%CI P-value Every 10 Year Increase of Age 0.51 0.28-0.95 0.033 Every 5 kg Increase of Weight 0.75 0.58-0.99 0.039 Pericardial Effusion 4.20 1.53-11.52 0.005 Without PAH Targeted Drug Treatment 7.82 2.75-22.26 <0.001 3.6.4 Prognosis of Congenital Heart Disease Patients with Eisenmenger Syndrome Data of 121 patients with newly diagnosis of Eisenmenger syndrome was collected from Jan. 2005 to Dec. 2009. Patients were divided into two groups: sildenafi l and conventional treatment. The survival curves are shown in Figure 3-6-2. Factors affecting their survival are shown in Table 3-6-4. 6XUYLYDO5DWH˄˅ P =0.025 6LOGHQDILO*URXS &RQYHQWLRQD*URXS 0RQWK Figure 3-6-2 Survival Rates of CHD-Eisenmenger Patients by Treatment [1] Jing ZC, Xu XQ, Han ZY, et al. Registry and survival study in Chinese patients with idiopathic and familial pulmonary arterial hypertension. Chest, 2007,132(2): 373-379. [2] Rich S, Dantzker DR, Ayres SM, et al. Primary pulmonary hypertension. A national prospective study. Ann Intern Med, 1987,107(2): 216-223. [3] Zhang R, Dai LZ, Xie WP, et al. Survival of Chinese Patients with Pulmonary Arterial Hypertension in the Modern Management Era. Chest, 2011,140(2):301-309. [4] Humbert M, Sitbon O, Chaouat A, et al. Pulmonary arterial hypertension in France: results from a national registry. Am J Respir Crit Care Med, 2006,173(9): 1023-1030. 136 Chapter 3 Cardiovascular Diseases Table 3-6-4 Prognostic Predictors of CHD-Eisenmenger Patients Parameters HR (95%CI) P-value Mean Pulmonary Arterial Pressure 1.35 (1.13-1.61) 0.001 WHO-FC≥III 5.20 (1.46-18.55) 0.001 Sildenafi l Treatment 0.55(0.34-0.87) 0.001 WHO-FC, World Health Organization-Functional Classifi cation 3.6.5 Long-term Survival Rates for CTEPH Patients A retrospective cohort study was conducted among 504 patients with CTEPH, who were treated surgically (n=360) or non-surgically (n=144) at Beijing Anzhen Hospital from 1989 to 2008. The patients in surgical group underwent a standard pulmonary thromboendarterectomy (PTE), while those in non-surgical group were given thrombolytic therapy. In-hospital mortality for surgery and non-surgery group was 4.44% and 3.50% respectively. For patients with proximal CTEPH, those treated with surgery had higher long-term survival rate than that of patients treated with thrombolytic therapy (p=0.0004). For distal CTEPH, there was no signifi cant difference between the two groups (p=0.874).[1] The long-term survival rates of patients with CTEPH were listed in Table 3-6-5. The long-term survival rates of CTEPH patients undergoing thromboendarterectomy in China and overseas were shown in Table 3-6-6. Table 3-6-5 Long-term Survival Rates of CTEPH Patients Proximal Type Distal Type * Groups P 10-year survival rate 15-year survival rate 10-year survival rate 15-year survival rate (%) (%) (%) (%) Surgery 94.60±2.38 90.96±4.24 71.78±4.66 29.57±15.10 <0.0001 Non-surgery 81.4±7.14 56.43±14.70 69.84±7.78 32.59±13.70 0.5 *, Comparison of the survival curves between proximal and distal CTEPH (Log rank test) [1] Gan HL, Zhang JQ, Bo P, et al. The actuarial survival analysis of the surgical and non-surgical therapy regimen for chronic thromboembolic pulmonary hypertension. J Thromb Thrombolysis, 2010, 29(1): 25-31. 137 Report on Cardiovascular Diseases in China (2013) Table 3-6-6 Survival Rates of CTEPH Patients UndergoingThromboendarterectomy in China and Overseas In-hospital Long-term Survival Rate of Country Medical Center Duration Cases Mortality Central CTEPH Beijing Anzhen 94.60%(10-Year) China 1989-2007 360 4.40% Hospital 90.96%(15-Year)) 96%(1-Year)) United States[1] UCSD MedicalCenter 1997-2007 988 4% 88%(5-Year)) 98%-99%(1-Year)) United Kingdom[2] Papworth Hospital 2001-2006 236 16% 93%-94%(3-Year)) 84%(5-Year)) Japan [3] Chiba University 1990-2010 77 9% 82%(10-Year)) 3.6.6 Long-term Survival Rates for PAH Patients after Lung Transplantation 244 lung transplants have been performed in 20 hospitals across China from January 1978 to December 2010, among which 100 cases were conducted by Wuxi People’s Hospital, including 72 cases of single- lung and 28 cases of bilateral lung transplantations. Patients receiving the transplants were those with IPAH, congenital PAH and PAH caused by chronic lung disease. [4] Survival rates are shown in Table 3-6-7. Table 3-6-7 Survival Rates after Lung Transplantation in China and Other Countries 1-year Survival 3-year Survival Periods Medical Center Cases 5-year Survival Rate Rate Rate 1978.1-2012.12 20 Hospitals in China 244 50 30 20 2002.6-2012.12 Wuxi People’s Hospital 100 73.3 53.5 40.7 2000.1-2009.6 ISHLT [5] (158 centers) 19 524 79 63 52 ISHLT: International Association of Heart and Lung Transplantation [1] Thistlethwaite PA, Kaneko K, Madani MM, et al. Technique and outcomes of pulmonary endarterectomy surgery. Ann Thorac Cardiovasc Surg, 2008, 14(5): 274-282. [2] Condliffe R, Kiely DG, Gibbs JS, et al. Improved outcomes in medically and surgically treated chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med, 2008, 177(10): 1122-1127. [3] Keiichi I, Masahisa M，Nobuhiro T, et al. Long-term outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg, 2012, 144(2): 321-326. [4] Mao W, Chen J, Zheng M，et al. Initial Experience of Lung Transplantation at a Single Center in China. Transplantation Proceedings, 2013, 45(1): 349-355. [5] Jason D, Leah B, Anna Y, et al. The registry of the international society for heart and lung transplantation: twenty-seventh offi cial adult lung and heart-lung transplant report-2010. J Heart Lung Transplant, 2010, 29(10): 1104-1118. 138 Chapter 3 Cardiovascular Diseases 3.7 Cardiovascular Surgery 3.7.1 Cardiovascular Surgery Volume in China The volume of cardiovascular surgery in the mainland of China in 2012 was 203 195 cases, including 158 597 cases performed under cardiopulmonary bypass (CPB) support. The total amount of cardiovascular surgeries and CPB in Hong Kong (special administrative region, SAR) reached 1 793 and 1 596 respectively in 2012. Table 3-7-1 Cardiac Surgery Volume (Mainland China, Hong Kong: 2010-2012) 2010 2011 2012 Region Province Total CPB Total CPB Total CPB North Beijing 22 818 15 145 24 553 16 995 27 538 18 060 Tianjin 3 563 2 541 3 623 2 187 3 784 2 217 Hebei 5 189 4 046 5 562 4 354 5 688 4 137 Shanxi 2 077 1 474 2 218 1 534 2 573 1 739 Inner Mongolia 1 257 906 1 379 916 1 369 856 Northeast Heilongjiang 3 047 2 129 3 242 2 204 3 386 2 172 Jilin 1 929 1 549 1 850 1 619 2 200 1 840 Liaoning 3 918 2 799 4 177 2 974 4 940 3 402 East Shanghai 14 879 12 588 15 381 12 958 16 099 12 887 Shandong 10 998 8 177 11 782 8 017 13 199 9 070 Jiangsu 7 935 6 550 8 391 7 022 8 908 7 072 Zhejiang 4 800 4 157 5 386 4 529 5 666 4 502 Central Hubei 9 767 9 009 10 963 9 915 11 665 10 539 Hunan 6 740 5 843 7 168 5 756 7 579 6 282 Jiangxi 2 753 2 527 4 486 4 069 4 200 3 808 Henan 13 263 11 431 17 616 14 659 19 650 15 787 Anhui 3 828 3 738 4 245 3 817 4 823 4 330 South Guangdong 13 101 11 288 14 325 12 350 15 036 13 018 Guangxi 3 407 3 054 3 703 3 243 3 894 3 630 Fujian 5 364 3 875 5 004 3 916 5 977 4 189 Hainan 680 625 850 745 1 040 847 Northwest Shanxi 7 674 5 343 7 079 5 630 6 997 5 778 Gansu 2 436 1 846 2 358 2 024 2 700 2 141 Qinghai 627 443 324 267 364 309 139 Report on Cardiovascular Diseases in China (2013) Table 3-7-1 Cardiac Surgery Volume (Mainland China, Hong Kong: 2010-2012) 2010 2011 2012 Region Province Total CPB Total CPB Total CPB Ningxia 739 434 911 478 910 568 Xinjiang 3 361 2 341 5 157 3 946 5 030 3 477 Southwest Chongqing 4 388 4 103 4 820 4 384 5 634 5 085 Sichuan 5 839 5 048 6 294 5 271 6 515 5 643 Yunnan 2 860 2 482 3 149 3 140 3 700 3 195 Guizhou 1 254 1 206 1 900 1 806 2 049 1 949 Tibet 87 62 82 68 Hong Kong 1 793 1 596 Total 170 491 136 697 187 983 150 787 204 988 160 193 Note: Data from the Extracorporeal Circulation Sub-committee of the Chinese Society of Biomedical Engineering In 2012, mainland China and Hong Kong completed 84 439 cases of surgeries for congenital heart disease, 218 cases of heart transplantation (including 5 cases of heart-lung transplant), and 399 cases of extracorporeal membrane oxygenation (ECMO) adjuvant treatment. Table 3-7-2 Volume of Different Cardiac Surgery in Mainland China and Hong Kong 2011 2012 Region Province Heart Heart CHD Macrovascular Transplant ECMO CHD Macrovascular Transplant ECMO North Beijing 8 096 1 168 67 58 8 367 1 452 60 98 Tianjin 684 54 3 22 1 202 102 1 18 Hebei 2 846 288 1 1 2 739 150 2 Shanxi 896 24 Inner Mongolia 524 59 286 89 Northeast Heilongjiang 1 367 52 2 925 90 1 1 Jilin 863 115 18 1 105 116 20 Liaoning 1 274 195 4 8 1 448 266 2 15 East Shanghai 7 319 614 28 34 7 589 746 23 22 Shandong 3 3 988 412 6 Jiangsu 3 051 232 14 2 533 353 10 56 Zhejiang 1 976 161 2 10 1 650 321 2 18 Central Hubei 6 107 501 29 14 5 684 658 46 22 140 Chapter 3 Cardiovascular Diseases Table 3-7-2 Volume of Different Cardiac Surgery in Mainland China and Hong Kong Continue 2011 2012 Region Province Heart Heart CHD Macrovascular Transplant ECMO CHD Macrovascular Transplant ECMO Hunan 4 227 154 1 2 4 073 145 7 Jiangxi 2 774 130 1 471 115 Henan 10 834 446 7 10 253 595 12 Anhui 1 994 289 4 175 187 2 South Guangdong 7 538 582 1 43 7 100 597 6 48 Guangxi 5 1 851 101 13 5 Fujian 1 909 151 11 3 2 144 337 18 7 Hainan 250 15 285 4 1 Northwest Shanxi 3 740 477 4 2 3 523 445 9 1 Gansu 1 486 138 1 629 95 Qinghai 204 12 211 10 Ningxia 118 40 267 59 Xinjiang 2 649 106 2 088 156 Southwest Chongqing 2 206 103 3 2 540 153 1 Sichuan 2 623 187 2 386 187 5 Yunnan 1 801 62 1 839 199 1 Guizhou 801 9 791 37 Xinjiang 2649 106 2088 156 Tibet 87 51 Hong Kong 246 123 23 35 Total 80 244 6 364 156 244 84 439 8 300 218 399 CHD, Congenital Heart Disease; ECMO, Extracorporeal Membrane Oxygenation Note: Data from the Extracorporeal Circulation Sub-committee of the Chinese Society of Biomedical Engineering 141 Report on Cardiovascular Diseases in China (2013) The annual volume of cardiovascular surgery has been increasing in the recent 10 years in mainland of China. (Figure3-7-1) 25 7RWDO &3% 20 15 10 &DVHV˄˅ 5 0 ˄ 3.7.2 Congenital Heart Disease Mainland China is gradually implementing a birth defect monitoring system. Congenital heart disease is one of the common birth defects, the incidence, however, varies by region. [1] (Table 3-7-3). Table 3-7-3 Incidence of Congenital Heart Disease in Some Regions of Mainland China Ranking in the Sample Area Period Survey Respondents Incidence (‰) Local Birth Size Defects Perinatal from 28 gestational - weeks to seven days Anren County, Hunan 43 931 1991.1.1 1999.12.31 postpartum (excluding fatal 0.98 Fifth death and stillbirth) Perinatal from 28 gestational - weeks to seven days Changsha, Hunan 65 298 2001.1.1 2005.12.31 postpartum (including fatal 2.79 First death and stillbirth) 50 km Adjacent area Perinatal from 28 gestational of Hongyanhe Nuclear 83 779 1996-2009 weeks to seven days 1.77 First [2] postpartum (including fatal Power Plant, Liaoning death and stillbirth) Beibei District, 20 136 1998.10-2001.9 All infants born in this region 0.695 First Chongqing during the surveyed period [1] Ministry of Health Prevention and Treatment Research Center for Cardiovascular Diseases. Report on Cardiovascular Diseases in China, 2011. Beijing: Chinese Encyclopedia Publication. [2] Zhou L, Yin ZH, Han ZH, et al. Baseline analysis of birth defects in regions adjacent to Hongyanhe nuclear power plant prior to plant operation. Chinese Radiation Medicine and Prevention, 2011, 31(2): 149-152. 142 Chapter 3 Cardiovascular Diseases Table 3-7-3 Incidence of Congenital Heart Disease in Some Regions of Mainland China Continued Ranking in the Sample Area Period Survey Respondents Incidence (‰) Local Birth Size Defects Multi-stage cluster random Children of 0 to 4 Year- sampling in children aged [1] 6 579 2010 0 to 4 year-old among 2.17 Second Old, Chongqing 23 districts (counties) of Chongqing Infants from 20 gestational Zhoushan Island, 41 396 2000.1.1-2006.12.31 weeks to 42 days postpartum 3.36 First Zhejiang (including fatal death and stillbirth) Perinatal from 28 gestational Bao'an District Street, 17 763 2000.10.1-2005.9.30 weeks to seven days 1.13 Fifth Shenzhen postpartum (including fatal death and stillbirth) Perinatal from 28 gestational Nanshan Hospital, weeks to seven days [2] 30 786 2002-2010 4.39 First Shenzhen postpartum (including fatal death and stillbirth) Twenty Hospitals Perinatal from 28 gestational in Bao’an District, 266 263 2006-2010 weeks to seven days 3.48 First [3] postpartum (including fatal Shenzhen death and stillbirth) Perinatal from 28 gestational Sixty-six Hospitals, weeks to seven days [4] 298 031 2008-2009 4.20 Shenzhen postpartum (including fatal death and stillbirth) Perinatal from 28 gestational Chongwen District, 6 699 2001.1.1-2005.12.31 weeks to seven days 2.23 Second Beijing postpartum (including fatal death and stillbirth) Perinatal from 28 gestational Shangdi Hospital, 10 956 2006-2007 weeks to seven days 5.84 First Beijing postpartum (including fatal death and stillbirth) - All infants born in this region Bengbu, Anhui 16 698 2001.7.1 2006.6.30 during the surveyed period 5.15 Second Zhongyang County All births and above 20 weeks and Jiaokou County, 6 420 2002.1.1-2004.12.31 of pregnancy (including fatal 7.32 Second Shanxi death and stillbirth) [1] Huang Q, Zhong CH, Li J, et al. Birth defects of children between the ages of 0 and 4 years old in Chongqing city in 2010. Chinese Preventative Medicine, 2012,46(6): 547-550. [2] Liang HL, Chen YH, Wang LP, et al. Perinatal birth defect: monitoring and analysis. Journal of Tropical Medicine, 2012, 12(1): 50-53. [3] Cheng YL, Zhang Y, Wang W, et al. Analysis of the monitoring data of perinatal birth defects in Bao’an district, Shenzhen, 2006-2010. Chinese Primary Health, 2012, 26(6): 70-72. [4] Ding R, Yan CR, Gong L, et al. Epidemiological characteristics of perinatal birth defects of 298,031 newborns in Shenzhen city. Chinese Women and Children’s Health Care, 2012, 27(20): 3123-3126. 143 Report on Cardiovascular Diseases in China (2013) Table 3-7-3 Incidence of Congenital Heart Disease in Some Regions of Mainland China Continued Ranking in the Area Sample Size Period Survey Respondents Incidence (‰) Local Birth Defects Perinatal from 28 gestational Shenzhen, 245 615 2003.1.1-2005.12.31 weeks to seven days 3.3 First Guangdong postpartum (including fatal death and stillbirth) Twenty-one Cities, Perinatal from 28 gestational 150 357 2007 weeks to seven days 5.89 First Guangdong postpartum Perinatal from 28 gestational [1] - weeks to seven days Haizhu, Guangzhou 14 076 2007.10.1 2008.9.31 postpartum (including fatal 2.20 Second death and stillbirth) Perinatal from 28 gestational - weeks to seven days Zhangzhou, Fujian 199 563 2003.1.1 2008.9.30 postpartum (including fatal 0.76 Third death and stillbirth) , Perinatal from 28 gestational Wudi County weeks to seven days [2] 31 693 2003.11.1-2009.12.31 0.88 Second Shandong Province postpartum (including fatal death and stillbirth) Perinatal from 28 gestational Qianshan County, weeks to seven days [3] 20 150 2004.1-2009.12 1.39 First Jiangxi postpartum (including fatal death and stillbirth) Perinatal from 28 gestational Seventy-fi ve weeks to seven days [4] 755 084 2007-2010 0.50 Fifth hospitals, Henan postpartum (including fatal death and stillbirth) Xi’an No. 4 Hospital, Perinatal from 28 gestational [5] 18 741 2008.1-2011.12 weeks to seven days 1.83 First Xi'an postpartum Perinatal from 28 gestational Zhangye People's weeks to seven days [6] 8 151 2001-2011 0.74 Hospital postpartum (including fatal death and stillbirth) Five counties, Newborns of more than 28 [7] 22 245 2009-2010 statistical year weeks pregnant (including 1.89 First Gansu fatal death and stillbirth) [1] Zhu RF, Liu CY, Lu XZ, et al. Analysis of the monitoring data of perinatal birth defects in Haizhu district in Guangzhou city, 2008. Journal of Chinese Women and Children’s Health, 2010, 1(5): 261-264. [2] Wang AL, Gao LJ, Zhang LH. Birth defect monitoring analysis of 31,693 perinatal birth in Wudi county, 2003-2009. Chinese Women and Children’s Health, 2011, 26(32): 5022-5024. [3] Yu Y, Chen ZL. Birth defect monitoring analysis and discussion on interventions in Qianshan county, Jiangxi province. Journal of Chinese Eugenics and Genetics, 2012, 20(3): 92-93. [4] Sun LH, Hu MC, Qu HM, Chen L. Epidemiological survey analysis based on hospital monitoring of perinatal congenital heart disease. Journal of Chinese Practical Medicine, 2012, 39(20): 71-72. [5] Yang PL. Epidemiological studies on 101 cases of newborns with birth defects. Journal of Shanxi Medicine, 2012, 41(9): 1233- 1235. [6] He L, Kan M. Analysis on 142 cases of birth defects. Chinese clinical research, 2012, 25(11): 1144. [7] Du WY, Fei LY, Ma RL, et al. Analysis on the status of birth defects in fi ve counties (cities) in Gansu province, 2009-2010. Journal of Chinese Epidemiological Studies, 2013, 34(2): 140-142. 144 Chapter 3 Cardiovascular Diseases The survey of congenital heart diseases among perinatal conducted in Bao'an district of Shenzhen [1] and Beijing [2] showed that its incidence presented an overall upward trend (Figure 3-7-2). %HLMLQJFLW\ %DRÿDQGLVWULFW6KHQ]KHQFLW\ Figure 3-7-2 Trends in Perinatal Incidence of Congenital Heart Diseases in Bao'an District, Shenzhen and Beijing City. The subtypes of congenital heart disease shown above for Bao’an district, Shenzhen and Beijing was similar to that of other regions in mainland China [3] (Table 3-7-4). Simple congenital heart disease (including ventricular septal defect, atrial septal defect and patent ductus arteriosus) accounted for 50%-60% of the total number of congenital heart disease cases. Among cyanotic congenital heart disease, the incidence of Tetralogy of Fallot was the highest (accounting for 4.35% and 4.12% of the total number of congenital heart diseases in Beijing city and Bao’an district of Shenzhen city, respectively). [1] Cheng YL, Zhang Y, Wang W, et al. Analysis of the monitoring data of perinatal birth defects in Bao’an district, Shenzhen, 2006-2010. Chinese Primary Health, 2011, 26(36): 5780-5782. [2] Liu KB, P Y, Li HM, et al. A 10-year analysis on perinatal congenital heart disease in Beijing city. Journal of Chinese Eugenics and Genetics, 2008, 16(3): 100-101. [3] Ministry of Health Prevention and Treatment Research Center for Cardiovascular Diseases. Report on Cardiovascular Diseases in China, 2011. Beijing: Chinese Encyclopedia Publication. 145 Report on Cardiovascular Diseases in China (2013) Table 3-7-4 Percentage Breakdown of Perinatal Congenital Heart Diseases in Bao'an District and Beijing (%) Bao’an District, Bao’an District, Disease Beijing Disease Beijing Shenzhen Shenzhen Ventricular Septal Defect 23.6 18.3 Aortic stenosis Atrial Septal Defect 15.1 9.1 Common arterial trunk 0.56 Patent Ductus Arteriosus 19.3 40.2 TECD 1.12 1.14 ASD+PDA 3.13 Single ventricle 1.06 ASD+VSD 5.35 2.13 Pulmonary atresia 0.62 PS+ASD TAPVC 0.4 Pulmonary Stenosis 1.8 1.3 Interrupted aortic arch TOF 4.35 4.12 Ebstein malformation 0.37 TGA 3.54 Tricuspid atresia VSD+PDA 2.27 Left heart hypoplasia 0.87 0 Coarctation of the Aorta 1.0 Right heart hypoplasia VSD, ventricular septal defect; ASD, atrial septal defect; PDA, patent ductus arteriosus; PS, pulmonary stenosis; TOF, tetralogy of Fallot; TGA, Complete transposition of great arteries; CAVCD: Complete atrio-ventricular canal defect; TAPVC, totally anomalous pulmonary venous drainage. 3.7.3 Clinical Application of Sino-SCORE Surgical Scoring System China Cardiovascular Surgery Registration Study analyzed clinical data of 15 637 patients receiving heart valve surgery between Jan 2007 and Dec 2008 in 43 centers. [1] The SinoSCORE (Chinese System for Cardiac Operative Risk Evaluation Model) and EuroSCORE (European System for Cardiac Operative Risk Evaluation Model) was calculated for each participant for predicting the death risk. The observed in-hospital mortality is also calculated for the whole cohort. By comparing the actual mortality and expected mortality, the two models’ performances on mortality prediction were evaluated. For the entire cohort, the observed mortality was 2.34% Area under the receiver operating characteristics curve (AUC) was used to study the discriminatory abilities of the models. AUC ≥ 0.7 is reasonable, AUC> 0.75 good, AUC> 0.8 is superior. The Hosmer-Lemeshow (H-L) goodness-of-fi t test was used to study the calibration of the predictive models. Calibration refers to the degree of accuracy of the model’s predictions, H-L goodness-of-fi t test with p<0.05 indicates signifi cant difference between observed mortality and predicted mortality; that is, the model has a low prediction accuracy. P>0.05 indicates a better model calibration (see Table 3-7-5). [1] Zheng S, Zheng Z, Fan H, Hu S. Is the European system for cardiac operative risk evaluation useful in Chinese patients undergoing heart valve surgery? Chinese Medical Journal, 2012, 125(20): 3624-3628. 146 Chapter 3 Cardiovascular Diseases Table 3-7-5 Studies on Clinical Validation of Sino-SCORE and EuroSCORE in 2012 Study Predicted Mortality AUC H-L Fit Test SinoSCORE 3.66 AUC=0.747 P=0.250 Additive EuroSCORE 3.71 AUC=0.699 P=0.051 Logistic EuroSCORE 3.19 AUC=0.696 P<0.001 In conclusion, the SinoSCORE is superior to the EuroSCORE at predicting in-hospital mortality in Chinese heart valve surgery patients. 3.7.4 Surgical Treatment of Coronary Artery Disease Coronary artery bypass grafting (CABG) has been widely implemented in mainland China. However, analysis of data from China Cardiovascular Surgery Registration Study [1] showed that there were variations in clinical outcomes following CABG surgery among different regions. The quality of clinical practice can be further improved. There are 43 healthcare centers from 17 provinces and 4 direct controlled municipalities involved in the China Cardiovascular Surgery Registration Study. They were grouped into east, north, south and central regions according to their geographical locations. Signifi cant variations existed in risk-standardized in- hospital all-cause mortality rates (RSMR) and risk-standardized in-hospital major complication rate (RSMCR) after CABG surgery in different regions after adjusted for risk factors (Table 3-7-6). Table 3-7-6 CABG Performance Quality by Regions Total East North South Central Average RSMR 1.9 1.6 2.0 1.7 2.5 Average RSMCR 6.4 5.8 6.5 7.7 6.5 3.7.5 Aortic Surgery 3.7.5.1 Aortic Dissection Investigators from Xijing Hospital retrospectively analyzed the data of 1 812 patients with acute aortic dissection (AAD) from 19 large hospitals in China (1 in northeast, 5 in southeast, 7 in central, 3 in northwest, and 3 in southwest; annual outpatient/emergency volume ≥ 200 000 patients, and size ≥ 1 000 beds) from January, 2008 to December, 2011. [2] The study showed early onset might be a feature of AAD in mainland China; however, the cause was still unclear. AAD was found more often in men. This could be attributed to [1] Hu S, Zheng Z, Yuan X, et al. Coronary artery bypass graft: contemporary heart surgery center performance in China. Circ Cardiovasc Qual Outcomes, 2012, 5(2): 214-221. [2] Li Y, Yang N, Duan W, et al. Acute aortic dissection in China. Am J Cardiol, 2012, 110(7): 1056-1061. 147 Report on Cardiovascular Diseases in China (2013) the fact that the smoking rate in men was much greater than that in women in China (50% vs 10%); In the IRAD study, the smoking rates were 30% and 20% for men and women respectively[1] . Additionally, other risk factors for AAD, such as hypertension and coronary heart disease, were more prevalence in men than in women. Moreover, presentation with atypical signs and symptoms were relatively high: up to 30% of the patients ultimately diagnosed with AAD were fi rst thought to have a different diagnosis. The distribution of Stanford Type A (affecting the ascending aorta) and Type B dissection (not involving the ascending aorta) was markedly different, with a preponderance of type B dissection. This difference might have originated from the fact that patients with Type A AAD have a higher pre-admission mortality. Patient baseline characteristics are showed in Table 3-7-7. In-hospital treatment, complications and mortality are showed in Table 3-7-8. Table 3-7-7 Baseline Characteristics of Patients with Acute Aortic Dissection in Mainland China Compared to Patients in Other Regions Age Type A <40 year-old ≥ 70 year-old Male: Female (years) Dissection Age (years) Mainland China 51.1±10.9 47.5±11.2 13.6% 5.1% 3.4 4:1 IRAD[2] 60.3±14.3 7.8% 29.4% 1.8 8:1 Japan [3] 65.2±11.1 Taiwan [4] 65.6±14.0 2.1 7:1 Note: IRAD (International Registry of Acute Aortic Dissection), Caucasian-dominant patient population Table 3-7-8 In-hospital Treatment, Complications, and Mortality Total Dissection Type P value (n=1 812) A (726) B (1 086) Treatment Medical Treatment 311 (17.2%) 117 (16.1%) 194 (17.9%) <0.001 Surgery 591 (32.6%) 547 (75.3%) 44 (4.1%) Endovascular Treatment 878 (48.5%) 52 (7.2%) 826 (76.1%) [1] Raghupathy A, Nienaber CA, Harris KM, et al. International registry of acute aortic dissection (IRAD) investigators. Geographic differences in clinical presentation, treatment, and outcomes in type A acute aortic dissection (from the International registry of Acute Aortic Dissection). Am J Cardiol, 2008, 102(11): 1562-1566. [2] Raghupathy A, Nienaber CA, Harris KM, et al. International registry of acute aortic dissection (IRAD) investigators. Geographic differences in clinical presentation, treatment, and outcomes in type A acute aortic dissection (from the International registry of Acute Aortic Dissection). Am J Cardiol, 2008, 102(11): 1562-1566. [3] Takeuchi T, Adachi H, Ohuchida M, et al. A case-control study found that low albumin and smoking were associated with aortic dissection. J Clin Epidemiol, 2004,57(4): 386-391. [4] Yu HY, Chen YS, Huang SC, et al. Late outcome of patients with aortic dissection: study of a national database. Eur J Cardiothorac Surg, 2004, 25(5): 683-690. 148 Chapter 3 Cardiovascular Diseases Table 3-7-8 In-hospital Treatment, Complications, and Mortality Continued Total Dissection Type P value (n=1 812) A (726) B (1 086) Hybrid Treatment 32 (1.8%) 10 (1.4%) 22 (2.0%) In-hospital Complications Coma 130 (7.2%) 96 (13.2%) 34 (3.1%) <0.001 Acute Renal Failure 121 (6.7%) 76 (10.5%) 45 (4.1%) <0.001 Myocardial Ischemia/infarction 101 (5.6%) 87 (11.9%) 14 (1.3%) <0.001 New Neurological Symptoms 63 (3.5%) 55 (7.6%) 8 (0.7%) <0.001 Endoleak 133 (7.3%) 8 (1.1%) 125 (11.5%) <0.001 In-hospital Mortality Overall Mortality 321 (17.7%) 248 (34.2%) 73 (6.7%) <0.001 Mortality of Medical Treatment 89 (28.6%) 51 (43.6%) 38 (19.6%) <0.001 Mortality of Surgical 198 (33.5%) 185 (33.8%) 13 (29.5%) 0.037 Treatment Mortality of Endovascular 28 (5.8%) 10 (19.2%) 18 (2.2%) <0.001 Treatment Mortality of Hybrid Treatment 5 (15.6%) 2 (20.0%) 3 (13.6%) 0.903 The overall in-hospital mortality for AAD was as high as 17.7%. The mortality rate of type A was signifi cantly higher than that of Type B (34.2% vs 6.7%). Most of the deaths were occurred within the fi rst week. 85.1% of all in-hospital deaths were due to aortic rupture. Multivariate analysis showed that hypertension, Marfan syndrome, anterior chest pain, abdominal pain, migrating pain, and aortic arch vessel involvement were predictive factors for increased in-hospital mortality in patients with AAD. Surgery was performed in 75.3% of patients with type A AAD. Endovascular treatment was performed in 76.1% of patients with type B AAD. Mortality was highest in patients with type A AAD receiving medical treatment (43.6%) and lowest in patients with type B AAD receiving endovascular treatment. 3.7.5.2 Treatment of Abdominal Aortic Aneurysm Researchers from Sun Yat-Sen University retrospectively reviewed all published literatures involving studies on open surgery (OS) and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) in China from January 1976 to December 2010 [1] . They analyzed a total of 2 862 patients with 1 757 undergoing OS (OS group) and 1 105 undergoing EVAR (EVAR group). There was no signifi cant difference in the success rate of the procedures. Operative time, length of ICU stay, duration of total postoperative stay, blood loss, and blood transfusion requirements [1] Wang S. Comparison of clinical curative effect between open surgery and endovascular repair of abdominal aortic aneurysm in China. Chinese Medical Journal, 2012, 125(10): 1824-1831. 149 Report on Cardiovascular Diseases in China (2013) during the procedure were signifi cantly lower in the EVAR group. The 30-day mortality rate, including aorta-related and non-aorta-related mortality, was signifi cantly lower in the EVAR group (p<0.01). A 30-day follow-up revealed higher rates of cardiac, renal, pulmonary, and intestinal complications in the OS group (p<0.01). Low-limb ischemia, however, was more common in the EVAR group (p <0.05). In long-term follow-up, there were more patients with graft occlusions and endoleak in the EVAR group (p<0.01). The overall late mortality rate was higher in the OS group (P<0.01), especially non-aorta-related late mortality and mortality during the fourth to the sixth year (p<0.01). In conclusion, EVAR was safer and less invasive for AAA patients. 3.8 Chronic Kidney Disease 3.8.1 Epidemiology of Chronic Kidney Disease (CKD) 3.8.1.1 Risk of CKD A study in Taiwan assessed the risk of developing CKD among heart disease patients by retrospective analysis of 26 005 patients with new diagnoses of heart disease and 52 010 patients without heart disease identifi ed between 2000 and 2001 through its national medical insurance database over a 7-year follow-up period. [1] After adjusting for sociodemographic characteristics and comorbidities, the hazard ratio for CKD among patients with heart disease was 2.37 (95% CI: 2.05-2.74). Another study in Taiwan followed 4 248 adults, among which 637 (15.0%) had metabolic syndrome (MS) at baseline. [2] After an average of 5.4 years of follow-up, 208 persons developed CKD. Multivariate analysis revealed compared with individuals without MS, the hazard ratio for CKD was 1.42 among individuals with MS (95% CI: 1.03-1.73). 3.8.1.2 Prevalence of CKD [3] A national CKD prevalence survey from September 2009 to September 2010 employed a sequential cross-sectional methodology to select responders among 47 204 adults across 13 different provinces, direct controlled municipalities, and autonomous regions. The results revealed that overall prevalence of CKD was 10.8%, the adjusted prevalence of eGFR <60 ml/min/1.73m2 was 1.7% (95% CI: 1.5-1.9), and of urine albumin-creatinine ratio > 30 mg/g was 9.4% (95% CI: 10.2-11.3). According to the standard population composition in 2009, the number of patients with CKD was estimated to be about 120 million. Age, gender, [1] Liu JH, Lin SY, Hsu CY, et al. The risk for chronic kidney disease in patients with heart diseases: A 7-year follow-up in a cohort study in Taiwan. BMC Nephrol, 2012, 13:77. [2] Yang T, Chu CH, Hsu CH, et al. Impact of metabolic syndrome on the incidence of chronic kidney disease: A Chinese cohort study. Nephrology, 2012, 17(6): 532-538. [3] Zhang L, Wang F, Wang L, et al. Prevalence of chronic kidney disease in China: A cross-sectional survey. Lancet, 2012, 379(9818): 815-822. 150 Chapter 3 Cardiovascular Diseases hypertension, diabetes, medical history of cardiovascular disease, hyperuricemia, living location and economic status were independent risk factors for CKD. 3.8.2 Cardiovascular Complications among CKD Patients 3.8.2.1 Hypertension Awareness, Treatment and Control Rates among CKD Patients Among 61 tertiary hospitals across 31 provinces, autonomous regions and direct controlled municipalities (excluding Hong Kong, Macao and Taiwan) that met the inclusion criteria (independent nephrology service, > 40 beds, and > 50 CKD patients per month), a total of 8 927 non-dialysis CKD patients were included (22.5% of this group were stage 5 non-dialysis CKD patients). [1] The prevalence, awareness, and treatment rates for hypertension were 67.3%, 85.8%, and 81.0% respectively. 33.1% and 14.1% had controlled BP to < 140/90 mmHg and < 130/80 mmHg, respectively. 3.8.2.2 Effects of Different Dialysis Modalities on Cardiovascular Complications in ESRD Patients CVD is the most common cause of mortality among dialysis patients. In a multi-center cohort study conducted by the Chinese Dialysis Association (comprising nine of the nation’s largest dialysis center databases), [2] 2 388 dialysis patients without cardiovascular complications prior to dialysis were included (1 775 patients were on hemodialysis and 613 on peritoneal dialysis). 57% of them developed cardiovascular complications after dialysis with no signifi cant difference between hemodialysis and peritoneal dialysis patients. Patients on peritoneal dialysis experienced more ischemic heart disease and stroke. A sub-analysis by age and dialysis length revealed that among patients older than 50 years or dialysis length greater than 36 months, cardiovascular complications were more prevalent among patients on peritoneal dialysis than hemodialysis patients. Multivariate analysis revealed that high blood glucose level was the most signifi cant risk factor for developing cardiovascular complications in peritoneal dialysis patients, but not for hemodialysis patients. At the same time, hyperglyceridemia and hypoalbuminemia were independent risk factors for cardiovascular complications in peritoneal dialysis patients only. 3.9 Peripheral Vascular Disease Peripheral arterial disease is a common manifestation of systemic atherosclerosis excluding the coronary and intracalvarium arteries. This report is only involved in lower extremity atherosclerotic disease (LEAD) and carotid atherosclerotic disease (CAD). [1] Zheng Y, Cai GY, Chen XM, et al. Prevalence, awareness, and treatment rates in chronic kidney disease patients with hypertension in China (PATRIOTIC) collaborative group. Prevalence, awareness, treatment, and control of hypertension in the non- dialysis chronic kidney disease patients. Chin Med J (Engl), 2013, 126 (12): 2276-2280. [2] Hou F, Jiang J, Chen J, et al. China collaborative study on dialysis: a multi-center cohort study on cardiovascular disease in patients on maintenance dialysis. BMC Nephrol, 2012, 13:94. 151 Report on Cardiovascular Diseases in China (2013) 3.9.1 Lower Extremity Atherosclerotic Disease (LEAD) 3.9.1.1 Prevalence of LEAD Lower extremity atherosclerotic disease is a common disease in middle-aged and elderly populations. Many epidemiological studies were conducted on LEAD prevalence by non-invasive methods including Rose Claudication Questionnaire, ankle-brachial index (ABI) and pulse wave velocity (PWV), etc. Table 3-9-1 shows related epidemiological results on LEAD in China. These studies showed that there was a signifi cant difference in LEAD prevalence among different populations, but in those with risk factors, the prevalence was similarly relatively high. In addition, the prevalence increased with age, and in most studies, it was higher in females than in males. Table 3-9-1 Epidemiological Results on the Prevalence of LEAD in China Prevalence (%) Group (study year) Cases Age (years) Male Female Average Beijing Wanshoulu District (2003)[1, 2] 2 124 60-95 12.7 18.1 16.4 Zhejiang Zhoushan (2005)[3] 2 668 35- 3.0 1.2 2.1 Metabolic Syndrome Group (2006)[4] 2 115 32-91 21.7 23.4 22.5 MUCA Study Group (2007)[5] 18 140 35- 5.4 9.3 6.0 Diabetes Group (2007)[6] 1 347 50- 18.3 20.4 19.4 Hypertension Group[7] 3 047 >50 — — 27.5 Natural Community Group (2009)[8] 21 152 18- 1.8 4.3 3.04 Wuhan Elderly Diabetes Group (2010)[9] 2 010 60- — — 24.1 Note: The diagnostic of LEAD was based on ABI <0.90. MUCA: multiple units cooperation of Chinese epidemiology cardiovascular diseases. [1] Li XY, Wang J, He Y, et al. Relationship between peripheral arterial occlusive disease and cardiovascular disease, cross-sectional; study in Wanshoulu area, Beijing. Chinese Medical J, 2003,83(21):1847-1851. [2] Wang J, Li XY, He Y, et al. A Cross-sectional study of peripheral arterial occlusive disease in Wanshoulu area, Beijing. Chinese Journal of Epidemiology, 2004, 25(3): 221-224. [3] Liu CG, Ruan LS. Prevalence of peripheral vascular disease in Zhejiang Zhoushan. Chinese J of Geriatrics, 2005,24(11):863-865. [4] Wei YD, Hu DY, Zhang RF, et al. A clinical study of peripheral arterial disease complicated with metabolic syndrome. Chinese Medical Journal, 2006, 86(30): 2114-2116 [5] Li X, Wu YF. The national prevalence of peripheral atherosclerosis and distribution of ankle brachial index in elderly population. Dissertation assembly of the forum on prevention and treatment of peripheral arterial disease in elderly, 2007:99. [6] Guan X, Liu ZM, Li GW, et al. Analysis of peripheral arterial obstructive disease realted factors among diabetic population aged≥50. Chinese Medical Journal, 2007. 87(1): 23-27. [7] Li Jue. Serial reports on study of lower extremity arterial disease in China-mortality of lower extremity arterial disease in high risk population and its odds ratio with mortality of cardiovascular diseases. Chinese Journal of Practical Internal Medicine, 2006. 26(21): 1685-1687. [8] Wang Y, Li J, Xu YW, et al. Prevalence and risk factors of lower extremity peripheral arterial disease in Chinese natural population. Chinese Journal of Cardiology, 2009. 37(12): 1127–1131. [9] Wang L, Du F, Mao H, et al. Prevalence and related risk factors of peripheral arterial disease in elderly patients with type 2 diabetes in Wuhan, Central China. Chin Med J (Engl), 2011. 124(24): 4264-4268. 152 Chapter 3 Cardiovascular Diseases 3.9.1.2 Risk Factors for LEAD Epidemiological studies suggest that the prevalence of LEAD increases with age and the risk factors associated with atherosclerosis. The main cause of LEAD is atherosclerosis, and all atherogenic risk factors such as smoking, diabetes, dyslipidemia, hypertension, and homocysteinemia can increase the risk of LEAD. 30% of cerebrovascular disease patients and 25% of ischemic heart disease patients also have LEAD. Therefore, LEAD is an important window refl ecting the systemic atherosclerotic diseases, and the early detection and treatment for LEAD are very important for dealing with systemic arteriosclerotic diseases. Recent research in 2013 revealed that cystatin C level was an independent predictor factor, and cystatin C > 1.2 mg/L markedly increased the risk of LEAD (OR 21.79, 95% CI: 10.05-47.28, p<0.001). [1] 3.9.1.3 Effect of LEAD on Mortality The mortality of patients with LEAD is clearly higher than those without LEAD at the same age, and the mortality of patients with LEAD gradually increases with the ABI reduction. One study investigated the relationship of ABI with all-cause mortality and cardiovascular mortality in Chinese inpatients after 3 years of follow-up. A total of 3 210 patients at high risk for atherosclerosis were divided into 4 groups based on ABI levels. The results showed patients with ABI ≤0.4 were 3 times as likely to die as those with ABI in the ranse 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 CVD as those with ABI in the range of 1.00-1.4 (Table 3-9-2). [2] Table 3-9-2 Morality Rates among Atherosclerosis High-risk Patients With 3-year Follow-up by ABI (%) Mortality Rate ABI ≤ 0.4 0.41-0.9 0.91-0.99 1.0-1.4 Total P-value All-cause mortality 37.7 24.4 13.2 12.1 15.7 <0.001 CVD mortality 27.5 14.5 8.1 6.3 8.9 <0.001 3.9.2 Carotid Atherosclerotic Disease (CAD) 3.9.2.1 Prevalence and Risk Factors for CAD CAD is another disease commonly seen among middle-aged and elderly people. Diagnostic methods used in epidemiological studies on its prevalence include atherosclerotic plaque detection rates and intima-media thickness (IMT) measurements via carotid ultrasound. The prevalence of CAD is associated with age, risk factors and baseline diseases. A Sino-US cooperation population-based cohort study in Shijingshan district and Beijing University [1] Liu F, Shen J, Zhao J, et al. Cystatin C: a strong marker for lower limb ischemia in Chinese type 2 diabetic patients? PLoS One, 2013, 8(7): e66907. [2] Li X, Luo Y, Xu Y, et al. Relationship of ankle-brachial index with all-cause mortality and cardiovascular mortality after a 3-year follow-up: the China ankle-brachial index cohort study. J Hum Hypertens, 2010, 24(2): 111-116. 153 Report on Cardiovascular Diseases in China (2013) community revealed that the rate of carotid atherosclerotic plaques among 2 681 patients aged 43 to 81 was 60.3% (66.7% in males, 56.2% in females). Carotid atherosclerotic plaques mainly located at the carotid sinus (Table 3-9-3). Multivariate analysis showed that IMT among males and females increased with elevations in blood pressure, blood glucose, and LDL-C levels. Compared to patients without any risk factors, plaque detection rates were higher among patients with hypertension, diabetes, smoking, or high LDL-C. The study suggested that carotid atherosclerosis was prevalent among Chinese middle-aged and elderly people and was associated with multiple cardiovascular risk factors. [1] A new cohort study of 1 195 patients followed from 1993-1994 to 2002 showed that carotid IMT was signifi cantly associated with blood lipid levels (TC, LDL-C, non-HDL-C, TC/HDL-C, and LDL-C/HDL-C) at baseline and at follow-up; the association with blood lipid levels at baseline was stronger. [2] Table 3-9-3 Atherosclerotic Plaque Rates among Middle-aged/elderly People in Beijing Atherosclerotic Plaque Detection Rates (%) Parameters n(%) a Internal Carotid a Common Carotid Carotid Sinus Carotid Artery Male <55 y 237(9.2) 7.1 46.9 15.5 53.1 55-59 y 121(4.7) 12.0 56.0 13.6 64.2 60-64 y 170(6.6) 24.0 58.7 23.5 63.1 65-69 y 168(6.6) 21.8 62.6 26.3 68.7 70-74 y 204(8.0) 32.1 72.0 33.9 78.9 >75 y 102(4.0) 32.4 78.8 38.9 79.6 Sum 1 002(39.1) 20.9 61.2 24.7 66.7 Chi-square 54.773 40.235 38.704 42.820 Female <55 y 360(14.0) 3.0 28.6 5.7 32.4 55-59 y 177(6.9) 6.1 38.7 7.7 45.3 60-64 y 410(16.0) 10.9 50.0 11.8 53.9 65-69 y 295(11.5) 20.7 64.3 14.8 69.2 70-74 y 217(8.5) 23.4 73.0 18.9 77.9 >75 y 103(4.0) 36.2 29.0 22.9 83.8 Sum 1 562(60.9) 13.8 51.6 12.2 56.2 Chi-square 115.822 180.461 40.053 187.935 Total 2 564(100) 16.6 55.4 17.2 60.3 [1] Wang W, Wu YF, Zhao D, et al. Distribution characteristics and risk factors of carotid atherosclerosis in middle-aged and elderly Chinese. Chinese Journal of Cardiology, 2010, 38(6): 553-557. [2] Huang Y, Yu X, Millican D, et al. The measurement of lipids currently and 9 years ago – which is more associated with carotid intima-media thickness? Clin Cardiol, 2012, 35(8): 512-517. 154 Chapter 3 Cardiovascular Diseases A 2007-2010 survey among 13 896 people aged ≥ 35 years in the Uyghur, Kazakh, and Han Chinese ethnic groups revealed that the overall rate of carotid atherosclerotic plaque was 10.2%, and that of the Uygur, Kazak and Han groups was 12.5%, 7.2%, and 10.4% respectively. The relatively low carotid artery plaque detection rate in the study was probably related to the low cardiovascular risk factors among these populations. [1] 3.9.2.2 CAD and the Risk for Ischemic Heart Disease A 5-year follow-up study showed that the baseline IMT was an independent predictor for ischemic heart disease in patients without carotid atherosclerotic plaques (HR = 1.59, 95% CI: 1.04-2.45). For patients with carotid plaques, the risk of ischemic heart disease increased with overall plaque surface area (HR=1.29, 95% CI: 1.08-1.55) and the number of plaques (HR=1.14, 95% CI: 1.02-1.27). [2, 3] [1] Yang YN, Wei N, Ma YT, et al. Survey on carotid atherosclerotic plaque detection rate in Uyghur, Kazakh, and Han Chinese ethnic groups. Chinese Medical Journal, 2011, 91(4): 225-228. [2] Xie W, Wu Y, Wang W, et al. A longitudinal study of carotid plaque and risk of ischemic cardiovascular disease in the Chinese population. J Am Soc Echocardiogr, 2011, 24(7): 729-737. [3] Xie W, Liang L, Zhao L, et al. Combination of carotid intima-media thickness and plaque for better predicting risk of ischemic cardiovascular events. Heart, 2011, 97(16): 1326-1331. 155 Chapter 4 Community-based Prevention and Control of CVD 4.1 Overview The exploration and practice on community-based prevention of cardiovascular diseases (CPCCVD) in China have been carried out for more than 40 years, and gradually become a comprehensive intervention program that focuses on prevention and treatment of hypertension. The fi rst hypertension prevention and treatment center in China, established in 1969 at the Capital Iron and Steel Company by Fuwai Hospital, was a model of functional community-based prevention work, recognized by the World Health Organization as the “Capital Iron Model.” Since the 1970s, different places have established similar centers and pilot projects in succession addressing comprehensive prevention and treatment of cardiovascular disease. Since 1997, 24 provinces, autonomous regions, and direct controlled municipalities including Beijing, Tianjin, Shanghai, and Zhejiang have launched model comprehensive care programs for chronic diseases. In 2010, the National Ministry of Health launched on the establishment of demonstration sites for chronic disease prevention and treatment, 140 of such sites were established by 2012. China’s community-based prevention work was explored a way forward and obtained obvious achievements. In 2009, the government issued new medical reform policies that brought community-based prevention of hypertension and diabetes into the domain of national public health services and launched prevention-oriented work at the national level. Over the course of more than 40 years, China’s community-based prevention of cardiovascular diseases has gone from a local pilot project to regional comprehensive interventions to a fundamental national public health service; from mere interventions of hypertensive patients to management of entire communities (including healthy persons, high-risk persons, and sick persons) and comprehensive management of multiple chronic diseases (diabetes, hyperlipidemia, coronary artery disease, stroke, etc.); from emphasizing the monitoring of prevalence, mortality, and risk factors of cardiovascular diseases to focusing on improving awareness, treatment, and prevention among the population; and from model research conducted by experts for the sake of science to preventative work led by the government through collaborative efforts. Comprehensive prevention of cardiovascular diseases in China is gradually developing towards standardization, socialization and informatization step by step. 156 Chapter 4 Community-based Prevention and Control of CVD 4.2 An Example of Community-based Prevention and Control of CVD — Shenzhen Mode for Prevention and Control of Chronic Diseases Chronic diseases, notably hypertension and diabetes, have caused a signifi cant economic burden on China. The national proportion of deaths due to chronic diseases exceeds 80% [1] and accounts for 68.6% of all disease burdens. [2] Because of this, prevention and treatment of chronic diseases demand immediate action. Prevention work on chronic diseases conducted in Shenzhen city, which has more than 10 years of exploration and practice since 1996, has shown defi nite progress in terms of prevention framework and implementation model. 4.2.1 The Organizational Model of the Shenzhen Chronic Disease Prevention and Control Program Through more than 10 years of hard work, Shenzhen established a three-tier prevention network with a city-level chronic disease center at the top, district-level chronic disease prevention units in the middle, and community health centers on the foundational tier (Figure 4-2-1). The Shenzhen chronic disease prevention and treatment team includes public health prevention personnel and clinical staff that serve to provide an integrative system, which delivers chronic disease management services and takes responsibilities for chronic disease management within districts. It is a specialized public health unit directly under the supervision of the Committee of Municipal Health, Population, and Family Planning. 571 community centers throughout the city provide chronic disease prevention services. The city of Shenzhen has assumed the task of chronic disease prevention through its unique framework that features very prominent local characteristics. At every level of its three-tiered network, different responsibilities are assigned. The city-level chronic disease center is responsible for formulating policies, plans, and work regulations. It also coordinates and implements training and monitoring; provides technical support and guidance; engages in practical research; introduces applicable new technologies; and organizes inspection and assessment. The district-level prevention units implement strategies for the prevention, control, treatment and management of chronic diseases within their areas of jurisdiction according to the policies, plans and regulations set at the city-level. The community health centers are responsible for the groundwork of prevention projects, directly providing services to the people. An important characteristic of chronic diseases is the close relationship between prevention and treatment. The organization of the chronic disease team integrates personnel focused on prevention and clinical care respectively to close the gap between the two fi elds. The team’s professionals are thus not only knowledgeable on preventative medicine and public health, but also equipped with clinical management skills. The chronic disease team sets up a specialized clinic that serves to fi nd and provide treatment for [1] Wang LD, Kong LZ, Wu F, et al. Preventing chronic diseases, Lancet, 2005, 366: 1821 – 1824. [2] WHO. 2009. Global health risks: Comparative risk assessment project. Geneva: WHO. 157 Report on Cardiovascular Diseases in China (2013) patients and at the same time manages registration and follow-up appointments. [1] This not only provides population-based prevention and treatment, but also gives individual-based services. &LW\3XEOLF+HDOWKDQG &LW\OHYHOFKURQLF 3RSXODWLRQ3ODQQLQJ&RPPLVVLRQ GLVHDVHFHQWHU 'LVWULFWSXEOLF 'LVWULFWOHYHOFKURQLF KHDOWKGHSDUWPHQW GLVHDVHSUHYHQWLRQXQLW 0XQLFLSDOKHDOWKFDUHXQLW &RPPXQLW\KHDOWKFHQWHU $GPLQLVWUDWLYHDVVRFLDWLRQ ,PSOHPHQWLQJDVVRFLDWLRQ Figure 4-2-1 Basic Framework of the Shenzhen Chronic Disease Prevention System. 4.2.2 Primary Strategies of the Shenzhen Chronic Disease Prevention and Control System [2] Shenzhen’s chronic disease prevention relies on its unique three-tiered model that “prioritizes prevention and integrates treatment” through long-term health management, which includes preventative measures, diagnosis and treatment, and patient management. Different preventative work is launched at every level and tier. The main strategies include the following: (1) Through the “prevent-treat-manage” model, improve the connections between public health and clinical care. At the city and district levels, preventative medicine clinics have been set up. They provide medical treatment, while at the same time provide technical support and work platform for effective implementation of different public health programs. This fully displays the “prevent-treat-manage” model. (2) Provide early diagnoses, interventions, and treatments for patients and high-risk population with the following methods. One, measure blood pressure for subjects over the age of 35 at their fi rst clinic visit., Establish a fi le for persons with elevated blood pressure and initiate health education and interventions with regular follow-up. Two, create self-check sites for health parameters at different locations. Self- check sites allow people to measure their height, weight, waist circumference, blood pressure, and blood glucose levels. Three, actively screening work is performed among patients and high-risk subjects at all [1] Zhang H, Li S, Fu YY et al. Study on the implementation of community chronic disease self management project . Modern Preventative Medicine, 2007, 34(11): 2148-2152. [2] Wu GY, Gong YL, Chen XX, et al. The role of community health service station in chronic disease management. Chinese Journal of Hospital management, 2001, 17(3): 158-160. 158 Chapter 4 Community-based Prevention and Control of CVD community health centers. Through routine blood pressure checks, home visits, regular physical exams, active community screenings and other routes, high-risk subjects and sick persons can be discovered for comprehensive interventions and follow-up. Four, encourage self-management initiatives among patients with chronic diseases and establish hypertension self-help small groups under the model of “physician- patient cooperation, mutual support among patients, and self-management”. A group leader guides each small group through regular activities that encourage the participants’ initiatives and willingness, together with the services provided by medical personnel, ultimately to limit morbidity, mortality, and social burdens due to hypertension. [1] (3) Take full advantage of the community health centers in the three-tier network. The city of Shenzhen established a system that allows community health centers and hospitals to work together. At the community health centers, the primary care physicians and nurses of the chronic disease teams sign memoranda of agreement with their patients that encourage patients to go to community health centers for minor illnesses and to hospitals for major diseases. (4) Establish a chronic disease prevention and treatment expert team to provide professional guidance. In order to further consolidate clinical and preventative models, strengthen connections between hospitals and public health units, encourage collaborations between the two and improve the quality of comprehensive prevention and treatment delivery, an expert group on chronic diseases was established in Shenzhen city. This group is divided into six panels, including hypertension, diabetes, stroke, cancer, oral hygiene and community health. Direct conversation and immediate training at conferences attended by these experts provide effective professional guidance and support for chronic disease primary care physicians. (5) Strengthen organizational infrastructure and surveillance. Prevention work for chronic diseases must act over a long-term period, so it must have an effective organization and improve its surveillance quality. Shenzhen’s primary strategies include: one, establish a monitoring system at the city and district levels. Through various communication systems, telephone checks and on-site consultations were conducted every season for high-risk population and patients. Consultation topics included reliability of medical information, completeness of patient fi les, regularity of patient management, effectiveness of treatment, and others. Two, increase the proportion of the community health budget for chronic disease management. Because of the high prevalence and diffi culty in managing hypertension and diabetes individuals, budget adjustment greatly improved the initiatives of community staffs. Three, implement an inspection system that allows community health center budgets to be directly associated with inspection results. With the help of information technology, the city-level chronic disease centers could accurately assess community health center and personnel’s workload and assign budgets and salaries accordingly. [1] Zhuo ZP, Yuan XL, Chen ZW, et al. The role of community health service station in chronic disease management . Chinese Journal of hospital management, 2013, 21(6): 656-658. 159 Report on Cardiovascular Diseases in China (2013) 4.2.3 Preliminary Successes of the Shenzhen Chronic Disease Prevention and Control Model The number of personnel and quality in the management of hypertensive and diabetic patients increases every year. Currently, management rate of hypertension is close to 40%, and standardized management rate exceeds 75%, and the blood pressure control rate is over 50% among managed hypertensive patients. In 2011, The Shenzhen Chronic Disease Epidemiology Survey revealed that hypertension awareness rate, treatment rate, and control rate under treatment were 59.1%, 84.9%, and 43.7%, higher than national averages (41.0%, 80.7%, and 22.9%, respectively). These results are intricately associated with the city’s implementation of comprehensive prevention and treatment, bolstering community chronic disease awareness and follow-up management of chronic disease patients. [1] In 2011, two districts in Shenzhen became the fi rst national model examples for comprehensive prevention of chronic diseases. In 2012, the other four districts were also selected as model examples, thus completing the establishment of all 6 national model districts. [1] Liu XL, Peng J, Zhou HB et al. Epidemiological study on chronic non-communicable diseases and relative risk factors in Shenzhen. Beijing: People’s Health Publishing House. 2009; 256-257. 160 Chapter 5 Medical Expenditure of Cardiovascular Diseases 5.1 Status of Service Utilization for Patients with Cardiovascular Diseases in China 5.1.1 Trends in Hospitalization and Discharge of CVD [1, 2, 3] In all patients discharged from hospital in 2012, 12.24% were related to CVD (14.352 9 million), including 5.82% diagnosed with cerebrovascular disease (6.827 9 million) and 6.42% with heart disease (7.525 million). Most CVD patients discharged from hospitals in 2012 had ischemic heart disease (5.047 4 million; including 295 200 acute myocardial infarction) and cerebral infarction (4.121 6 million), accounting for 35.17% and 28.72% of total CVD patients, respectively. Other types of CVD included hypertension (2.239 4 million; including 178 100 patients with hypertensive heart disease and renal disease), intracranial hemorrhage (1.204 7 million), and rheumatic heart disease (238 300). Additionally, 2.391 3 million diabetes mellitus patients were discharge from hospital in 2012. From 1980 to 2012, the annual average growth rate in the number of patients discharges for CVD in China was 9.45%, which is faster than all-cause discharges (6.13%). The annual discharge rates for cerebral infarction, coronary artery disease, intracranial hemorrhage, acute myocardial infarction, hypertension, and hypertensive heart disease/renal disease increased faster than for other CVD by 12.22%, 11.61%, 10.14%, 8.53%, 8.18%, and 5.46%, respectively. The discharges for rheumatic heart disease also increased by 1.37%, though without statistical signifi cance. The discharges for diabetes increased annually by 14.08% during the same period (Figure 5-1-1). [1] Ministry of Health of P.R.C., China Health Statistics Yearbook, 1980-2001. [2] Ministry of Health of P.R.C., China Health Statistics Yearbook, 2002-2012. [3] National Health and Birth Control Committee, China Health and Birth Control Statistics Yearbook, 2013. 161 Report on Cardiovascular Diseases in China (2013) 7RWDO &DUGLR &HUHEUR Year 1980 1990 2000 2012 Total 79.80 176.93 333.50 1435.29 Cardio- 60.28 116.91 187.46 752.50 Cerebro- 19.52 60.02 146.04 682.79 'LVFKDUJH Figure 5-1-1 Trend of Discharge Numbers for CVD, 1980 – 2012 Note: CVD including ischemic heart disease (angina, acute myocardial infarction, and other ischemic heart diseases), rheumatic heart disease, pulmonary heart disease, hypertension (hypertensive heart disease and renal disease), and cerebrovascular disease (intracranial bleeding and cerebral infarction). Before 2002, ischemic heart disease was classifi ed as coronary artery disease in the Health Statistics Yearbook. Rheumatic HD Ischemic HD Acute MI Cerebral Infarction Hypertensive HD/CKD DM HTN Intracranial hemorrhage Year 1980 1990 2000 2012 Rheumatic HD 15.43 16.24 13.62 23.83 Ischemic HD 15.03 42.47 88.71 504.74 Acute MI - 4.75 10.07 29.52 Hypertensive HD/CKD 3.25 9.97 11.08 17.81 DM 3.53 13.59 36.89 239.13 HTN 18.09 44.57 70.60 223.94 Discharge (10 000) Intracranial hemorrhage 5.48 16.09 41.06 120.47 Cerebral Infarction 10.29 31.63 76.97 412.16 (Year) Figure 5-1-2 Trend of Discharge Numbers for Diabetes and Certain Types of CVD, 1980–2012 162 Chapter 5 Medical Expenditure of Cardiovascular Diseases $QQXDO,QFUHDVH Diabetes Rheumatic Ischemic Acute myocardial Hypertension Hypertensive heart Intracranial Cerebral heart Disease heart Disease Infarction Disease/Chronic Hemorrhage Infarction Kidney Disease Figure 5-1-3 Annual Growth Rates for CVD and Diabetes Patiens Discharged from Hospitals, 1980–2012 5.2 Hospitalization Costs of CVD [1, 2] For hospitalizations associated with CVD in 2012, total medical expenses of acute myocardial infarction, intracranial hemorrhage, and cerebral infarction were RMB 4.96 billion Yuan, 14.71 billion Yuan, and 29.85 billion Yuan, respectively (Figure 5-2-1). After adjusting for price infl ation, the annual increase of expenditure for acute myocardial infarction, intracranial hemorrhage, and cerebral infarction increased from 2004 by 25.00%, 18.94%, and 24.80%, respectively. The expenses for each hospitalization in 2012 were RMB 16 802.4, 12 207.4, and 7 241.3 for acute myocardial infarction, intracranial hemorrhage, and cerebral infarction, respectively, with an annual increase of 5.78%, 4.80%, and 0.96% since 2004. $FXWH0,,&+&, +RVSLWDOL]DWLRQ&RVW PLOOLRQ Figure 5-2-1 Trend of Total Hospital Expenses of CVD, 2004-2012 Note: acute MI: acute myocardial infarction; ICH: intracranial hemorrhage; CI: cerebral infarction [1] Ministry of Health of P.R.C., China Health Statistics Yearbook, 2005-2012. [2] National Health and Birth Control Committee, China Health and Birth Control Statistics Yearbook, 2013. 163 Report on Cardiovascular Diseases in China (2013) $FXWH0,,&+&, +RVSLWDOL]DWLRQ&RVW \XDQ ˄ Figure 5-2-2 Trend of Hospital Expenses for Each Hospitalization, 2004-2012 $YHUDJH$QQXDO,QFUHDVH5DWHIRU $YHUDJH$QQXDO,QFUHDVH5DWHIRU(DFK 7RWDO+RVSLWDOL]DWLRQ&RVWV +RVSLWDOL]DWLRQ&RVWV $QQXDO,QFUHDVH $FXWH0,,QWUDFUDQLDOKHPRUUKDJH&HUHEUDOLQIDUFWLRQ Figure 5-2-3 Change in Hospital Expenses for CVD, 2004-2012 5.3 Pharmaceutical Market of Cardiovascular Diseases In 2012, the total pharmacy expense among hospitals in China with at least 100 beds was RMB 442.48 billion Yuan, in which 12.10% was used in CVD treatment (53.524 billion). The fi ve most frequently purchased medications are for central and peripheral vascular diseases; for other CVD, calcium antagonists, lipid lowering drugs, and angiotensin II receptor antagonists. 164 Chapter 5 Medical Expenditure of Cardiovascular Diseases Table 5-3-1 Commonly Used Medication in Chinese Hospitals, 2012 Medicine Hospital expenses (thousand million) Cardio-cerebrovascular circulation improving medications* 154.88 Other nutritional supplements and coronary circulation 120.19 improving medications Calcium channel blockers 48.35 Lipid lowering drugs 47.98 Angiotensin II receptor antagonist 34.60 Antianginal medications excluding calcium channel blockers 23.16 and nitrates Medication for varicose veins 14.57 Nitrates 14.37 β-Adrenergic Receptor Blocking Agents 12.86 Angiotensin converting enzyme Inhibitor 12.02 Angiotensin II antagonists 9.87 Diuretics 5.05 Antihypertensive agents 4.25 Medications for low ejection fraction 2.99 Cardiac stimulants excluding cardiac glycosides 1.86 Others 28.23 Overall 535.24 * Cardio/cerebrovascular circulation improving medications mainly include Erigeron breviscapus, Fik Weitz, Xingding, Ginaton, Ginkgo bilboa extract, Shuxuening, Duxil,fl unarizine, Mailuoning, DA Lowe etc. Data obtained from IMS Health (Shanghai) consulting company. In this study, 1 600 hospitals with at least 100 beds were included. Medications in this study included both typical medications used in CVD treatment worldwide, and Chinese medications which are commonly seen in Asia. 5.4 Content and Cited Data in This Report For more information about medical expenses of CVD in 2012, please see the Chinese Health Statistics Yearbook 2012. Hospital expenditures for CVD in 2012: for representativeness and scientifi c value, the data here is based on hospitalization expenditures of the 30 most common diseases reported on patient charts in a nationwide hospital sample and reported in the Health Statistics Yearbook. Number of discharges for CVD in 2003 was excluded from this report because of the changes in defi nition and diagnosis standards based on guidelines in 1987 and 2002 from the Statistics Information Center of National Health and Family Planning Commission, respectively. 165 Report on Cardiovascular Diseases in China (2013) Ischemic heart disease: since different diagnosis standards are employed in different local hospitals, some systematic error existed in the estimation of the relevant discharge rate. However, the trend of hospitalization for ischemic heart disease is not infl uenced by this. Medical care consumer price index (published in the Chinese Statistics Yearbook 2012) was used to adjust the medication expenses in this report to eliminate the effect of price infl ation. 166