The Burden of CVD in Asia: Stroke Deaths
by Country, 2002
WHO CVD Atlas. 2002. WHO Stroke Atlas. 2002.
2
The Burden of CVD in Asia: CHD Deaths by
Country, 2002
WHO CVD Atlas. 2002. WHO Stroke Atlas. 2002.
3
Age-Standardized Stroke and CHD Death
Rates by Country, 2002
Ueshima H et al. Circulation. 2008;118:2702-2709.
4
Stroke Type in China
• Sino-MONICA-Beijing project indicate from 1984 to 2004
– the incidence of hemorrhagic stroke declined by 1.7% annually
– the incidence of ischemic stroke increased by 8.7% annually
• Stroke subtypes in urban areas
Shanghai
Beijing
1.4
2.2
18.9
Ischemic
78.9
1.4
27.4
ICH
69.9
SAH
Undet
ICH = Intracranial hemorrhage, SAH = subarachnoid hemorrhage, undet = undetermined
Jiang et al. Stroke. 2006;37:63-68. Zhao et al. Stroke. 2008;39:1668-1674.
5
Projected Stroke and CHD Increase to
2030: Effect of Population Aging and
Risk-Factor Changes in China
Moran et al. Circ Cardiovasc Qual Outcomes. 2010;3;243-252.
6
Burden of Diabetes in Asia
40
35
30
Deaths Attributable to Diabetes,
Ages 20-79 Years
600,000
Age group, y
20-39
40-59
60-79
500,000
No. of Deaths
No. With Diabetes (millions)
No. with Diabetes
25
20
15
Men
Women
400,000
300,000
200,000
10
100,000
5
0
Africa
EMME Europe North SACA
America
Chan JC et al . JAMA. 2009;301:2129-2140.
SEA Western
Pacific
0
Africa
EMME Europe North SACA
America
SEA Western
Pacific
7
High Cumulative Incidence of Stroke in
Asians With Type 2 Diabetes
Asia
Eastern Europe
Established Market Economies
Major Cerebrovascular Events
Cumulative Incidence
12
P < 0.0001
10
8
6
4
2
0
0
1
2
3
Clarke PM et al. PLoS Med. 7:e1000236. doi:10.1371/journal.pmed.1000236.
4
8
Increase in Age-Standardized Mean Total
Cholesterol Levels in East and Southeast
Asia and Pacific Region, 1980-2008
Men
Women
Southeast Asia: Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Maldives, Myanmar, Philippines,
Sri Lanka, Thailand, Timor-Leste, Vietnam
East Asia: China, Hong Kong (China), Macau (China), Democratic People’s Republic of Korea, Taiwan,
Brunei, Darussalam, Japan, Republic of Korea, Singapore, islands of Oceania
Farzadfar et al. Lancet. 2011;377:578-586.
9
900,000
participants
from 61
prospective
cohort studies
(10% from
Japan or China)
Hazard ratio
(floating absolute risks & 95% CI)
Relationship of CHD Mortality With Usual
Total Cholesterol by Age: Prospective
Studies Collaboration
Age at
risk
1 mmol/L 
total cholesterol
256
80-89
15%  risk
128
70-79
18%  risk
60-69
28%  risk
50-59
42%  risk
40-49
56%  risk
64
32
16
8
4
2
Overall, 1 mmol/L
lower total cholesterol
 risk by 1/3
1
0·5
4·0 5·0 6·0 7·0 8·0
Usual total cholesterol (mmol/L)
Prospective Studies Collaboration. Lancet . 2007;370:1829-1839.
10
Hazard Ratio
(floating absolute risks & 95% CI)
Association of Stroke Mortality With Usual
Total Cholesterol by Age: Prospective
Studies Collaboration
64
Age at risk:
HR (95% CI)
per 1 mmol/L 
32
80-89
1.06 (1.00-1.13)
70-79
1.04 (0.99-1.09)
60-69
1.02 (0.97-1.08)
40-59
0.90 (0.84-0.97)
16
8
4
2
1
4·0
5·0
6·0
7·0
8·0
Usual Total Cholesterol, mmol/L
Prospective Studies Collaboration. Lancet . 2007;370:1829-1839.
11
Relationship of Cholesterol Level to
CV Mortality in Asians: Asia Pacific
Cohort Studies Collaboration
• 29 cohorts
• 352,033 individuals
– 283,544 Asians
– 68,489 Australians/New Zealanders
• 2 million person-years of follow-up
• 4841 cardiovascular deaths
Zhang X et al. Int J Epidemiol. 2003;32:563-572.
12
Association Between Usual Cholesterol
Level and CHD Death or Nonfatal MI:
Asia Pacific Cohort Studies Collaboration
CHD death in the
entire study population
Hazard ratio
3.0
3.0
2.0
2.0
1.4
1.4
1.0
1.0
0.7
1 mmol/L lower total cholesterol
associated with 35% (26%-44%)
lower coronary death
4.5
5.0
5.5
6.0
CHD death or nonfatal MI
in the entire study population
0.7
6.5
4.5
5.0
5.5
6.0
6.5
Mean usual total cholesterol (mmol/L)
MI = myocardial infarction.
Zhang X et al. Int J Epidemiol. 2003;32:563-572.
13
Association Between Usual Cholesterol
Level and Stroke: Asia Pacific Cohort
Studies Collaboration
Fatal stroke in the
entire study population
Hazard ratio
1.5
1.5
1.2
1.2
1.0
1.0
0.8
0.8
4.5
5.0
5.5
6.0
Fatal or nonfatal stroke
in the entire study population
6.5
4.5
5.0
5.5
6.0
6.5
Mean usual total cholesterol (mmol/L)
Zhang X et al. Int J Epidemiol. 2003;32:563-572.
14
Association Between Usual Cholesterol
Level and Ischemic Stroke: Asia Pacific
Cohort Studies Collaboration
Hazard ratio
Fatal ischemic stroke
2.0
2.0
1.5
1.5
1.2
1.2
1.0
1.0
0.8
0.8
0.6
0.6
4.5
5.0
5.5
6.0
6.5
Fatal or nonfatal
ischemic stroke
1 mmol/L lower total cholesterol
associated with 25% (13%-40%) lower
ischemic stroke (fatal or nonfatal)
4.5
5.0
5.5
6.0
6.5
Mean usual total cholesterol (mmol/L)
Analyses are stratified by study and sex and adjusted for age at risk, systolic blood pressure (BP), and smoking.
Zhang X et al. Int J Epidemiol. 2003;32:563-572.
15
Association Between Usual Cholesterol
Level and Hemorrhagic Stroke: Asia
Pacific Cohort Studies Collaboration
Fatal or nonfatal
hemorrhagic stroke
Fatal hemorrhagic stroke
2.0
Hazard ratio
1.5
2.0
1 mmol/L lower total cholesterol
associated with 20% (8%-30%)
higher hemorrhagic stroke (fatal)
1.5
1.2
1.2
1.0
1.0
0.8
0.8
0.6
0.6
4.5
5.0
5.5
6.0
6.5
4.5
5.0
5.5
6.0
6.5
Mean usual total cholesterol (mmol/L)
Analyses are stratified by study and sex, and adjusted for age at risk, systolic BP, and smoking.
Zhang X et al. Int J Epidemiol. 2003;32:563-572.
16
Summary
• Stroke is the leading cause of death in the East Asia and
Western Pacific region
• CV risk factors and CV mortality are projected to increase
• Increased cholesterol levels are a major cause of the high
risk for ischemic stroke in Asian Pacific countries
17