The risk factors of cardiovascular disease (CVD) are increasing persistently in China. The
morbidity and mortality of CVD are still at a high level. The burden of CVD is aggravated, and
becomes an important issue of public health. The prevention and treatment of CVD should be
1. Epidemiology of CVD
In general, the morbidity and mortality of CVD (heart disease and stroke) are elevating
continuously in Chinese population. It is estimated that the number of patients with CVD is 230 million, of which, 200 million are afflicted with hypertension, more than 7 million with stroke, 2 million with myocardial infarction, 4.2 million with heart failure, 5 million with pulmonary heart disease, 2.5 million with rheumatic heart disease, and 2 million with congenital heart disease. One out of 5 adults is suffered from CVD.
2. Mortality of CVD
The crude death rate of coronary heart disease (CHD) is 94.9 per 100 000 in urban citizens
and 71.27 per 100 000 in rural residents. The crude death rate of stroke is 126.3 per 100 000 in urban citizens and 152.1 per 100 000 in rural residents. About 3 million Chinese die of CVD annually, which accounts for 41% of all-cause death and is the leading cause of death. The acceleration of CVD death in rural residents is higher than that in urban citizens.
3. Risk Factors of CVD are Increasing Persistently
Hypertension is a principal risk factor of CVD in China. More than half of CVD is associated
with elevated blood pressure (BP). The prevalence of hypertension is increasing steadily. It was 18.8% in adults according to a National Survey in 2002, and reached approximately 25% in recent years according to investigation reports of some provinces and cities. It is supposed that 200 million Chinese are hypertensives, which means 1 of 5 adults is afflicted with hypertension. The major risk factors of hypertension are high-salt diet, overweight/obesity, over consumption of alcohol, and chronic intensive stress. Some study suggested that the prevalence of hypertension was increased by a factor of 3 in patients with obesity (body mass index [BMI] â‰¥28kg/m2) and by a factor of 2 in patients with overweight (BMI 24.0??27.9 kg/m2) in comparison with that in individuals with normal weight (BMI 24 kg/m2). The prevalence of hypertension is elevated by 72% in drinkers with alcohol intake â‰¥40g/d. A long-term follow-up study showed that 2.33 million CVD deaths were associated with elevated BP annually (2.10 million due to hypertension, and 0.22 million due to high normal BP), of which 1.27 million were premature CVD deaths (1.15 million due to hypertension, and 0.12 million due to high normal BP). The relationship between subtypes of hypertension and risk of CVD death. The risk of CVD death is 1.68 (95% confidence interval [CI] 1.58??1.78) in patients with isolated systolic hypertension, 1.45 (1.27??1.65) in isolated diastolic hypertension, and 2.53 (2.39??2.68) in combined systolic/diastolic hypertension, respectively. The risk of CVD death after antihypertensive treatment is 1.61 (1.28??2.08)
in patients with BP ??140/90 mmHg, and 2.88(2.60??3.09)in patients with BP??140/90 mmHg. The risk of CVD death is significantly reduced in patients with optmi al target BP.
Identification of high normal BP. The identification of high normal BP is higher in 2002 than that in 1991. It is reported that the risk in patients with high normal BP is increased by 56% for stroke, 44% for CHD, and 52% for all CVD. Close attention should be paid to the high normal BP in prevention of hypertension. Hypertension in children Identification of hypertension in children depends upon weight gain. The secondary hypertension accounts for half of the hypertension in children and should be taken into consideration.
Smoking is an important risk factor of CVD in China. The prevalence of smoking in male
has reached a plateau, but that is slightly increased in young female. Active smokers are 350 million, and passive smokers are 540 million. Although the abstinence from smoking is improved a little in population older than the age of 15 years, the combat against cigarette is still arduous.
The levels of plasma lipid in Chinese population are rising constantly in recent years, and that
in juveniles should be noted especially. According to a National Survey in 2002, the prevalence of dyslipidemia was 18.6% in adults, of which 2.9% was hypercholesterolemia (total cholesterol [TC] â‰¥5.72 mmol/L), 11.9% was hypertriglyceridemia (triglyceride [TG] â‰¥1.70 mmol/L), and 7.4% was low high-density lipoprotein cholesterol (HDL-C) level (HDL-C??1.04 mmol/L). It is estimated that dyslipidemia affects at least 200 million individuals, with hypercholesterolemia as the main risk factor of CVD (CHD).
3.4 Diabetes Mellitus
Diabetes mellitus is a common chronic disease and is also a potential risk factor of CVD.
The prevalence of diabetes mellitus is increasing rapidly in China with the change of lifestyle.
A survey was conducted by Chinese Diabetes Society in 14 provinces to investigate the prevalence of diabetes mellitus in residents â‰¥20 years old of central cities and their nearby countryside with the measurement of fast blood glucose and oral glucose tolerance test (OGTT). The age-standardized prevalence of diabetes mellitus was 9.7%, which was much higher than that in 2002. The prevalence of diabetes mellitus increases with age and BMI.
Prevention of diabetes mellitus A long-term follow-up study of diabetes prevention in Daqing
suggested that lifestyle modification in patients with impaired glucose tolerance could prevent or postpone the occurrence of diabetes mellitus.
Overweight/obesity is a pivotal risk factor of CVD. According to a survey in 2002, the
prevalence of overweight was 17.6% and that of obesity was 5.6%. It is estimated that the individuals with overweight and obesity may be as much as 240 million and 70 million, respectively. The prevalences of overweight/obesity in both children and adults are growing steadily, which is worthy of note.
3.6 Physical Inactivity
Physical inactivity is a risk factor of CVD. Lack of activity results in overweight/obesity,
hypertension, dyslipidemia, hyperglycemia and elevated risk of CVD. An investigation in 9 provinces and cities showed that the physical activity was reduced in young and middle-age residents. The physical activities in 2006 declined by 27.8% in male and 36.9% in female in comparison with those in 1997. A 2005 survey of physical health in college students with age of 19~22 years indicated that in comparison with that in 1985, the physical functionality decreased strikingly and the prevalence of overweight/obesity increased notably, which suggested that the physical activity of college students was going on a downward trend.
3.7 Diet and Nutrition
In general, the diet was improved remarkably in recent years, but some features of diet are still inadequate. The intake of grain reduced significantly, whereas the intake of fat increased dramatically. The daily intake of salt (15.9 g/d) is much greater than that of diet recommendation, which is less than 6g/d. The intake of vegetables and fruits is either insufficient.
3.8 Metabolic Syndrome
According to the Chinese National Nutrition and Health Survey in 2002, the prevalence of
metabolic syndrome in individuals with age 18 years was 6.6% diagnosed by CDS criteria and 13.8% by ATP III criteria.
4. Major Research on Prevention and Intervention of CVD
4.1 Coronary Artery Disease (CAD)
According to the Registry study, percutaneous coronary intervention (PCI) was increasing
rapidly in Mainland China. The number of PCIs was 182 312 in 2008, increased by a factor of 26% in comparison with that in 2007. In 2007, PCI could be performed independently in 870 hospitals. The number of hospitals where PCIs were completed greater than 100 annually was 299, which accounted for 34.4% of aforementioned hospitals. In 2008, 1.39 out of 10 000 individuals received PCI, which could be performed independently in 1061 hospitals. The average of PCIs was 172 for each hospital. The number of hospitals where PCIs were completed greater than 400 annually was 94 (8.86%). Effect of glucose level on the early mortality of acute myocardial infarction (AMI).The 30-day mortality of AMI increases with the glucose level from 4.5 mmol/L on hospitalization. The risk of mortality in patients with glucose level >11.0 mmol/L was increased by a factor of 3 in comparison with that in patients with glucose level of 4.5??5.5 mmol/L. But the mortality was also increased in patients with glucose level <4.5 mmol/L.Observational data from 52 medical centers in 6 cities of China indicated that a large proportion of out-patients received lipid modification, but the control rate was low. Research on secondary prevention of CHD in China suggested that the risk of cardiovascular events and mortality could be greatly reduced by treatment with Xuezhikang in hypertensive patientswith prior myocardial infarction.
Stroke is a threatening disease for Chinese population. China is an epidemic area of stroke.
According to a survey on 340 000 death cases from 1999 to 2004 in Tianjin, cerebrovascular
disease, heart disease, and malignant tumor ranked the 3 leading cause of death. Analysis on the subtype of stroke indicated that the proportion of death from cerebral infarction increased gradually, while that of cerebral hemorrhage decreased. The standardized mortality of stroke displayed a declining trend. Secondary prevention of stroke (1) Post-stroke Antihypertensive Treatment Study (PATS) in China demonstrated that cerebrovascular disease could be prevented by treatment of hypertension with diuretics. The risk of recurrent stroke was reduced by 31% and that of cardiovascular events by 25%. Anti-hypertension is beneficial for secondary prevention of stroke.(2) Prospective registry study in 23 hospitals showed that the risk of all-cause death and recurrent cerebrovascular events could be reduced by antiplatelet therapy in adult patients with prior stroke in the last 1 to 6 months.
4.3 Chronic Kidney Disease
The prevalence of end-stage renal disease (ESRD): Investigation by Chinese Society of Blood
Purification in 27 provinces and cities showed that 65,074 patients with ESRD received hemodialysis or peritoneal dialysis. This number got up to 102,863 by the end of 2008. The major cause of death from ESRD is cardiovascular complications, stroke and infection.
4.4 Cardiac Surgery
The number of cardiac surgeries in China: The number of cardiac surgeries in Mainland China was 157,444 in 2009, which was increased by a factor of 8.7% in comparison with that in 2008. Of these surgeries, 128 358 was performed on-pump. Congenital heart disease: According to a survey in 2007, the prevalence of congenital heart disease was 8.2â€° in 84,062 newborn babies in Beijing. In the survived infants with congenital heart disease, 34.0% was afflicted with ventricular septal defect, 23.7% with patent ductus arteriosus, and
10.8 with atrial septal defect. Data from 18 hospitals demonstrated that 36, 072 patients with congenital heart disease had been treated with intervention therapy by the end of March in 2008. The incidence of complications was 1.97% ~ 4.45%, and the death rate was less than 0.11%.
4.5 Heart Failure
According to a survey from 20 towns and countrysides in 10 provinces and cities, the incidence of chronic heart failure in population aged 35 ~ 74 years was 0.9%. There were 4 million patients with heart failure in China. The prevalence was higher in female than in male, and higher in north than in south.
4.6 Peripheral Artery Disease (PAD)
The prevalence of PAD varies substantially among different samples of Chinese population. For example, it was 2.1% in Zhoushan fisherman, 6.0% in natural population above the age of 35 years in Beijing, 2%~4% in natural populations of multiple domestic regions, 16.4% in elderly population above the age of 60 years in Beijing, 19.4% in patients with diabetes mellitus, 22.5% in individuals with metabolic syndrome, and 27.5% in hypertensives. The prevalence of PAD increases with age, and is higher in female than in male.
20,000 patients underwent permanent cardiac pacemakers implantation in 2006.
The number of patients who were treated with radiofrequency ablation was 20 000 in 2006,
which demonstrated an upward trend. Radiofrequency ablation in treatment of atrial fibrillation develops rapidly. The incidence of sudden cardiac death (SCD) in China is 42 out of 100 000 persons. It is estimated that 540 000 SCDs occur annually.
5. Community-based Prevention and Treatment of CVD
Management of hypertension was started in 1969 in population of Capital Steel Corporation.
The incidence of stroke was reduced considerably by 50%. Various projects on the prevention and treatment of CVD were carried out thereafter. Detailed management of hypertension-associated disease was launched in Shanghai in 2006. Health management specialist bridged the communication between patients and doctors, and was in charge of the follow-up. After 1-year management, the control rate of blood pressure in management group was increased by 47% in comparison with that of reference group, while the plasma total cholesterol and BMI were lower.
6. Expenses for CVD
6.1 Number of Patients with CVD Discharged from Hospital
7.4 million patients with CVD (including cerebrovascular disease) were discharged from
hospital in 2008, which accounted for 10% of the total discharge, of which, the discharge of heart disease was 3.85 million (5.2%), and that of cerebrovascular disease 3.56 million (4.8%). The number of patients with heart disease discharged from hospital exceeded that of cerebrovascular disease. Most patients with CVD discharged from hospital in 2008 were those with ischemic heart disease (2.41 million) and cerebral infarction (2 million), which accounted for 32.5% and 27.1%, respectively. The other discharges were patients with hypertension (1.24 million), diabetes mellitus (1.24 million), cerebral hemorrhage (0.91 million), and rheumatic heart disease (0.2 million). The average increment of CVD discharge (8.28%) during 1980 ~ 2008 was more rapid than that of all diseases (5.27%). The average increment of discharge was ranked as diabetes mellitus (13.57%), cerebral infarction (11.19%), and hypertension (7.11%).
6.2 Expenses for CVD Hospitalization
The expense for hospitalization in 2008 was 2.45 billion RMB for AMI, 8.07 billion for
cerebral hemorrhage, and 12.7 billion for cerebral infarction. The annual increment of expenses for hospitalization since 2004 were 36.5%, 26.9%, and 31.1% for above specific disease, respectively. The expenses for every hospitalization was 12 566.2 RMB for AMI, 8488.5 for cerebral hemorrhage, and 6046.6 for cerebral infarction. The annual increment of expenses for every hospitalization since 2004 were 9.68%, 5.7%, and 2.69% for above specific disease, respectively.
6.3 Market of Medicines to Treat CVD
256,603 billion RMB was used to purchase various drugs in hospitals with more than 100
sickbeds in 2009, of which 30.39 billion was expended on medicines to treat CVD.