The burden of CVD & T2DM in

South East Asia: Call for action

Pham Manh Hung, MD

Hanoi, Vietnam

Diabetes & Cardiovascular Disease: What are the challenges?

Asian Cardio Diabetes ForumMarch 30-31, 2019 - Hanoi, Vietnam

2

Diabetes is the world’s

THIRD MOST

POPULOUS country1

by 2040

629 MILLIONwill have Diabetes1

425 MILLION have Diabetes

>90% of cases are T2DM1

4 MILLION Number of deaths due to Diabetes1

Number of

FDA-approved

DIABETES

DRUGS3

1. 2017 IDF Diabetes Atlas 2. 2013 National Nutrition Survey 3. Gourgari E et al. Journal of Diabetes and Its Complications 2017;31:1719-1727.

Global Snapshot: The Emergence of Diabetes Nation…

17 Medications

12 Classes

19 Combinations

WHO Region

3

South – East Asia Western Pacific

Number of people with diabetes

worldwide and per region

in 2017 and 2045 (20-79 years)

IDF Atlas 2017

5

o 1 in 11 adults have diabetes.

o ~170 million people have diabetes; will rise to 208 million by

2045.

o highest number of people with diabetes among the IDF regions.

o More than half (54%) of them have not been diagnosed and are

at a higher risk of developing harmful and costly complications.

o Home to 37% of the total number of diabetics in the world.

o Highest number of deaths due to diabetes (1.7 million) among

the IDF regions.

o Despite being the region with the highest diabetes burden, only

USD 136.1 billion will be spent on treating diabetes – 16% of

the total worldwide.

2017 IDF Diabetes Atlas

1. China

2. Indonesia

3. Japan

4. Thailand

5. Philippines

Top 5 Countries

Diabetes is Highest in the Western Pacific Region

6

“Rising Star”: Diabetes in Southeast Asia

1. India

2. Bangladesh

3. Sri Lanka

4. Nepal

5. Mauritius

Top 5 Countries

o 1 in 12 adults have diabetes.

o 84 million have diabetes (2nd highest region); will rise to 156 million by 2045.

o More than half (58%) have not been diagnosed and are at a higher risk of harmful & costly complications.

o Second highest number of deaths due to diabetes (1.3 million) among the IDF regions.

o Second lowest diabetes-related expenditure per person with diabetes (USD 9.7 billion).2017 IDF Diabetes Atlas

High propotion of undiagnosed diabetes patients in SEA and WP

IDF Atlas 2017

9

Plausible Factors for High Propensity to Develop DM Among Asians

Ramchandran A et al. Diabetes Research and Clinical Practice 2014;231-237.

11

88%

78%

35%

61%

80%

25%

89% 86%

26%

59%

84%

27%

0%

20%

40%

60%

80%

100%

YOD LOD

Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries

enrolled between November 2007 to December 2012

Prevalence of Cardio-Metabolic Risk Factors in Asian Diabetics

Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

At diagnosis of early onset T2D, Higher prevalence of macro-

and micro-vascular complication in South Asian patients

0

2

4

6

8

10

12

14

16

18

European South Asian

An International Journal of Medicine, Volume 95, Issue 4, 1 April 2002, Pages 241–246

132017 IDF Diabetes Atlas

Trends in Age-Standardized Rates of Diabetes-Related Complications among U.S. Adults with and without Diagnosed Diabetes, 1990-2010. Adapted from Gregg et al. N Engl J Med 2014;370:1514‒23.

Pre-statin era Pre-ACEI/ARB era

Diabetes-related CV complications have declined with improved care,

but substantial burden remains

Initial presentation of CV diseases

in type 2 diabetes patients

Lancet Diabetes Endocrinol 2015; 3: 105–13

16.2%

14.1%

16

Diabetes confers a 60–80% greater

probability of CV death and all-cause

mortality in those with established HF2,3*

People with diabetes

have a 2- to 5-fold higher

risk of developing HF1

2–5

People with Diabetes are at Increased Risk of Heart Failure

Sarwar N et al. Lancet 2010;375:2215.

17

Kaplan–Meier survival curves of HF patients hospitalised with LVEF ≥50% (n=498) and <50% (n=754)

Su

rviv

al

pro

po

rtio

n

Time (years)

p=0.0322RR=1.41

LVEF ≥50%

Diabetes No diabetes

1.0

0.8

0.6

0.4

0.2

0.00 2 4 6 8 10 12

0.4

0.2

0.00 2 4 6 8 10 12

p<0.0001

RR=1.73

LVEF <50%

Diabetes No diabetes

Time (years)

1.0

0.8

0.6

0.0

Varela-Roman A et al. Eur J Heart Failure 2005;7:859.

Diabetes Worsens Heart Failure Prognosis

Higher Diabetes Prevalence in Asian than White Patients

With Heart Failure

Bank et al J Am Coll Cardiol 2017;5:14-24

Number of death due to diabetes

IDF Atlas 2017

20

Stroke(%)

MI (%)

Angina (%)

Heart Failure (%)

Atherosclerosis(%)

CAD (%)

CVD (%)

Africa 5 NR NR NR NR 23.6 28.6

Europe 7.2 10 14.6 19 33 15.4 30

Middle East &

North Africa7.1 11.4 NR NR NR 27.4 26.9

North America &

Carribean10.9 13.6 17.2 29.5 NR 20.1 46

South &

Central America5.5 NR NR 4.2 NR 22.6 27.5

Southeast Asia 3.1 NR NR NR NR 29.4 42.5

Western Pacific 11.4 NR NR 4.3 26 23.6 33.6

Prevalence of Cardiovascular Disease in T2DM

Einarson TR et al. Cardiovasc Diabetol 2018;17:83.

21

0%

10%

20%

30%

40%

50%

60%

CV Disease Renal causes Other causes

Type 1 DM Type 2 DM

CV Disease is the Most Common Cause of Death in Diabetics

Morrish NJ1,et al. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia. 2001 Sep;44 Suppl 2:S14-21.

22

0

20

40

60

80

100

120

140

0 1 2 3

Ag

e-a

dju

ste

d C

VD

death

ris

k/1

0,0

00

pers

on

-years

Number of risk factors

Diabetes

No diabetes

CV Death is Increased in Patients with DM +/- Other Risk Factors

Stamler J et al. Diabetes Care 1993;16:434.

23

Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries

enrolled between November 2007 to December 2012

Attainment of Glycemic Control in Asian Diabetics

0 20 40 60 80 100

Total (6109/27153)

Thailand (68/206)

Taiwan (14/87)

Singapore (98/272)

Vietnam (110/533)

Korea (276/1457)

Philippines (847/3770)

India (1135/3700)

China (887/4495)

Hong Kong (2674/12633)

Percentage with HbA1c <7.0%

YOD LOD

Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

24

Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries

enrolled between November 2007 to December 2012

Attainment of Blood Pressure Control in Asian Diabetics

Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

0 20 40 60 80 100

Total (7327/32978)

Thailand (68/206)

Taiwan (12/92)

Singapore (98/271)

Vietnam (113/590)

Korea (270/1445)

Philippines (1345/5943)

India (1820/7138)

China (919/4636)

Hong Kong (2682/12657)

Percentage with BP <130/80 mm Hg

YOD LOD

25

Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries

enrolled between November 2007 to December 2012

Attainment of LDL-C Control in Asian Diabetics

Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

0 20 40 60 80 100

Total (5888/27167)

Thailand (68/205)

Taiwan (5/47)

Singapore (95/263)

Vietnam (113/585)

Korea (242/1267)

Philippines (706/3062)

India (1181/4852)

China (877/4438)

Hong Kong (2601/12457)

Percentage with LDL-C <100 mg/dL

YOD LOD

26

Data from a web-based T2DM registry that included 41,029 patients from 9 Asian countries

enrolled between November 2007 to December 2012

Attainment of BP, Glucose & LDL-C Control in Asian Diabetics

0 20 40 60 80 100

Total (5336/24341)

Thailand (68/203)

Singapore (94/259)

Vietnam (110/527)

Korea (232/1238)

Philippine (531/2385)

India (856/3009)

China (847/4270)

Hong Kong (2598/12450)

Percentage (95%CI)

YOD LOD

Yeung RO et al. Lancet Diabetes Endocrinol 2014; 2: 935-943.

VietnamTotal population (2016) 94,569,000

Gross national income per capita (PPP international $, 2013) 5,030

Life expectancy at birth m/f (years, 2016) 72/81

Probability of dying under five (per 1 000 live births, 2017) 21

Probability of dying between 15 and 60 years m/f (per 1 000 population, 2016) 182/66

Total expenditure on health per capita (Intl $, 2014) 390

Total expenditure on health as % of GDP (2014) 7.1

WHO statistics: https://www.who.int/countries/vnm/en/

Major cause of death 2016 in VN

WHO statistics: https://www.who.int/countries/vnm/en/

Time trends of Diabetes in VN

2,7

5,4

0

1

2

3

4

5

6

2002 2007

%

Series 1

Series 1

Not Aware of Diabetes: 68.9%

Data from National Survey Program of Institute of Endocrinology

Time trends of Cardiovascular DiseaseIn- hospital Data

(CAD and Rheumatic VHD at VNHI from 1990 – 2015)

4,3 5,7

11,3

18,8

27,7

37,5

60,557,8

41,2

31,5

25,121,7

0

10

20

30

40

50

60

70

1990 1995 2000 2005 2010 2015

%

Year

Grafiektitel

CAD VHD

Internal Data of VNHI

PTMC and PCI at VNHI

147327

491 560 610705

553 523 495 509 504 510396 322 348

248 255 246 211 18295 134 165

297461

719 794988 1042

1368 14061611

20502252 2310

2731

3016

4049

4712

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

PTMC PCI

Data from Cardiac Cath. Lab. Vietnam National Heart Institute

Coronary artery Profile on Angiography of DM Patient at VNHI (3000 pts. From 2005 – 2010)

• 30% PCI Patients has Diabetes

• Coro. Disease more severe:

– 3VD: 45% (vs 30% in non-diabetic)

– More diffuse disease

– Cor. Artery diameter: smaller

– LVEF: DM < non- DM’s

Data from VNHI

CONCLUSIONS

37

- The epidemic of diabetes is very alarming most especially in Western Pacific and Southeast Asia where majority of patients are located and exponential increase in new cases is expected.

- Diabetes is often associated with other cardio-metabolic risk factors that further increase the risk of developing serious and costly complications.

- Cardiovascular death is the most frequent cause of death among diabetic patients.

- A significant treatment gap exists among diabetic patients in Asia with suboptimal attainment of A1c, blood pressure, and hypertension goals that may lead to cardiovascular diseases.

- Optimization of disease management strategies and programs must be prioritized to help curb the diabetes epidemic.