How do we define ethnic healthcare disparities? Ethnic Disparity. Cardiovascular Disease in Asians: Are Asians at Increased Risk?

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1 Cardiovascular Disease in Asians: Are Asians at Increased Risk? November 17, 2007 Gordon L. Fung, MD, MPH, PhD, FACC, FAHA, FACP Director, Asian Heart & Vascular Center Clinical Professor of Medicine UCSF School of Medicine Ethnic Disparity Healthcare vs. Health Disparity Mortality Diagnosis impact of language Management impact of culture, ADRs Etiology and Genetics How do we define ethnic healthcare disparities? Differences in quality of healthcare that are not attributable to any of the following: Clinical needs e.g. indication for CABG Patient preferences e.g. choosing to undergo CABG Appropriateness of intervention e.g. will benefits of CABG outweigh risks of procedure for the patient? Access (a known problem in US health care) 1

2 Health Disparities U.S. Public Law U.S. Department of Health and Human Services: Office of Minority Health: Health disparities are defined as significant differences between one population and another. The Minority Health and Health Disparities Research and Education Act of 2000: Differences in the overall rate of disease incidence, prevalence, morbidity, and mortality or survival rates. There are several factors that contribute to health disparities: racial and ethnic minorities, residents of rural areas, gender, age children and elderly, and persons with diabilities. Cardiovascular Disease in the Asian Population Epidemiology and Statistics Coronary Heart Disease Traditional Risk Factors Hypertension Metabolic Syndrome Atherosclerotic Plaque Composition Leading Causes of Death for All Males and Causes Females of Death for all United States: 2003* Males and Females, US A Total CVD B Cancer C Accidents 287 Deaths in Thousands A B C D E A B D F E Source: CDC/NCHS and NHLBI. *Preliminary D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer s Disease Males Females Leading Causes of Death for White Males and Females, US Percent of Total 2003 Deaths Leading Causes of Death for White Males and Females United States: 2003* A Total CVD B Cancer C Accidents A B C D E A B D F C Source: CDC/NCHS and NHLBI. *Preliminary Males Females D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer s Disease 2

3 Leading Causes of Death for Asian or Pacific Islander Males and Females United States: 2002 Percent of Total Deaths (35.7) (24.2) A B C D E A B E C F (D) (ALZ) (C) A Diseases of the Heart, and Stroke B Cancer C Accidents Source: CDC/NCHS. (39.7) (21.5) Males Females D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Influenza and Pneumonia Deaths for Women From Major CVD Klatsky1 Klatsky2 Klatsky 2005 Klatsky

4 Klatsky3 CVD mortality Trends for Males and Females, 2003* US Cardiovascular Disease Mortality Trends for Males and Females United States: * Deaths in Thousands Years Males Females Klatsky 2005 Source: CDC/NCHS. * Preliminary Trends in Age-Adjusted Trends in Age-Adjusted Adjusted Prevalence Prevalence of Health of Health Conditions, U.S. Adults Conditions, Ages US Adults Ages 20- NHANES: to Percent of Population Overweight/Obesity Hypertension High Blood Cholesterol Source: Ann. Rev. of Nut. July Vol.24: Percentage Breakdown of Deaths From Cardiovascular Diseases United States:2003* % Breakdown of Deaths from CVD, US % 13% 0.4% 0% 17% 0.5% 1% 4% 6% 6% Coronary Heart Disease Stroke HF Heart Failure High Blood Pressure Diseases of the Arteries Congenital Cardiovascular Defects Coronary Rheumatic Heart Fever/Rheumatic Disease Heart Disease Stroke Other Heart Failure High Blood Pressure Diseases of the Arteries Congenital Cardiovascular Defects Rheumatic Fever/Rheumatic Heart Disease Other Source: CDC/NCHS and NHLBI. *Preliminary 4

5 Number of Deaths due to CVD and % due to stroke and Ischemic Heart Disease, by Geographic Region Number and Average Age of the Post-acute MI Cohort by Ethnic Surname and Sex in Ontario, 1994/ /97 Ethnicity-Specific 30-day and One Year Mortality Rates after an Acute Myocardial Infarction in Ontario 1994/ /97 Average Coronary Artery Bypass Rate per 100,000 Population by Surname Ethnicity in Ontario 1991/ /97 5

6 Average Angioplasty Rate per 100,000 Population by Surname Ethnicity in Ontario 1991/ /97 Age, Sex and Surname Ethnicity Odds Ratio for Angioplasty patients Age 45 and over in Ontario 1991/ /97 Age, Sex and Surname Ethnicity Odds Ratio for Coronary Artery Bypass Surgery Patients aged 45 years and older in Ontario 1991/ /97 6

7 Ethnicity-Specific Cardiac Procedure Rates One Year following an Acute Myocardial Infarction in Patients 45 years and over in Ontario, 1994/ /97 Age/Sex-adjusted Drug Utilization Rates for Acute Myocardial Infarction Patients aged 65 years and over in Ontario 1994/ /97 Trends in CVD Risk Factors in 74 the US Aged Trends in Cardiovascular Risk Factors in the U.S. Population Aged NHES: , 62, NHANES: to Cardiac Risk Factors of the Chinese Percent of Population High Total Cholesterol High Blood Pressure Smoking Diagnosed Diabetes Source: JAMA :

8 Prevalence of CVD RF in Thailand MESA1 Kramer H AJH 2004 MESA2 MESA3 Kramer H AJH 2004 Kramer H AJH

9 MESA4 MESA5 Kramer H AJH 2004 Kramer H AJH 2004 MESA6 CHEFS1 Kramer H AJH

10 China Hypertension Survey Epidemiology Follow-up Study (CHEFS) CHEFS2 JNC VI - Classification Relative Risk and Population Attributable Risk of HTN on CHD 10

11 Estimated Excess CVA deaths due to HTN in PRC 1990 % Awareness, TX and Control HTN in Urban and Rural China % Awareness, Tx and Control of HTN in Urban and Rural China Prevalence of HTN by Age in China 11

12 Atherosclerotic lesion in the right CCA from a 59- year old Chinese patient. The lesion appears homogeneous, with a large LR-NC (dotted line) corresponding to an AHA lesion type V. The wall is massively enlarged, whereas the lumen is near norrmal (asterisk). Heavily calcified lesion from a 55- year-old American patient in the left CCA corresponding to an AHA lesion type VII. The wall is enlarged (arrowheads); the lumen (asterisk) is best depicted on TOF images. Calcium is hypointense in all 4 weightings (arrow). Arterioscler Thromb Vasc Biol. March 2005 Arterioscler Thromb Vasc Biol. March 2005 Stress by Cultures Summary CVD in the Chinese population appears to be favorable in the United States CVD is still the major cause of death in the Chinese population and uncontrolled or suboptimally treated HTN may be a major factor in the reason Stroke is a stronger contributor than Ischemic heart disease to the CVD mortality in China Diabetes Mellitus is prevalent in the Chinese- American population Genetic factors are being identified as causal to the Metabolic Syndrome and can increased the risk of CVD 12

13 Thank you 13