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    Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis. Cai Xiaoyan,Zhang Yunlong,Li Meijun,Wu Jason Hy,Mai Linlin,Li Jun,Yang Yu,Hu Yunzhao,Huang Yuli BMJ (Clinical research ed.) OBJECTIVE:To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease. DESIGN:Updated meta-analysis. DATA SOURCES:Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020. REVIEW METHODS:Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke. RESULTS:A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10). CONCLUSIONS:Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease. 10.1136/bmj.m2297
    Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. Roth Gregory A,Johnson Catherine,Abajobir Amanuel,Abd-Allah Foad,Abera Semaw Ferede,Abyu Gebre,Ahmed Muktar,Aksut Baran,Alam Tahiya,Alam Khurshid,Alla François,Alvis-Guzman Nelson,Amrock Stephen,Ansari Hossein,Ärnlöv Johan,Asayesh Hamid,Atey Tesfay Mehari,Avila-Burgos Leticia,Awasthi Ashish,Banerjee Amitava,Barac Aleksandra,Bärnighausen Till,Barregard Lars,Bedi Neeraj,Belay Ketema Ezra,Bennett Derrick,Berhe Gebremedhin,Bhutta Zulfiqar,Bitew Shimelash,Carapetis Jonathan,Carrero Juan Jesus,Malta Deborah Carvalho,Castañeda-Orjuela Carlos Andres,Castillo-Rivas Jacqueline,Catalá-López Ferrán,Choi Jee-Young,Christensen Hanne,Cirillo Massimo,Cooper Leslie,Criqui Michael,Cundiff David,Damasceno Albertino,Dandona Lalit,Dandona Rakhi,Davletov Kairat,Dharmaratne Samath,Dorairaj Prabhakaran,Dubey Manisha,Ehrenkranz Rebecca,El Sayed Zaki Maysaa,Faraon Emerito Jose A,Esteghamati Alireza,Farid Talha,Farvid Maryam,Feigin Valery,Ding Eric L,Fowkes Gerry,Gebrehiwot Tsegaye,Gillum Richard,Gold Audra,Gona Philimon,Gupta Rajeev,Habtewold Tesfa Dejenie,Hafezi-Nejad Nima,Hailu Tesfaye,Hailu Gessessew Bugssa,Hankey Graeme,Hassen Hamid Yimam,Abate Kalkidan Hassen,Havmoeller Rasmus,Hay Simon I,Horino Masako,Hotez Peter J,Jacobsen Kathryn,James Spencer,Javanbakht Mehdi,Jeemon Panniyammakal,John Denny,Jonas Jost,Kalkonde Yogeshwar,Karimkhani Chante,Kasaeian Amir,Khader Yousef,Khan Abdur,Khang Young-Ho,Khera Sahil,Khoja Abdullah T,Khubchandani Jagdish,Kim Daniel,Kolte Dhaval,Kosen Soewarta,Krohn Kristopher J,Kumar G Anil,Kwan Gene F,Lal Dharmesh Kumar,Larsson Anders,Linn Shai,Lopez Alan,Lotufo Paulo A,El Razek Hassan Magdy Abd,Malekzadeh Reza,Mazidi Mohsen,Meier Toni,Meles Kidanu Gebremariam,Mensah George,Meretoja Atte,Mezgebe Haftay,Miller Ted,Mirrakhimov Erkin,Mohammed Shafiu,Moran Andrew E,Musa Kamarul Imran,Narula Jagat,Neal Bruce,Ngalesoni Frida,Nguyen Grant,Obermeyer Carla Makhlouf,Owolabi Mayowa,Patton George,Pedro João,Qato Dima,Qorbani Mostafa,Rahimi Kazem,Rai Rajesh Kumar,Rawaf Salman,Ribeiro Antônio,Safiri Saeid,Salomon Joshua A,Santos Itamar,Santric Milicevic Milena,Sartorius Benn,Schutte Aletta,Sepanlou Sadaf,Shaikh Masood Ali,Shin Min-Jeong,Shishehbor Mehdi,Shore Hirbo,Silva Diego Augusto Santos,Sobngwi Eugene,Stranges Saverio,Swaminathan Soumya,Tabarés-Seisdedos Rafael,Tadele Atnafu Niguse,Tesfay Fisaha,Thakur J S,Thrift Amanda,Topor-Madry Roman,Truelsen Thomas,Tyrovolas Stefanos,Ukwaja Kingsley Nnanna,Uthman Olalekan,Vasankari Tommi,Vlassov Vasiliy,Vollset Stein Emil,Wakayo Tolassa,Watkins David,Weintraub Robert,Werdecker Andrea,Westerman Ronny,Wiysonge Charles Shey,Wolfe Charles,Workicho Abdulhalik,Xu Gelin,Yano Yuichiro,Yip Paul,Yonemoto Naohiro,Younis Mustafa,Yu Chuanhua,Vos Theo,Naghavi Mohsen,Murray Christopher Journal of the American College of Cardiology BACKGROUND:The burden of cardiovascular diseases (CVDs) remains unclear in many regions of the world. OBJECTIVES:The GBD (Global Burden of Disease) 2015 study integrated data on disease incidence, prevalence, and mortality to produce consistent, up-to-date estimates for cardiovascular burden. METHODS:CVD mortality was estimated from vital registration and verbal autopsy data. CVD prevalence was estimated using modeling software and data from health surveys, prospective cohorts, health system administrative data, and registries. Years lived with disability (YLD) were estimated by multiplying prevalence by disability weights. Years of life lost (YLL) were estimated by multiplying age-specific CVD deaths by a reference life expectancy. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility. RESULTS:In 2015, there were an estimated 422.7 million cases of CVD (95% uncertainty interval: 415.53 to 427.87 million cases) and 17.92 million CVD deaths (95% uncertainty interval: 17.59 to 18.28 million CVD deaths). Declines in the age-standardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries. Ischemic heart disease was the leading cause of CVD health lost globally, as well as in each world region, followed by stroke. As SDI increased beyond 0.25, the highest CVD mortality shifted from women to men. CVD mortality decreased sharply for both sexes in countries with an SDI >0.75. CONCLUSIONS:CVDs remain a major cause of health loss for all regions of the world. Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI, but only a gradual decrease or no change in most regions. Future updates of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD. 10.1016/j.jacc.2017.04.052
    Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Zhou Maigeng,Wang Haidong,Zeng Xinying,Yin Peng,Zhu Jun,Chen Wanqing,Li Xiaohong,Wang Lijun,Wang Limin,Liu Yunning,Liu Jiangmei,Zhang Mei,Qi Jinlei,Yu Shicheng,Afshin Ashkan,Gakidou Emmanuela,Glenn Scott,Krish Varsha Sarah,Miller-Petrie Molly Katherine,Mountjoy-Venning W Cliff,Mullany Erin C,Redford Sofia Boston,Liu Hongyan,Naghavi Mohsen,Hay Simon I,Wang Linhong,Murray Christopher J L,Liang Xiaofeng Lancet (London, England) BACKGROUND:Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. METHODS:We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). FINDINGS:Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (-3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). INTERPRETATION:China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. FUNDING:China National Key Research and Development Program and Bill & Melinda Gates Foundation. 10.1016/S0140-6736(19)30427-1
    Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors. Joseph Philip,Leong Darryl,McKee Martin,Anand Sonia S,Schwalm Jon-David,Teo Koon,Mente Andrew,Yusuf Salim Circulation research Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions. 10.1161/CIRCRESAHA.117.308903
    Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease. Leong Darryl P,Joseph Philip G,McKee Martin,Anand Sonia S,Teo Koon K,Schwalm Jon-David,Yusuf Salim Circulation research In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness. 10.1161/CIRCRESAHA.117.311849
    Incidence, risk factors, and prevention of hepatitis C reinfection: a population-based cohort study. Islam Nazrul,Krajden Mel,Shoveller Jean,Gustafson Paul,Gilbert Mark,Buxton Jane A,Wong Jason,Tyndall Mark W,Janjua Naveed Zafar, The lancet. Gastroenterology & hepatology BACKGROUND:People remain at risk of reinfection with hepatitis C virus (HCV), even after clearance of the primary infection. We identified factors associated with HCV reinfection risk in a large population-based cohort study in British Columbia, Canada, and examined the association of opioid substitution therapy and mental health counselling with reinfection. METHODS:We obtained data from the British Columbia Hepatitis Testers Cohort, which includes all individuals tested for HCV or HIV at the British Columbia Centre for Disease Control Public Health Laboratory during 1990-2013 (when data were available). We defined cases of HCV reinfection as individuals with a positive HCV PCR test after either spontaneous clearance (two consecutive negative HCV PCR tests spaced ≥28 days apart without treatment) or a sustained virological response (SVR; two consecutive negative HCV PCR tests spaced ≥28 days apart 12 weeks after completing interferon-based treatment). We calculated incidence rates of HCV reinfection (per 100 person-years of follow-up) and corresponding 95% CIs assuming a Poisson distribution, and used a multivariable Cox proportional hazards model to examine reinfection risk factors (age, birth cohort, sex, year of HCV diagnosis, HCV clearance type, HIV co-infection, number of mental health counselling visits, levels of material and social deprivation, and alcohol and injection drug use), and the association of opioid substitution therapy and mental health counselling with HCV reinfection among people who inject drugs (PWID). FINDINGS:5915 individuals with HCV were included in this study after clearance (3690 after spontaneous clearance and 2225 after SVR). 452 (8%) patients developed reinfection; 402 (11%) after spontaneous clearance and 50 (2%) who had achieved SVR. Individuals were followed up for a median of 5·4 years (IQR 2·9-8·7), and the median time to reinfection was 3·0 years (1·5-5·4). The overall incidence rate of reinfection was 1·27 (95% CI 1·15-1·39) per 100 person-years of follow-up over a total of 35 672 person-years, with significantly higher rates in the spontaneous clearance group (1·59, 1·44-1·76) than in the SVR group (0·48, 0·36-0·63). With the adjusted Cox proportional hazards model, we noted higher reinfection risks in the spontaneous clearance group (adjusted hazard ratio [HR] 2·71, 95% CI 2·00-3·68), individuals co-infected with HIV (2·25, 1·78-2·85), and PWID (1·53, 1·21-1·92) than with other reinfection risk factors. Among the 1604 PWID with a current history of injection drug use, opioid substitution therapy was significantly associated with a lower risk of reinfection (adjusted HR 0·73, 95% CI 0·54-0·98), as was engagement with mental health counselling services (0·71, 0·54-0·92). INTERPRETATION:The incidence of HCV reinfection was higher among HIV co-infected individuals, those who spontaneously cleared HCV infection, and PWID. HCV treatment complemented with opioid substitution therapy and mental health counselling could reduce HCV reinfection risk among PWID. These findings support policies of post-clearance follow-up of PWID, and provision of harm-reduction services to minimise HCV reinfection and transmission. FUNDING:The British Columbia Centre for Disease Control and the Canadian Institutes of Health Research. 10.1016/S2468-1253(16)30182-0
    Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Walli-Attaei Marjan,Joseph Philip,Rosengren Annika,Chow Clara K,Rangarajan Sumathy,Lear Scott A,AlHabib Khalid F,Davletov Kairat,Dans Antonio,Lanas Fernando,Yeates Karen,Poirier Paul,Teo Koon K,Bahonar Ahmad,Camilo Felix,Chifamba Jephat,Diaz Rafael,Didkowska Joanna A,Irazola Vilma,Ismail Rosnah,Kaur Manmeet,Khatib Rasha,Liu Xiaoyun,Mańczuk Marta,Miranda J Jaime,Oguz Aytekin,Perez-Mayorga Maritza,Szuba Andrzej,Tsolekile Lungiswa P,Prasad Varma Ravi,Yusufali Afzalhussein,Yusuf Rita,Wei Li,Anand Sonia S,Yusuf Salim Lancet (London, England) BACKGROUND:Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies. METHODS:In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death. FINDINGS:From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease. INTERPRETATION:Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men. FUNDING:Full funding sources are listed at the end of the paper (see Acknowledgments). 10.1016/S0140-6736(20)30543-2
    Prevention and Control of Cardiovascular Disease in the Rapidly Changing Economy of China. Wu Yangfeng,Benjamin Emelia J,MacMahon Stephen Circulation With one-fifth of the world's total population, China's prevention and control of cardiovascular disease (CVD) may affect the success of worldwide efforts to achieve sustainable CVD reduction. Understanding China's current cardiovascular epidemic requires awareness of the economic development in the past decades. The rapid economic transformations (industrialization, marketization, urbanization, globalization, and informationalization) contributed to the aging demography, unhealthy lifestyles, and environmental changes. The latter have predisposed to increasing cardiovascular risk factors and the CVD pandemic. Rising CVD rates have had a major economic impact, which has challenged the healthcare system and the whole society. With recognition of the importance of health, initial political steps and national actions have been taken to address the CVD epidemic. Looking to the future, we recommend that 4 priorities should be taken: pursue multisectorial government and nongovernment strategies targeting the underlying causes of CVD (the whole-of-government and whole-of-society policy); give priority to prevention; reform the healthcare system to fit the nature of noncommunicable diseases; and conduct research for evidence-based, low-cost, simple, sustainable, and scalable interventions. By pursuing the 4 priorities, the pandemic of CVD and other major noncommunicable diseases in China will be reversed and the global sustainable development goal achieved. 10.1161/CIRCULATIONAHA.115.008728
    Potential Impact of Time Trend of Life-Style Factors on Cardiovascular Disease Burden in China. Li Yanping,Wang Dong D,Ley Sylvia H,Howard Annie Green,He Yuna,Lu Yuan,Danaei Goodarz,Hu Frank B Journal of the American College of Cardiology BACKGROUND:Cardiovascular disease (CVD) is a leading cause of death in China. Evaluation of risk factors and their impacts on disease burden is important for future public health initiatives and policy making. OBJECTIVES:The study used data from a cohort of the China Health and Nutrition Survey to estimate time trends in cardiovascular risk factors from 1991 to 2011. METHODS:We applied the comparative risk assessment method to estimate the number of CVD events attributable to all nonoptimal levels (e.g., theoretical-minimum-risk exposure distribution [TMRED]) of each risk factor. RESULTS:In 2011, high blood pressure, high low-density lipoprotein cholesterol, and high blood glucose were associated with 3.1, 1.4, and 0.9 million CVD events in China, respectively. Increase in body mass index was associated with an increase in attributable CVD events, from 0.5 to 1.1 million between 1991 and 2011, whereas decreased physical activity was associated with a 0.7-million increase in attributable CVD events. In 2011, 53.4% of men used tobacco, estimated to be responsible for 30.1% of CVD burden in men. Dietary quality improved, but remained suboptimal; mean intakes were 5.4 (TMRED: 2.0) g/day for sodium, 67.7 (TMRED: 300.0) g/day for fruits, 6.2 (TMRED: 114.0) g/day for nuts, and 25.0 (TMRED: 250.0) mg/day for marine omega-3 fatty acids in 2011. CONCLUSIONS:High blood pressure remains the most important individual risk factor related to CVD burden in China. Increased body mass index and decreased physical activity were also associated with the increase in CVD burden from 1991 to 2011. High rates of tobacco use in men and unhealthy dietary factors continue to contribute to the burden of CVD in China. 10.1016/j.jacc.2016.06.011
    Time Trends in Cardiovascular Disease Mortality Across the BRICS: An Age-Period-Cohort Analysis of Key Nations With Emerging Economies Using the Global Burden of Disease Study 2017. Zou Zhiyong,Cini Karly,Dong Bin,Ma Yinghua,Ma Jun,Burgner David P,Patton George C Circulation BACKGROUND:Brazil, Russia, India, China, and South Africa (BRICS) are emerging economies making up almost half the global population. We analyzed trends in cardiovascular disease (CVD) mortality across the BRICS and associations with age, period, and birth cohort. METHODS:Mortality estimates were derived from the Global Burden of Disease Study 2017. We used age-period-cohort modeling to estimate cohort and period effects in CVD between 1992 and 2016. Period was defined as survey year, and period effects reflect population-wide exposure at a circumscribed point in time. Cohort effects are defined as differences in risks across birth cohort. Net drift (overall annual percentage change), local drift (annual percentage change in each age group), longitudinal age curves (expected longitudinal age-specific rate), and period (cohort) relative risks were calculated. RESULTS:In 2016, there were 8.4 million CVD deaths across the BRICS. Between 1992 and 2016, the reduction in CVD age-standardized mortality rate in BRICS (-17%) was less than in North America (-39%). Eighty-eight percent of the increased number of all-cause deaths resulted from the increase in CVD deaths. The age-standardized mortality rate from stroke and hypertensive heart disease declined by approximately one-third across the BRICS, whereas ischemic heart disease increased slightly (2%). Brazil had the largest age-standardized mortality rate reductions across all CVD categories, with improvement both over time and in recent birth cohorts. South Africa was the only country where the CVD age-standardized mortality rate increased. Different age-related CVD mortality was seen in those ≥50 years of age in China, ≤40 years of age in Russia, 35 to 60 years of age in India, and ≥55 years of age in South Africa. Improving period and cohort risks for CVD mortality were generally found across countries, except for worsening period effects in India and greater risks for ischemic heart disease in Chinese cohorts born in the 1950s and 1960s. CONCLUSIONS:Except for Brazil, reductions of CVD mortality across the BRICS have been less than that in North America, such that China, India, and South Africa contribute an increasing proportion of global CVD deaths. Brazil's example suggests that prevention policies can both reduce the risks for younger birth cohorts and shift the risks for all age groups over time. 10.1161/CIRCULATIONAHA.119.042864
    Epidemic of Cardiovascular Disease in China: Current Perspective and Prospects for the Future. Shen Chengxing,Ge Junbo Circulation 10.1161/CIRCULATIONAHA.118.033484
    Epidemiology of Cardiovascular Disease in China and Opportunities for Improvement: JACC International. Du Xin,Patel Anushka,Anderson Craig S,Dong Jianzeng,Ma Changsheng Journal of the American College of Cardiology The burden of cardiovascular (CV) disease is very high in China, due to highly prevalent and poorly controlled risk factors resulting from changing sociodemographic structure and lifestyles in its large population. Rapid economic development and urbanization have been accompanied by changing patterns, expression, and management of CV disease. However, the health care system in China lacks a hierarchical structure, with a focus on treating acute diseases in hospital while ignoring long-term management, and primary health care is too weak to effectively control CV risk factors. To address these challenges, the Chinese central government has ensured health is a national priority and has introduced reforms that include implementing policies for a healthy environment, strengthening primary care, and improving affordability and accessibility within the health system. Turning the inverted pyramid of the health care system is essential in the ongoing battle against CV disease. 10.1016/j.jacc.2019.04.036
    Epidemiology of cardiovascular disease in China: current features and implications. Zhao Dong,Liu Jing,Wang Miao,Zhang Xingguang,Zhou Mengge Nature reviews. Cardiology Cardiovascular disease (CVD) is the leading cause of death in China. To develop effective and timely strategies to cope with the challenges of CVD epidemics, we need to understand the current epidemiological features of the major types of CVD and the implications of these features for the prevention and treatment of CVD. In this Review, we summarize eight important features of the epidemiology of CVD in China. Some features indicate a transition in CVD epidemiology owing to interrelated changes in demography, environment, lifestyle, and health care, including the rising burden from atherosclerotic CVD (ischaemic heart disease and ischaemic stroke), declining mortality from haemorrhage stroke, varied regional epidemiological trends in the subtypes of CVD, increasing numbers of patients with moderate types of ischaemic heart disease and ischaemic stroke, and increasing ageing of patients with CVD. Other features highlight the problems that need particular attention, including the high proportion of out-of-hospital death of patients with ischaemic heart disease with insufficient prehospital care; the wide gaps between guideline-recommended goals and levels of lifestyle indicators; and the huge number of patients with undiagnosed, untreated, or uncontrolled hypertension, hypercholesterolaemia, or diabetes mellitus. 10.1038/s41569-018-0119-4
    Burden of Cardiovascular Diseases in China, 1990-2016: Findings From the 2016 Global Burden of Disease Study. Liu Shiwei,Li Yichong,Zeng Xinying,Wang Haidong,Yin Peng,Wang Lijun,Liu Yunning,Liu Jiangmei,Qi Jinlei,Ran Sha,Yang Shiya,Zhou Maigeng JAMA cardiology Importance:Cardiovascular disease (CVD) remains the top cause of death in China. To our knowledge, no consistent and comparable assessments of CVD burden have been produced at subnational levels, and little is understood about the spatial patterns and temporal trends of CVD in China. Objective:To determine the national and province-level burden of CVD from 1990 to 2016 in China. Design, Setting, and Participants:Following the methodology framework and analytical strategies used in the 2016 Global Burden of Disease study, the mortality, prevalence, and disability-adjusted life-years (DALYs) of CVD in the Chinese population were examined by age, sex, and year and according to 10 subcategories. Estimates were produced for all province-level administrative units of mainland China, Hong Kong, and Macao. Exposures:Residence in China. Main Outcomes and Measures:Mortality, prevalence, and DALYs of CVD. Results:The annual number of deaths owing to CVD increased from 2.51 million to 3.97 million between 1990 and 2016; the age-standardized mortality rate fell by 28.7%, from 431.6 per 100 000 persons in 1990 to 307.9 per 100 000 in 2016. Prevalent cases of CVD doubled since 1990, reaching nearly 94 million in 2016. The age-standardized prevalence rate of CVD overall increased significantly from 1990 to 2016 by 14.7%, as did rates for ischemic heart disease (19.1%), ischemic stroke (36.6%), cardiomyopathy and myocarditis (23.1%), and endocarditis (26.7%). Substantial reduction in the CVD burden, as measured by age-standardized DALY rate, was observed from 1990 to 2016 nationally, with a greater reduction in women (43.7%) than men (24.7%). There were marked differences in the spatial patterns of mortality, prevalence, and DALYs of CVD overall as well as its main subcategories, including ischemic heart disease, hemorrhagic stroke, and ischemic stroke. The CVD burden appeared to be lower in coastal provinces with higher economic development. The between-province gap in relative burden of CVD increased from 1990 to 2016, with faster decline in economically developed provinces. Conclusions and Relevance:Substantial discrepancies in the total CVD burden and burdens of CVD subcategories have persisted between provinces in China despite a relative decrease in the CVD burden. Geographically targeted considerations are needed to tailor future strategies to enhance CVD health throughout China and in specific provinces. 10.1001/jamacardio.2019.0295
    Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Yusuf Salim,Joseph Philip,Rangarajan Sumathy,Islam Shofiqul,Mente Andrew,Hystad Perry,Brauer Michael,Kutty Vellappillil Raman,Gupta Rajeev,Wielgosz Andreas,AlHabib Khalid F,Dans Antonio,Lopez-Jaramillo Patricio,Avezum Alvaro,Lanas Fernando,Oguz Aytekin,Kruger Iolanthe M,Diaz Rafael,Yusoff Khalid,Mony Prem,Chifamba Jephat,Yeates Karen,Kelishadi Roya,Yusufali Afzalhussein,Khatib Rasha,Rahman Omar,Zatonska Katarzyna,Iqbal Romaina,Wei Li,Bo Hu,Rosengren Annika,Kaur Manmeet,Mohan Viswanathan,Lear Scott A,Teo Koon K,Leong Darryl,O'Donnell Martin,McKee Martin,Dagenais Gilles Lancet (London, England) BACKGROUND:Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels. METHODS:In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs. FINDINGS:Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs. INTERPRETATION:Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries. FUNDING:Full funding sources are listed at the end of the paper (see Acknowledgments). 10.1016/S0140-6736(19)32008-2
    World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions. The Lancet. Global health BACKGROUND:To help adapt cardiovascular disease risk prediction approaches to low-income and middle-income countries, WHO has convened an effort to develop, evaluate, and illustrate revised risk models. Here, we report the derivation, validation, and illustration of the revised WHO cardiovascular disease risk prediction charts that have been adapted to the circumstances of 21 global regions. METHODS:In this model revision initiative, we derived 10-year risk prediction models for fatal and non-fatal cardiovascular disease (ie, myocardial infarction and stroke) using individual participant data from the Emerging Risk Factors Collaboration. Models included information on age, smoking status, systolic blood pressure, history of diabetes, and total cholesterol. For derivation, we included participants aged 40-80 years without a known baseline history of cardiovascular disease, who were followed up until the first myocardial infarction, fatal coronary heart disease, or stroke event. We recalibrated models using age-specific and sex-specific incidences and risk factor values available from 21 global regions. For external validation, we analysed individual participant data from studies distinct from those used in model derivation. We illustrated models by analysing data on a further 123 743 individuals from surveys in 79 countries collected with the WHO STEPwise Approach to Surveillance. FINDINGS:Our risk model derivation involved 376 177 individuals from 85 cohorts, and 19 333 incident cardiovascular events recorded during 10 years of follow-up. The derived risk prediction models discriminated well in external validation cohorts (19 cohorts, 1 096 061 individuals, 25 950 cardiovascular disease events), with Harrell's C indices ranging from 0·685 (95% CI 0·629-0·741) to 0·833 (0·783-0·882). For a given risk factor profile, we found substantial variation across global regions in the estimated 10-year predicted risk. For example, estimated cardiovascular disease risk for a 60-year-old male smoker without diabetes and with systolic blood pressure of 140 mm Hg and total cholesterol of 5 mmol/L ranged from 11% in Andean Latin America to 30% in central Asia. When applied to data from 79 countries (mostly low-income and middle-income countries), the proportion of individuals aged 40-64 years estimated to be at greater than 20% risk ranged from less than 1% in Uganda to more than 16% in Egypt. INTERPRETATION:We have derived, calibrated, and validated new WHO risk prediction models to estimate cardiovascular disease risk in 21 Global Burden of Disease regions. The widespread use of these models could enhance the accuracy, practicability, and sustainability of efforts to reduce the burden of cardiovascular disease worldwide. FUNDING:World Health Organization, British Heart Foundation (BHF), BHF Cambridge Centre for Research Excellence, UK Medical Research Council, and National Institute for Health Research. 10.1016/S2214-109X(19)30318-3
    The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990-2016. The Lancet. Global health BACKGROUND:The burden of cardiovascular diseases is increasing in India, but a systematic understanding of its distribution and time trends across all the states is not readily available. In this report, we present a detailed analysis of how the patterns of cardiovascular diseases and major risk factors have changed across the states of India between 1990 and 2016. METHODS:We analysed the prevalence and disability-adjusted life-years (DALYs) due to cardiovascular diseases and the major component causes in the states of India from 1990 to 2016, using all accessible data sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016. We placed states into four groups based on epidemiological transition level (ETL), defined using the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed heterogeneity in the burden of major cardiovascular diseases across the states of India, and the contribution of risk factors to cardiovascular diseases. We calculated 95% uncertainty intervals (UIs) for the point estimates. FINDINGS:Overall, cardiovascular diseases contributed 28·1% (95% UI 26·5-29·1) of the total deaths and 14·1% (12·9-15·3) of the total DALYs in India in 2016, compared with 15·2% (13·7-16·2) and 6·9% (6·3-7·4), respectively, in 1990. In 2016, there was a nine times difference between states in the DALY rate for ischaemic heart disease, a six times difference for stroke, and a four times difference for rheumatic heart disease. 23·8 million (95% UI 22·6-25·0) prevalent cases of ischaemic heart disease were estimated in India in 2016, and 6·5 million (6·3-6·8) prevalent cases of stroke, a 2·3 times increase in both disorders from 1990. The age-standardised prevalence of both ischaemic heart disease and stroke increased in all ETL state groups between 1990 and 2016, whereas that of rheumatic heart disease decreased; the increase for ischaemic heart disease was highest in the low ETL state group. 53·4% (95% UI 52·6-54·6) of crude deaths due to cardiovascular diseases in India in 2016 were among people younger than 70 years, with a higher proportion in the low ETL state group. The leading overlapping risk factors for cardiovascular diseases in 2016 included dietary risks (56·4% [95% CI 48·5-63·9] of cardiovascular disease DALYs), high systolic blood pressure (54·6% [49·0-59·8]), air pollution (31·1% [29·0-33·4]), high total cholesterol (29·4% [24·3-34·8]), tobacco use (18·9% [16·6-21·3]), high fasting plasma glucose (16·7% [11·4-23·5]), and high body-mass index (14·7% [8·3-22·0]). The prevalence of high systolic blood pressure, high total cholesterol, and high fasting plasma glucose increased generally across all ETL state groups from 1990 to 2016, but this increase was variable across the states; the prevalence of smoking decreased during this period in all ETL state groups. INTERPRETATION:The burden from the leading cardiovascular diseases in India-ischaemic heart disease and stroke-varies widely between the states. Their increasing prevalence and that of several major risk factors in every part of India, especially the highest increase in the prevalence of ischaemic heart disease in the less developed low ETL states, indicates the need for urgent policy and health system response appropriate for the situation in each state. FUNDING:Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India. 10.1016/S2214-109X(18)30407-8
    The Burden of Cardiovascular Diseases Among US States, 1990-2016. ,Roth Gregory A,Johnson Catherine O,Abate Kalkidan Hassen,Abd-Allah Foad,Ahmed Muktar,Alam Khurshid,Alam Tahiya,Alvis-Guzman Nelson,Ansari Hossein,Ärnlöv Johan,Atey Tesfay Mehari,Awasthi Ashish,Awoke Tadesse,Barac Aleksandra,Bärnighausen Till,Bedi Neeraj,Bennett Derrick,Bensenor Isabela,Biadgilign Sibhatu,Castañeda-Orjuela Carlos,Catalá-López Ferrán,Davletov Kairat,Dharmaratne Samath,Ding Eric L,Dubey Manisha,Faraon Emerito Jose Aquino,Farid Talha,Farvid Maryam S,Feigin Valery,Fernandes João,Frostad Joseph,Gebru Alemseged,Geleijnse Johanna M,Gona Philimon Nyakauru,Griswold Max,Hailu Gessessew Bugssa,Hankey Graeme J,Hassen Hamid Yimam,Havmoeller Rasmus,Hay Simon,Heckbert Susan R,Irvine Caleb Mackay Salpeter,James Spencer Lewis,Jara Dube,Kasaeian Amir,Khan Abdur Rahman,Khera Sahil,Khoja Abdullah T,Khubchandani Jagdish,Kim Daniel,Kolte Dhaval,Lal Dharmesh,Larsson Anders,Linn Shai,Lotufo Paulo A,Magdy Abd El Razek Hassan,Mazidi Mohsen,Meier Toni,Mendoza Walter,Mensah George A,Meretoja Atte,Mezgebe Haftay Berhane,Mirrakhimov Erkin,Mohammed Shafiu,Moran Andrew Edward,Nguyen Grant,Nguyen Minh,Ong Kanyin Liane,Owolabi Mayowa,Pletcher Martin,Pourmalek Farshad,Purcell Caroline A,Qorbani Mostafa,Rahman Mahfuzar,Rai Rajesh Kumar,Ram Usha,Reitsma Marissa Bettay,Renzaho Andre M N,Rios-Blancas Maria Jesus,Safiri Saeid,Salomon Joshua A,Sartorius Benn,Sepanlou Sadaf Ghajarieh,Shaikh Masood Ali,Silva Diego,Stranges Saverio,Tabarés-Seisdedos Rafael,Tadele Atnafu Niguse,Thakur J S,Topor-Madry Roman,Truelsen Thomas,Tuzcu E Murat,Tyrovolas Stefanos,Ukwaja Kingsley Nnanna,Vasankari Tommi,Vlassov Vasiliy,Vollset Stein Emil,Wakayo Tolassa,Weintraub Robert,Wolfe Charles,Workicho Abdulhalik,Xu Gelin,Yadgir Simon,Yano Yuichiro,Yip Paul,Yonemoto Naohiro,Younis Mustafa,Yu Chuanhua,Zaidi Zoubida,Zaki Maysaa El Sayed,Zipkin Ben,Afshin Ashkan,Gakidou Emmanuela,Lim Stephen S,Mokdad Ali H,Naghavi Mohsen,Vos Theo,Murray Christopher J L JAMA cardiology Importance:Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously. Objective:To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes. Design, Setting, and Participants:Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017. Exposures:Residing in the United States. Main Outcomes and Measures:Cardiovascular disease disability-adjusted life-years (DALYs). Results:Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors. Conclusions and Relevance:Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures. 10.1001/jamacardio.2018.0385