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Andrew To Cardiologist North Shore Hospital, Auckland, New Zealand June 2014 Cardiovascular Health in Chinese New Zealanders

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Cardiovascular Health in Chinese New Zealanders - Outline CVS Health & Ethnicity Disease prevalence & incidence Risk factors Risk prediction models Pharmacogenetics Specific IssuesAction Points & Take Home Messages

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STATE OF CARDIOVASCULAR HEALTH IN CHINA

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Chinese Heart Health High prevalence of smoking, incl. physicians! High sodium intake Low fruit intake Urban vs. Rural Changes in rates of CVD Availability of medical technology Access and health care utilization Urbanization and related issues

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DIVERSITY

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Risk factors -Hypertension -Hypercholesterolaemia -Diabetes -Physical inactivity -Smoking

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Diversity - Genes, Environment, Lifestyle choices Secondt hird generation Chinese Newly arrived Chinese immigrant

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Acculturation

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PAUCITY OF DATA

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2013 Census Chinese171,411 Indian155,178 Filipino40,350 Korean30,171 Japanese14,118 Sri Lankan11,274 Cambodian8,601 Vietnamese6,660 Asian ethnic group 2013 NZ Census Databases Death certificates Hospital discharge information Population based studies

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AWARENESS PHYSICIANS & PATIENTS

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Palaniappan et al. Circ 2010

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DISEASE PREVALENCE AND INCIDENCE

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Disease prevalence and incidence Limited DATA! Overseas data Lower rates of hospitalizations for IHD vs. whites More hemorrhagic strokes Lower prevalence of peripheral arterial disease Kaltsky et al. Am J public Health 1994 Fang et al. Ethn Dis 2004 Allison et al. JACC 2006

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RISK FACTORS

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Differential body fat distribution Lower mean BMI But similar body fatness WHO recommendations for lowering BMI thresholds Central distribution of body fat - ?metabolically more active Alternative arthrometric measurements Waist circumference, waist-to-hip, trunk-to-total height distribution

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Diet Favourable Less saturated fat Less animal protein Greater vegetables Garlic Black and green teas Red yeast rice Omega-3 fatty acids Unfavourable Sodium

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Physical inactivity

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RISK PREDICTION MODELS

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Framingham risk scores - the need for calibration

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Recalibration of risk prediction models J Epidemiol Community Health. Feb 2007; 61(2): 115121

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Recalibration of risk prediction models in New Zealand - PREDICT cohort Ridell et al. NZMJ 2010

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Recalibration of risk prediction models in New Zealand - PREDICT cohort Original Framingham Heart Study risk prediction score overestimates risk for the New Zealand European population but underestimates risk for the combined high risk ethnic populations (Maori, Pacific and Indian) Adjusted Framingham score used in New Zealand clinical guidelines overcompensates for this underestimate, resulting in a score that overestimates risk among the European, Maori, Pacific and Indian ethnic populations at all predicted risk levels Ridell et al. NZMJ 2010

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PHARMACOGENETICS

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Statins CYP3A4 Lovastatin, Simvastatin, Atorvastatin CYP2C9 Fluvastatin, Rosuvastatin Renal Pravastatin OATP1B1 uptake transporter (SLCO1B1 gene) 521T>C polymophism reduces uptake of statins from bloodstream into hepatocytes Increases serum level, for most; except Fluvastatin; esp. Simvastatin acid ABCG2 transporter (ABCG2 gene) 421C>A polymorphism reduces uptake and increases exposure Affects most statins, esp. Rosuvastatin, Atorvastatin, Fluvastatin Explains increased risk for AE of Rosuvastatin in Chinese

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Warfarin Dosing tables dependent on CYP2C9*2, CYP2C9*3, VKORC1(-1639G>A)

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Warfarin

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Clopidogrel AsiansWhitesAfrican- americans CYP2C19*2 (c.681G>A)55%28%24%LOF CYP2C19*317%T)4%41%23%GOF

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ACTION POINTS & SUMMARY

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Action points - Individual level Recognizes the differences in Chinese vs. white population Risk factors Risk prediction model Pharmacogenetics

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Action points - Population level GENERAL PAUCITY OF DATA Recognize heterogeneous populations Appropriate data collection Specific Asian groups Databases Death certificates Hospital discharge information Population based studies AWARENESS

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