University College London New frontiers in Diabetes management New frontiers in Diabetes management Call for action to prevent CV disease & diabetes in Asia: New strategies for intervention Key-slides prepared and presented at CDMC on April 20, 2013 in Hanoi, Vietnam by John Deanfield, MD University College London London, United Kingdom

A fall of 55% since baseline Death Rates from All Circulatory Disease in England 1993-2011 180 A fall of 55% since baseline 160 140 Target: 40% minimum reduction from 1995-97 120 100 Death / 100,000 population 80 60 40 Immortality Guaranteed by 2026 20 1993/5 1995/7 1997/9 2001/3 2003/5 2005/7 2007/9 1999/2001 2009/11 2009/11 B/L Progress target Source: ONS (ICD9 390-459; ICD10 I00-I99)

Evolution of Atherosclerosis Genetic Environmental Clinical Events 20 40 60 Age (yrs)

Forecasting Future CVD in USA 900 800 700 600 500 Billions 2008 $ 400 300 200 100 Indirect Direct 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Heidenreich Circ 2011; 123: 933-944

Coronary Heart Disease Mortality in Beijing 1984-1999 2500 1822 Extra deaths Attributable to Risk Factor Changes 2000 Cholesterol 77% 1000 Diabetes 19% BMI 4% Smoking 1% 500 642 fewer deaths by treatments AMI treatments 41% Hypertension treatment 24% Secondary prevetion 11% Heart failure 10% Aspirin for Angina 10% Angina: CABG & PTCA 2% -500 -1000 1984 1999 Critchley J. Circulation, 2004;110:1236-1244

Potential Impact of Annual 0.5% RF Reduction on CHD Deaths in China: 1999-2010 Cheng BMC Public Health 2009, 9:30 1-10

Potentially Modifiable Risk Factors and MI : INTERHEART Study 15152 Cases 14820 Controls in 262 Centres in 52 Countries 9 RFs acounted for 90% of MI in men and 94% in women 3 Odds Ratio 2 1 DM BP Stress Fr/Veg Smoking Obesity Phys Act. Alcohol 60 ApoB/ApoA1 40 PAR (%) 20 -20 Yusuf Lancet September 11 2004

Diabetes in China : 1994-2008 Yang NEJM 2010 362 1090-101 8 8

BMI and Diabetes Prevalence: DECODA Study Ma Ann. N.Y. Acad. Sci. 1281 (2013) 64–91

Diabetes in Asia: Age 20-79yrs Death from Diabetes Chan JAMA 2009; 301: 2129-2140

Diabetes in Asia: Age 20-79yrs Death from Diabetes Obesity • Beta cell function Visceral fat • Developmental factors Diet • Genetic susceptability Smoking • Other factors eg. Thalassaemia Chan JAMA 2009; 301: 2129-2140

Mortality from NCDs in Asian Women Rajadurai, J. et al. Nat. Rev. Cardiol. 9, 464–477 (2012)

Incremental Benefit of Intensive Lowering of LDL and Blood Pressure 0.8 P<0.001 for trend 0.6 0.4 Change Percent Atheroma Volume 0.2 0.0 LDL <70 SBP <120 LDL <70 SBP >120 LDL >70 SBP <120 LDL >70 SBP >120 Chhatriwalla, Nicholls J Amer Coll Cardiol 2009

BMI and Hypertension: Johns Hopkins Precursor Study 508 of 1337 subjects developed hypertension over 46 years Shihab Circulation. 2012; 126: 2983-2989

Cost effectiveness of interventions for CVD, DM, and tobacco use Ortegón BMJ 2012; 344

Impact of Metabolic Syndrome in Youth on cIMT Magnussen J Am Coll Cardiol 2012; 60: 1631–9

Potential Benefit of CV RF treatment in Obesity Excess Total CHD Events Excess Deaths from CHD 100000 100000 Average projection Treatment for DBP and LDL Treatment for DBP, LDL and HDL 10000 10000 1000 1000 No. of excess events No. of excess events 100 100 10 Average projection Treatment for DBP and LDL Treatment for DBP, LDL and HDL 10 1 1 2021 2023 2025 2027 2029 2031 2033 2035 2021 2023 2025 2027 2029 2031 2033 2035 Year Year Bibbins-Domingo NEJM 2007; 357: 2371-2379

CV disease is preventable “Life-long Rx likely to be cost-effective and often cost saving” Circulation 2011;124:967-990

CV Risk Management Strategies Lifetime approach to CV management is key to tackling the increasing population risk Emerging obesity and resulting diabetes is a particular issue for Asia Developing countries need to increase national capacity, effective treatments and improve primary prevention