我国心血管病防治：挑战、成因和对策

我国心血管病防治：挑战、成因和对策

中国医学科学院阜外心血管病医院国家心血管病中心医学研究统计中心

杨进刚

on behalf of China PEACE investigators

Fuwai Hospital, National Center for Cardiovascular Diseases, China

China Patient-centered Evaluative Assessment of Cardiac Events

Trends in Characteristics, Treatment andOutcomes Among Patients With AMI

in China from 2001 to 2011China PEACE-Retrospective AMI Study

China PEACE-Retrospective AMI Study

Three time points over a decade: 2001, 2006, 2011

A nationally representative sample ofhospitalizations for AMI using two-stage randomsampling.

Standardized central medical chart abstraction(accuracy >98%)

Rigorous data quality monitoring at each stage

4

Hospitalization Rate for AMI

20

15

Trends in Testing

100

Troponin Creatinine Echocardiogram

% 50

0

2001 2006 2011*

*

P<0.001

*

*

Trends in Medications

100

Aspirin* Clopidogrel* Statins BB* ACE-I/ARB

%50

0

2001 2006 2011P<0.001

P=0.24P=0.13

****

Trends in Reperfusion Therapy

Trends: In-hospital Outcomes

Marked increases in rate of AMI hospitalization

More frequent use of procedures and testing

Persistent gaps in quality of care

No significant improvement in mortality

Summary: AMI in China 2001-2011

Evidence for Future Quality Improvement Strategies

N=2432

NINGXIA

Provincial level Prefecture level County level

Hospital Distribution throughout mainland of China

105 Hospitals30 Provincial level44 Prefecture level31 County level

N=12999

22.40%

10.90%

26.20%

40.50% 1-7 day12-24 h6-12 h≤6 h

STEMI

Times from symptom onset to hospital arrival

38.90%

14.70%

16.90%

29.60%

NSTEMI

provincial perfecture county0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

no-reperfusionPrimary PCIfibronolysis

Percentage of Reperfusion in pts with STEMI

provincial perfecture county0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

2.50%

4.10%

8.30%

mortality

In-hospital mortality rate in pts with AMI

省级(n=5325)

地市级(n=8508)

县级(n=2255)

年龄 60.50 ±13.83 61.93 ±15.66 64.10 ±15.02

既往 PCI/GABG 363 (7.1%) 434 (5.2%) 59 (2.7%)

糖尿病 1107 (22.2%) 1653 (20.3%) 359 (17.5%)

吸烟史 2567 (50.1%) 3584 (42.6%) 854 (38.5%)

Killip>III 级 377 (6.7%) 827 (9.8%) 283 (12.6%)

转院 1876 (36.1%) 1870 (22.0%) 95 (4.2%)

距发病时间 <3h 877 (16.9%) 1876 (22.4%) 667 (30.4%)

D2N,min(Q1,Q3) 130(28, 1064) 65 (27,260) 75 (30,615)

D2B, min(Q1,Q3)

165 (85,885) 136 (80,750) 291 (91,760)

GP2b/3a 拮抗剂 2004 (41.3%) 2182 (28.0%) 360 (16.9%)

三个级别医院就诊患者的差别

Conclusion

• Findings from the China Acute Myocardial Infarction Registry provide an overview of the treatment that patients actually receive and the outcome, providing the opportunity to assess daily practice in a large population of patients with AMI in China.

• The variation in the management and outcome in patients with AMI by region and by type of hospitals reported in this study in China merit further investigation to reduce the observed disparities.

Cost-effectiveness of optimal use of AMItreatments and impact on CHD mortality inChina

Dong Zhao

Capital Medical University Beijing Anzhen Hospital

Beijing Institute of Heart, Lung & Blood Vessel Diseases

5

Strategies of reducing AMI mortality

Primary prevention

Acute treatment

Secondary prevention

Increasing survival from improving treatment

11

Key treatment strategies of AMIrecommended by the guidelines

17

Questions & Hypotheses:

1.Which of these recommended treatmentstrategies would be cost-effective in China ifthe utilities of each or combinations of themwere optimal to 100%.

2.If the opitmal use of recommened treatmenthave remarkable impact on total CHD mortalityin China?

Treatments strategies in acute period

A1 Rising the use of Aspirin, β-blockers, statins and ACEI during

The first 30 days after onset from current utility rate to 100%

A2 Rising the use of clopidogrel in patients with AMI to 100%

B Rising the use of unfractinated heparin in patients with NSTEMI to 100%

C1 Rising the use of primary PCI in tertiary hospital and thrombolysis

in secondary hospital in patients with STEMI (with considerationof the availibility of PCI technology) to 100%

C2 Rising the use of primary PCI in all patients with STEMI to 100%

C3 Rising the use of primary PCI in high risk patients with NSTEMI in tertiary

hospital to 100%

20

21

Cost-effectiveness measurements• Incremental cost-effectiveness ratios were used to evaluate

the cost-effectiveness of optimal use of the key treatments.ICERs were calculated by dividing the incremental changesin total health care costs by the incremental changes inQALYs.

• WHO- CHOICE criteria were used to assess the degree ofcost-effectiveness.

• Highly cost-effective: ICER less than the GDP per capita.

• Moderately cost-effective: ICERs were between 1 to 3 timesof GDP per capita.

• Not cost-effective: ICER more than 3 times of GDP per

capita.

(In

crea

sed

acu

te t

reat

men

t co

st in

mil

lion

s)

Comparison of options of optimal use of treatmentstrategies for effects, cost and cost-effectiveness

-9800.00-3300.00 -3200.00

-1900.00

-30000

-20000

-10000

0

pPCIin STEMI

pPCI+Thrombolysis

Fourmedications

PCI inNSTEMI

Clopidogrelin AMI

Unfractionatedheparin

(C2) in STEMI(C1) (A1) (C3) (A2) ( B)

-36300 deaths

-53600 deaths

$1099millions

$610millions

$152millions $112millons

0

200

400

-40000

-50000

-600001200

1000

800

600

pPCIin STEMI

(C2)

pPCI+Thrombolysisin STEMI(C1)

PCI inNSTEMI

(C3)

Clopidogrelin AMI(A2)

$34millionsFour

medications(A1)

$5millionsUnfractionatedheparin 23

(B)

ICERBA1C1C2A2C3

$2800$3100$9000$10700$17600$23400

Nu

mb

er o

f d

eath

pre

ven

ted

du

rin

g

acu

te p

erio

d

Nu

mb

er o

f d

eath

pre

ven

ted

du

rin

g

acu

te p

erio

d

-36300 deaths

-53600 deaths

-9800.00-3300.00 -3200.00

-1900.00

-30000

-20000

-10000

0

pPCIin STEMI

pPCI+Thrombolysis

Fourmedications

PCI inNSTEMI

Clopidogrelin AMI


(C2) in STEMI(C1) (A1) (C3) (A2) ( B)

$1099millions

$152millions$112.millions $34millons

0

200

800$610millions

600

400

1000

-40000

-50000

-600001200

pPCIin STEMI

(C2)


PCI inNSTEMI

(C3)


Fourmedications

(A1)

$5millons

Unfractionatedheparin 24

(B)

A1+BA1+B+A2A1+B+C1

Highly cost-effectiveNot cost-effectiveModerate cost effective

A1+B+C1+C3 Not cost-effective

Cost-effectiveness of combined strategies(I

ncr

ease

d a

cute

tre

atm

ent

cost

in m

illi

ons)

Number of death prevented duringacute period

(Percentage of reduction inmortality rate

-36300 deaths

-53600 deaths

-9800.00-3300.00 -3200.00

-1900.00

-30000

-20000

-10000

0

pPCIin STEMI

pPCI+Thrombolysis

Fourmedications

PCI inNSTEMI

Clopidogrelin AMI


(C2) in STEMI(C1) (A1) (C3) (A2) ( B)

-7.5%

-5%

-1.3%

-0.3%

-5

-6

-7

-8

-3

-4

-2

-40000

-50000

-600000

-1

pPCIin STEMI

(C2)


PCI inNSTEMI

(C3)


Fourmedications

(A1)

Unfractionatedheparin 25

(B)

A1+B+C1+C3 Maximum a 10%reduction in mortality rate of CHD.

Impact on CHD mortality by optimal use of thetreatment strategies

-0.4% -0.4%

26

Conclusions

o Most hospital-based AMI treatment strategies recommended by the guidelines would be highly or moderately cost-effective in China;

o Full and simultaneous improvements of all standard hospital based AMI treatment strategies assessed in this study would only attributed to 9.6% reduction in the CHD mortality rate;

o Given the trend toward higher absolute numbers and rates of CHD in China, prehospital emergency care, public education on symptoms of AMI and availability of treatments for AMI should be improved.

341,745

1980

-30000

-50000

-10000

10000

fewer deathsin 2000

Risk Factors worse +17%Obesity (increase)Diabetes (increase)

+7%+10%

Risk Factors better -65%Population BP fall -20%Smoking -12%Cholesterol (diet) -24%Physical activity -5%

Treatments -47%AMI treatments -10%Secondary prevention -11%Heart failure -9%Angina:CABG & PTCA -5%Hypertension therapies -7%Statins (primary prevention) -5%

Unexplained -9%

2000

Explaining the fall in CHD deaths in USA1980-2000 : RESULTS

NEJM 2007; 356: 2388.

1981

Explaining the fall in coronary heart diseasedeaths in England & Wales 1981-2000

-60000

-80000

0

-20000

-40000

Risk Factors worse +13%Obesity (increase) +3.5%Diabetes (increase) +4.8%Physical activity (less) +4.4%

Risk Factors better -71%Smoking -41%Cholesterol -9%Population BP fall -9%Deprivation -3%Other factors -8%

Treatments -42%AMI treatments -8%Secondary prevention -11%Heart failure -12%Angina:CABG & PTCA -4%Angina: Aspirin etc -5%Hypertension therapies -3%

Unal, Critchley & CapewellCirculation 2004 109(9) 1101

68,230fewer deathsin 2000

2000

2007 年 2008 年 2009 年0.0

20.0

40.0

60.0

80.0

100.0

71.7 71.8 73.2 69.1 69.4 70.2

院前

死亡

构成

比（

%）

女性男性

2007-2009 年北京市男女两性急性冠心病事件院前死亡构成比（ % ）

39孙佳艺，等 . 《中华心血管病杂志》， 2012

0 20 40 60 80 100

91.4

88.6

84.2

80.0

70.7

67.6

70.4

0 20 40 60 80 100

93.8

83.6

84.6

73.3

67.8

70.1

78.3

85+

75-84

65-74

55-64

45-54

35-44

25-34

2007-2009 年合计北京市男女两性各年龄组急性冠心病事件院前死亡构成比（ % ）

40

男性女性

孙佳艺，等 . 《中华心血管病杂志》， 2012

Clinical Pathways for Acute Coronary Syndromes in China

Dr. Du Xin

The George Institute for Global HealthBeijing Anzhen Hospital, Capital Medical University

• A long-term collaboration between The George Institute,Chinese Society of Cardiology and Ministry of Health

• The study was sponsored by Sanofi

• CPACS Phase 1(2004-2006): Prospective register study– 51 hospitals across the country– 3000 patients

• CPACS Phase 2(2007-2011): cluster randomised trial ofclinical pathway for evidence-based management of ACS– 75 hospitals across the country– >16,000 patients

CPACS: A quality of care improvementinitiative in China

Implement and evaluate a quality improvementinitiative for the care of hospitalised ACSpatients in China

CPACS 2: cluster randomised trial

Participating centres

75 participating centers

50 level 3 hospitals

25 level 2 hospitals

Intervention: performance measurement andfeedback

Clinical pathway implementation with cyclicalaudit feedback and pathway modification

• % of reperfusion therapy for STEMI• Door-to-needle time• Door-to-balloon time

• % diagnoses consistent with ECG and biomarker findings• % of high-risk patients undergoing invasive therapy• % of low-risk patients undergoing functional testing• % on optimum medical therapy on discharge• Length of hospital stay

key performance indicators used inCPACS-2

• Major bleeding episodes

Primary and secondary outcomes

• Primary outcome: 8 key performance indicators• Secondary outcome : in hospital events

• Death• Cardiac death• Major Adverse Cardiovascular Events (MACE) comprising all-

cause mortality, MI and stroke

Group A(early intervention):32 hospitals

Lost to follow-up: 0 hospital

Analysis: 32 hospitals50 (range 50-50) patients per hospital

Group B (late intervention): 38 hospitals

Lost to follow-up: 0 hospital

Analysis: 38 hospitals50 (range 50-50) patients per hospital

CPACS-2 resultsAssessed for eligibility: 82 hospitals

Excluded: 7 hospitalsRefused to participate (4)Other reason (3)

Eligible: 75 hospitals

Pilot hospitals: 5 hospitals

Randomised: 70 hospitals

Length of stay in days (ICC=0.107)

11.31 (7.43) 12.05 (9.03)Un-adjusted

Adjusted

-0.74 (-2.11, 0.63)

-0.77 (-2.15, 0.62)

0.290

0.278

(n=1900) (n=1600)Control Intervention Mean difference

(95% CI) p-valueFavoursControl

FavoursIntervention

-3 0 3Mean difference (day)

-25 0 25Mean difference (min)

DTN time for STEMI patientsundergoing thrombolysisin min (ICC=0.191)

99.00 (81.41) 79.06 (66.15)Un-adjusted

Adjusted

11.89 (-21.3,45.06)

18.06 (-13.4,49.54)

0.483

0.261

DTB timefor STEMI patientsundergoing primary PCI in min (ICC=0.114)

130.09 (90.98) 141.09 (103.69)Un-adjusted

Adjusted

-10.6 (-44.4,23.21)

-11.0 (-45.2,23.22)

0.539

0.528

(n=1900) (n=1600)Control Intervention Mean difference

(95% CI) p-valueFavoursControl

FavoursIntervention

Primary outcome: Continuous KPIs

Patientswith final diagnosis(UAP or MI) consistentwith biomarkerfinding (ICC=0.08)

1720/1855 (92.7%) 1398/1568 (89.2%)Un-adjusted

Adjusted

0.96 (0.91, 1.01)

0.95 (0.89, 1.02)

0.118

0.163

Low-riskpatientsundergoing functionaltesting(ICC=0.058)

Un-adjusted 9/141 (6.4%) 1/90 (1.1%) 0.25 (0.03, 2.07) 0.197

Adjusted

High-risk patientsundergoing coronaryangiography(ICC=0.462)

689/1504 (45.8%) 690/1350 (51.1%)Un-adjusted

Adjusted

1.14 (0.82, 1.58)

1.02 (0.81, 1.29)

0.444

0.849

Patientsdischarged on appropriate medicaltherapy (ICC=0.112)

932/1822 (51.2%) 976/1555 (62.8%)Un-adjusted

Adjusted

1.23 (1.06, 1.42)

1.21 (1.06, 1.37)

0.007

0.004

STEMI patientsreceiving appropriate reperfusion therapy (ICC=0.096)

229/720 (31.8%) 290/679 (42.7%)Un-adjusted

Adjusted

0.069

0.070

Control(n=1900)

Intervention(n=1600)

Risk ratio(95% CI) p-value

Favours FavoursControl Intervention

0.1 1Risk ratio

1.24 (0.98, 1.55)

1.25 (0.98, 1.59)

10

Primary outcome: Binary KPIs

Death (ICC=0.018)

78/1900 4.11% 41/1596 2.57%Un-adjusted

Adjusted

1.60 (0.97, 2.64)

1.78 (0.85, 3.72)

0.066

0.128

Cardiac death (ICC=0.013)

60/1900 3.16% 35/1596 2.19%Un-adjusted

Adjusted

1.44 (0.85, 2.45)

1.37 (0.67, 2.80)

0.178

0.390

Major adverse cardiovascular events(ICC=0.087)

122/1900 6.42% 92/1596 5.76%Un-adjusted

Adjusted

1.12 (0.58, 2.14)

1.59 (0.86, 2.96)

0.741

0.142

Major bleeding episodes(ICC=0.131)

42/1893 2.22% 19/1596 1.19%Un-adjusted

Adjusted

1.87 (0.84, 4.19)

1.91 (0.59, 6.15)

0.125

0.277

Control(n=1900)

Intervention(n=1600)

Risk ratio(95% CI) p-value

FavoursControl

FavoursIntervention

0.20 1 5Risk ratio

Abbreviations:DNT, door-to-needle; DTB, door-to-balloon;PCI, Percutaneouscoronaryinterventions;STEMI, ST segementelevationmyocardialinfarction;ICC, inter-clustercoordination

Secondary outcomes: in hospital events

Time trend analysis

System barriers to the evidence-basedcare of ACS patients

• Lack of leadership and support for implementing qualityimprovement

••

Variation in the capacity of clinical services and QI resources

Healthcare funding constraints and high out-of-pocketexpenses

••

Fears of patient disputes and litigation

Patient-related factors

城市男性城市女性农村男性农村女性0

50

100

150

200

250

300

350

244.1

213.6234

206.6231.1

198.0

255.1

217.2

2004 2008

5.33% 9.02%7.30% 5.13%

粗死

亡率

(1/

100

000)

张啸飞，等 . 《中华心血管病杂志》， 2012

2004 年和 2008 年城乡男女两性心血管病死亡率

55

张啸飞，等 . 《中华心血管病杂志》， 2012

2004 年和 2008 年我国人群缺血性心脏病死亡率

全国城市男性城市女性农村男性农村女性0

20

40

60

80

100

66.1

78.672.1

63.858.7

70.0

80.2 72.5 72.5

63.4

2004 2008

7.46%2.03% 0.55% 13.64% 8.00%

粗死

亡率

(1/

100

000)

标化率： 2004 ： 57.9/10 万 2008 ： 56.2/10 万

56

城市农村城市农村男女

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

3.3 2.9

1.4 1.3

5.9

3.7

6.6

4.1 3.7

2.5

9.0

5.8

18-44 45-59 ≥60

高胆固醇血症患病率（%）

年龄

中国城市农村人群高总胆固醇血症（ TC ≥6.22mmol/L) 的患病率（ 97 409 名 18 岁以上人群， 2010 年）

李剑虹等中华预防医学杂志 2012 46:414-418

总患病率 3.3%

东部中部西部东部中部西部男女

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2.2

1.4 1.5

1.2 0.9

0.5

3.6

1.8

3.2

4.2

1.9

2.9

3.4

1.6 1.8

6.2

3.1

4.3

18-44 45-59 ≥60

高低密度脂蛋白血症患病率（%）

中国各地区人群高 LDL-C （ LDL-C≥4.14 mmol/L) 的患病率（ 97 409 名 18 岁以上人群， 2010 年）


2.1%

城市农村城市农村男女

30.0

35.0

40.0

45.0

50.0

55.0

60.0

56.2

52.6

38.7 40.2

49.8

46.3

35.1

38.8

48.0

42.6

39.1 37.8

18-44 45-59 ≥60低高密度脂蛋白血症患病率（%）

中国城市农村人群低 HDL-C （ HDL-C ＜ 1.04 mmol/L) 的患病率（ 97 409 名 18 岁以上人群， 2010 年）


总患病率 44.3%

东部中部西部东部中部西部男女

30.0

35.0

40.0

45.0

50.0

55.0

60.0

52.9 51.7

56.8

38.4 37.1

44.7 46.3

47.9 49.1

34.6

39.6 40.3

44.7

39.9

48.8

39.1

34.5

41.1

18-44 45-59 ≥60低高密度脂蛋白血症患病率（%）

中国各地区人群低 HDL-C （ HDL-C ＜ 1.04 mmol/L) 的患病率（ 97 409 名 18 岁以上人群， 2010 年）


年龄组( 岁 )

男性女性

2007 2008 2009增加率（ % ） 2007 2008 2009

增加率（ %

）

25-34 11.2 8.9 10.5 -6.3 1.6 0.4 0.5 -68.8

35-44 61.1 70.0 79.6 30.3 7.9 6.5 7.3 -7.6

45-54 170.2 193.4 205.9 21.0 26.2 29.6 29.0 10.7

55-64 335.8 376.4 393.6 17.2 110.3 123.3 124.5 12.9

65-74 689.9 745.9 744.5 7.9 491.6 500.5 499.2 1.5

75-84 1330.9 1378.9 1343.6 1.0 1208.0 1274.4 1243.2 2.9

≥85 2353.4 2319.6 2093.5 -11.0 2495.9 2577.2 2379.7 -4.7

2007-2009 年北京市男女两性不同年龄组急性冠心病事件发病率（ 1/10 万）

61孙佳艺，等 . 《中华心血管病杂志》， 2012

A: 西城区B: 东城区C: 宣武区D: 崇文区

51 ～ 100

101 ～ 150

151 ～ 200

201 ～ 250


51 ～ 100

101 ～ 150

151 ～ 200

201 ～ 250


51 ～ 100

101 ～ 150

151 ～ 200

201 ～ 250

2007-2009 年北京市各区县 25 岁以上居民急性冠心病事件年龄标化发病率

62

2007 2008 2009


标化

发病

率（

1/10

万）

2008年

2007 年 2009年

2007-2009 年北京市不同地区急性冠心病事件年龄标化发病率

63

城四区近郊远郊0

50

100

150

200

250


北京急性冠心病院前死亡占 95.0%

• 2007-2009 年北京地区 25 － 45 岁急性冠心病事件共3489 例（男 3183 例，女 306 例），年龄（ 40.5±4.3 ）岁

• 总病死率 3 年合计为 26.0% ，女性明显高于男性（ 51.0% 比 23.6% ， P<0.05 ）

• 郊区和农村地区的总病死率高于城区（ 28.9% 比22.9% ， P<0.05 ）。

• 25~45 岁急性冠心病事件院前死亡在总死亡中的比例 3年合计为 95.0% （男 95.2% ，女 94.2% ）

• 64.8% 的院前死亡发生地点在家中。

北京青年急性冠心病事件院前死亡流行病学研究 . 中华内科杂志 2012

在最近的 3 年里，深圳一共发生了 4619 例心源性猝死，平均每天 4 例；在这 4619 例病例中，只有 143 例（ 3.1% ）被“活着”送往医院，最后只有 3 例（ 0.06% ）出院。

冠心病患者的初次临床表现

女性

0患者比例 (%)

男性

20 40 60

Murabito et al Circ 1993 88: 2548

Framingham Heart Study (n=5144) 首次事件为心梗或猝死的患者比例

约 60%约 60%

约 45%约 45%

首次冠心病的表现 : Framingham 研究

表现（ % ）心肌梗死心绞痛猝死

年龄男女男女男女 35-64 43% 28% 41% 59% 9% 4%65-84 55% 44% 28% 41% 11% 7.4%

跟踪了 44 年

____________________________________________________________

________________________________________________________

____________________________________________________________

70Libby P. Lancet. 1996;348:S4-S7.

中膜

–T lymphocyte

– Macrophagefoam cell (tissue factor+)– “Activated” intimal SMC (HLA-DR+)–Normal medial SMC

纤维帽内膜脂核

管腔

斑块的解剖

引起心肌梗死的斑块所致的狭窄

68%

18% 14%

0

20

40

60

<50% 50%–70% >70%

狭窄程度

心梗 (%)

Falk et al:Circulation 1995;92:657–671

www.drsarma.in 74

火山爆发

血栓

纤维帽

脂肪核

小结 1 ：中国心肌梗死诊疗面临的几个问题

• 医院内心肌梗死患者在增加• 院前死亡率高• 患者从发病到达医院较晚， 1/4 在发病 24 小

时后到达• 心血管病年轻化趋势明显• 再灌注治疗仍然不足，县医院有待提高• 提高医疗质量需要强有力的有效的干预措施• 我国血脂异常有新动向，农村心血管病发病率

增加迅猛

中国居民 DALY 中所占比例最高的 10 种危险因素

Rapid health transition in China, 1990–2010. Lancet 2013; 381: 1987

肿瘤心血管病循环系统疾病糖尿病和内分泌系统疾

病慢性呼吸道疾病

The Prospective Urban Rural Epidemiologic (PURE) study of

154,000 people from 628 communities in 17 countries

Prospective Urban Rural Epidemiologic (PURE) Study

155,000 adults(400,000 people) from 17 countries (LIC, MIC, HIC)

Urban and Rural 600 communities

Societal level influences (Socioeconomic, tobacco & other health policies, relative food prices and availability, built environment,

indoor/outdoor pollution)

Lifestyle behaviours X genes

Individual risk factors

CVD, DM, Obesity, Cancers,Obstructive Airways Disease,Renal dis,Injuries,Depression.

Canada - 82

Brazil - 14

Argentina - 20

Chile - 5

Colombia - 58

South Africa - 8

Zimbabwe - 3

India - 90

Pakistan - 4

B’desh - 56

Sweden - 31

Poland - 4

Turkey - 44

UAE-3

Iran - 20China - 115

Malaysia - 71

Classification of Countries

Based on World Bank classifications at the beginning of the study (2003 – 2007):

HIC: Canada, Sweden & UAE.• UMIC: Argentina,Brasil,Chile,Poland,Turkey, S

Africa,Malaysia.• LMIC: Colombia,Iran,China .• LIC: India,Bangladesh,Pakistan,Zimbabwe.

Age and gender standardized rates per 1000 pers-years by Economic Levels

Death MI † Stroke †Heart

Failure † CVD ‡

N Rate N Rate N Rate N Rate N RateHIC 138 1.7 139 1.8 106 1.5 36 0.5 564 7.8

MIC 1131 3.8 452 1.5 509 1.7 152 0.5 1370 4.6

LIC 1031 7.4 419 2.9 152 1.1 45 0.3 730 5.1

Total 2300 4.4 1010 2.0 767 1.5 233 0.4 2664 5.2

†MI = MI/Sudden Unexpected Death/Non-sudden Unexpected Death/Other Heart Disease‡CVD = MI/Stroke/heart failure

Age and gender standardized rates per 1000 pers-years by Economic Levels

CVD Fatal CVD Severe CVDOther Hosp

CVD

N Rate N Rate N Rate N RateHIC 564 7.8 39 0.5 273 3.7 291 4.0

MIC 1370 4.6 387 1.3 1079 3.6 291 1.0

LIC 730 5.1 383 2.7 603 4.2 127 0.9

Total 2664 5.2 809 1.6 1955 3.8 709 1.4

Note: CVD = MI + Stroke + Heart Failure + other hospitalized CVD Fatal CVD = Fatal MI + Fatal Stroke + Fatal Heart Failure + other fatal CVD Severe CVD = Fatal CVD + MI + Stroke + Heart Failure

Case fatality rates by Economic Levels

MI Stroke Heart Failure

Overall FatalFatality Rate Overall Fatal

Fatality Rate

Overall Fatal

Fatality Rate

N N % N N % N N %HIC 139 23 16.5 106 5 4.7 36 5 13.9

MIC 452 225 49.8 509 126 24.8 152 46 30.3

LIC 419 294 70.2 152 73 48.0 45 23 51.1

Total 1010 542 53.7 767 204 26.6 233 74 31.8

Fatality rate = (N Fatal/N overall)*100.

Age and gender standardized event rates/1000 person-years – by Country economy

Case fatality rate (%) – by Country economy

Proportion of Causes of Death by Economic Status of the Country

Overall CVD Cancer Injury

Respiratory

Other NCD Other

N % % % % % %HIC 126 23.8 53.2 5.6 4.0 5.6 7.9MIC 871 36.9 30.3 6.3 5.2 4.9 16.4LIC 745 45.5 11.8 9.4 9.0 8.2 16.1Total Number 1742 39.6 24.1 7.6 6.7 6.4 15.7

Number of hospitalizationsby Economic Level

Economic

Level ParticipantOnce or

MoreTwice or

MoreThree or

MoreHIC 15904 2769(17.4) 714(4.5) 212(1.3)

MIC 98487 4986(5.1) 866(0.9) 232(0.2)

LIC 30514 2498(8.2) 252(0.8) 40(0.1)

Total 144905 10253(7.1) 1832(1.3) 484(0.3)

Number of hospitalizationsby Country

Country ParticipantOnce or

MoreTwice or

MoreThree or

MoreBrazil 6081 746(12.3) 163(2.7) 33(0.5)

South Africa 3120 148(4.7) 3(0.1)

Colombia 6656 100(1.5) 7(0.1) 1(0.0)

China 46347 586(1.3) 67(0.1) 21(0.0)

India 27719 2269(8.2) 228(0.8) 36(0.1)

Pakistan 1699 104(6.1) 4(0.2)

Zimbabwe 1096 125(11.4) 20(1.8) 4(0.4)

Total 144905 10253(7.1) 1832(1.3) 484(0.3)

PURE: Contrasting associations between risk factor burden, CVD incidence and mortality in high, middle and low income countries

中美最新心血管病报告对比

1984到 1999年北京冠心病死亡率变化1984到 1999年北京冠心病死亡率变化

增加了 1608 例死亡

胆固醇 77%

糖尿病　 19% BMI 4% 吸烟 1%

治疗改善减少的死亡AMI 治疗 41%二级预防 20%心衰 10%心绞痛 :CABG & PTCA 2%降压治疗 24%

20001984

治疗改善减少了 642 例死亡

Circulation J Critchley, J Liu D Zhao 2004 110:1236-1244

危险因素恶化

小结 2

• 疾病谱的转变– 从传染性疾病转向慢性非传染性疾病– 从严重致命性心血管病转向非致命性心血管病– 从心血管病转向肿瘤

• 从社会角度看，单纯从生物医学技术角度看（危险因素的多少）并不能说明一个人的心血管危险情况。

• 心血管病的干预有充分的循证医学证据• 两国心血管病流行面临双重压力：危险因素的流行和疾

病治疗的薄弱• 全社会动员，而非仅依靠医生，才能做好心血管病的防

治。

Good Outcome

Intermediate Outcome

Bad Outcome

Outcomes from an RCT

Traditional EBM Approach

Mean Treatment Effect

• Clinical trials and EBM provide answers for “average” patients

• In real life, however, there are no average patients

• Clinical trials and EBM provide answers for “average” patients

• In real life, however, there are no average patients

“Well designed clinical trials are good experiments but poor surveys”——N. Longford

The health professions - and health care delivery –are changing ...

From craft-based practice individual physicians, working alone (house/staff = apprentices) handcraft a customized solution for each patient based on a core ethical commitment to the patient and vast personal knowledge gained from training and experience

To profession-based practice groups of peers, treating similar patients in a shared setting plan coordinated care delivery processes (e.g., standing order sets) which individual clinicians adapt to specific patient needs early experience shows

► less expensive (facility can staff, train, supply an organize to a single core process)► less complex (which means fewer mistakes and dropped handoffs, less conflict) ► better patient outcomes

Challenges and opportunities in applying new research methodologies.

美国心血管疾病临床注册• 美国胸科医师学会 : 1000+ 医院

– Coronary artery bypass surgery– Valve surgery– Congenital heart surgery– Thoracic surgery

• 国家心血管疾病注册 : 1600+ 医院– Cath/Percutaneous coronary intervention– Implantable cardiac defibrillators (ICD)– Acute coronary syndromes (ACS)– Carotid stenting– IC3: Ambulatory CV disease (launching)

• AHA-依从指南项目 : 1500+ 医院– Coronary artery disease (CAD)– Heart failure – Stroke – Outpatient: Ambulatory module (launching)

这些临床注册…• 大规模并具有代表性

– 患者，医生，病情• 包含详细的临床资料

– 就诊资料，治疗，短期预后• 采用相似的标准化的数据定义• 高质量的

– 准确、完整、接受质控• 正在演变为纵向研究 !

– 与其它数据来源衔接

贯穿治疗过程的心血管病注册

一级预防导致入院的事件

事件后 :心脏康复二级预防出院

住院治疗住院

HF/Stroke AMI/Care

ACTION GWTG HF, CVAACC-PCI, ICD PVD, CongenitalSTS-CABG, Valve

ACC IC3 GWTG OutpatientTRANSLATE ACSORBIT-AF

AHA H360

临床注册 : 促进实践的改变 !

• 发现进步的“机会”– 追踪有效治疗的应用– 发现治疗的差异 (e.g., disparities)– 追踪不恰当的治疗

• 医生行为的评价 – 标准治疗及预后– 支持质量控制 ( 与 P4P 或公开信息链接）

• 易化医生主导的质量改进– 应用反馈工具来促进治疗时间的变化

住院死亡率与总的指南依从性的联系住院死亡率与总的指南依从性的联系

Peterson et al, JAMA 2006;295:1863-1912

5.95

5.16 4.97

4.16

5.064.63

4.15

6.31

0

1

2

3

4

5

6

7

<=25% 25 - 50% 50 - 75% >=75%

Hospital Composite Quality Quartiles

% I

n-H

osp

Mo

rtal

ity

Adjusted Unadjusted

Every 10% in guidelines adherence 10% in mortality (OR=0.90, 95% CI: 0.84-0.97)

At the End of the Day…

注册研究能够• 有效地收集高质量的临床数据• 追踪患者的长期治疗 • 作为科学发现的源泉• 促进新的证据转化为治疗常规

“Humanity’s greatest advances are not in its discoveries – but in how those discoveries are applied ...”

Bill Gates, June 7, 2007Harvard Commencement Address

New Paradigm of Research

• Learn from real-world results• Focus on system and teams• Involve patients and clinicians• Integrate learning and doing

• 中国临床研究面临的问题是，医生普遍不善于提出临床研究问题，也没有掌握临床研究的科学设计方法。

• 临床研究是诊疗工作密切结合、不可或缺，是改变临床实践的最根本的手段。

• 中国的医学研究人员还是“兼职、作坊和游击队式的工作方式”。

中国的临床资源丰富，潜力巨大。中国能够出最好的研究主要在临床研究方面。

Coronary Mortality in China: Fence, Ambulance, or Hospital Treatments

Thank you!

我国心血管病防治：挑战、成因和对策

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