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Heart Disease in Asia
Shigetake Sasayama
Circulation 2008;118;2669-2671
DOI: 10.1161/CIRCULATIONAHA.108.837054
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Editorial
Heart Disease in Asia
Shigetake Sasayama
People desirous of knowing the diversities of the
races of mankind, as well as the diversities of regions
of all parts of the East, read through this book and
you will find in it the greatest and most marvelous
characteristics of the people . . .
From the Prologue to The Travels of Marco Polo
W
ith the advent of an aging society, heart disease has
become one of the most important health problems
worldwide. Heart disease is estimated to increase continuously during the next few decades. In fact, the number of
people ⱖ60 years of age is expected to double by 2025 and
to triple by 2050 globally.1 The proportion of this aged
population is likely to increase more in the Asian-Pacific
region; thus, half of the world’s cardiovascular burden is
predicted to occur in this area.2
Risk Factors of Cardiovascular Diseases
Increases in levels of risk factors, in particular total cholesterol and blood pressure, appear to account for a substantial
amount of the age-related increase in coronary heart disease.
This themed issue highlights the perspective for the contributions of risk factors to the excess coronary heart disease
mortality in populations of the Asia-Pacific region. Cardiovascular risk factors are traditionally derived from studies in
whites. However, relationships between these traditional risk
factors and cardiovascular disease may differ in Asian and
Western societies. The ethnic differences in the association
between diabetes mellitus and ischemic heart disease are
noted even within Asian populations.3 In Asian countries, as
a consequence of the economic developments, the prevalence
of overweight and obesity is increasing, and more important,
rates of diabetes are increasing even more quickly. In particular, a moderate increase in body mass index makes South
Asians more prone to insulin resistance and related diseases.4
Thus, it has been suggested that lower cutoff points for body
mass index be adopted in Asian than in Western countries.
In most Asian countries, mean levels of total cholesterol
are lower than those found in Western countries, with a lower
incidence of coronary heart disease. In the Asia-Pacific
region, up to two thirds of cardiovascular diseases are
indicated to be attributed to hypertension, underscoring the
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From Doshisha University, Department of Life and Medical Science,
Kyotanabe, Kyoto, Japan.
Correspondence to Shigetake Sasayama, Doshisha University, Department of Life and Medical Science, Tatara Miyakodani Kyotanabe, Kyoto
610 – 0321, Japan. E-mail [email protected]
(Circulation. 2008;118:2669-2671.)
© 2008 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.108.837054
importance of blood pressure–lowering strategies.2 Recent
data show that in the Asia-Pacific region, there is clear
evidence of the hazards of higher blood pressure at all levels
of cholesterol and of the hazards of higher cholesterol at all
levels of blood pressure as reported in the Western population.5 Stroke is a major cause of death and disability in most
populations of eastern Asia, and the incidence, particularly of
hemorrhagic stroke, is generally higher than in the Western
population. The Eastern Stroke and Coronary Heart Disease
Collaborative Research Group assessed the contributions of
blood pressure and blood cholesterol concentration to stroke
risk in populations from eastern Asia and reported that blood
pressure is an important determinant of stroke risk, whereas
cholesterol concentration is less important, affecting the
proportions of stroke subtypes more than overall stroke
numbers.6 This themed issue provides information on the
association between risk factors and cardiovascular disease,
as evidenced by studies carried out in the Asia-Pacific region,
and it highlights different modifiable factors that may influence heart disease.
Socioeconomic Status and
Cardiovascular Diseases
There is a considerable body of evidence for a relation
between socioeconomic factors and all-cause mortality. Studies carried out in developed countries provide convincing
evidence of an inverse relationship between socioeconomic
status and cardiovascular disease, primarily coronary artery
disease7 and stroke.8 However, this relation is quite variable,
and a growing vulnerability to coronary heart disease has
been shown in lower socioeconomic groups.9
In the Asia-Pacific region, many countries are attaining
economic development, and as this region undergoes a
transition to a Western lifestyle, living more sedentary lives
and consuming foods with higher energy and fat, cardiovascular disease is increasing.10 The proportion of overweight
individuals is increasing very rapidly in China, especially
among adults, associated with an increase in hypertension and
stroke. In India, the shift is most pronounced among urban
residents and high-income rural residents with adult-onset
diabetes.11 In rapidly developing economies, income inequality and the double burden of undernutrition and overnutrition
has brought about the coexistence of diseases associated with
both poverty and affluence.12 The negative consequences of
economic development have been shown in many lower- and
middle-income countries in the Asia-Pacific region.13 Governments are expected to implement a strong intervention
policy to prevent obesity, particularly among children, in
these countries.14 The review of the Asian-Pacific Cohort
Collaboration provides valuable insight into this matter.
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Circulation
December 16/23, 2008
Racial Difference in Cardiovascular Diseases
Cardiovascular disease may affect different races differently.
Genetic factors appear to contribute to the ethnic differences
in the prevalence of coronary heart disease as exemplified by
Asian Indians in whom the incidence of premature coronary
heart disease is among the highest reported for any major
ethnic group. This genetic predisposition can be exaggerated
by nutritional and environmental factors.15 The profile of
cardiovascular disease tends to be different in Asia, where
there are more strokes than coronary heart disease events, and
strokes are more often hemorrhagic than ischemic compared
with the West. Clinical and pathophysiological differences
between Asian and white patients are noted in many aspects of
heart disease. The incidence of organic coronary artery disease,
a major cause of heart failure in Western countries, is relatively
low in East Asian countries. The age-adjusted death rate resulting from ischemic heart disease in Japan has been estimated to
be one-sixth that observed in the United States.16 The study
comparing the posthospital outcomes of acute myocardial infarction in Japanese and North Americans during an average
follow-up of 26 months revealed a significantly greater risk of
experiencing a primary end point of cardiac death, nonfatal
myocardial infarction, or unstable angina in North American
patients.17
Despite a lower incidence of organic coronary artery
disease, vasomotor angina is reported to be more common in
East Asia. Oriental patients with recent myocardial infarction
have greater coronary vasoreactivity than their white counterparts, and spasm is more important in the pathogenesis of
myocardial infarction in oriental patients.18 The first comparative study of coronary spasm across racial groups19 recruited
patients by the same criteria, using the same provocative tests
applied by the same team of investigators and centralized
analysis of the angiograms. In this study, focal or segmental
spasm was observed in 80% of Japanese and 37% of white
patients. The spastic response increased from proximal to
distal coronary segments in both populations, but the rate was
significantly higher in Japanese in all segments. Medical
treatment carried out during the acute phase of myocardial
infarction differed significantly between the 2 racial groups.
It is of particular interest that the greater use of calcium
antagonist in Japanese was proportional to the difference in
the incidence of vasospastic angina. On the basis of these
findings, it was suggested that coronary spasm is more
important in Japan as the pathogenesis of myocardial infarction. These ethnic differences are reflected in the interventional strategies summarized in this issue.
The racial difference in therapeutic strategies is also
exemplified by the use of inotropic agents in chronic treatment of heart failure. Several extensive clinical trials carried
out in Western society have revealed that newly synthesized
orally active inotropic agents that increase the concentration
of intracellular cAMP either by promoting its synthesis by
␤-adrenergic receptor agonists or by inhibiting its degradation by phosphodiesterase inhibitors produce a dramatic
short-term hemodynamic benefit in patients with advanced
heart failure, yet the long-term use of these agents is associated with mortality excess. Therefore, all of these agents are
now contraindicated for the treatment of chronic heart failure.
However, patients enrolled in heart failure trials in Western
countries do not represent typical patients encountered in
Japan. Similar studies of these agents carried out in Japan
demonstrated that inotropes favorably modified the prognosis
and quality of life of heart failure patients without affecting
mortality. Therefore, in Japanese patients, chronic therapy
with inotropic agents may be justified as the optimal treatment strategy in the context of relief of symptoms and an
improved quality of life.20
Diseases Recognized in Asia and the
Treatment Developed in Asia
This issue also provides several reviews recognizing Asia’s
contribution to the discovery of new diseases and the development of new therapeutic strategies. One hundred years ago,
a Japanese ophthalmologist, Mikito Takayasu, reported a
21-year-old woman who had some particular retinal anastomotic shunts of arterioles and venules. This condition was
later called Takayasu’s arteritis. However, the discovery of
Takayasu’s arteritis likely dates back as far as 1830, when
Rokushu Yamamoto, an expert in Japanese oriental medicine,
described in old Japanese literature a case of a 45-year-old
man who initially had high fever and developed pulselessness
in the radial and carotid arteries 1 year later.21 The disease is
characterized by female predominance and ethnic difference,
but its origin is still unknown. Nevertheless, the pathological
process of vasculitis is being elucidated by recent progress in
vascular biology and immunology.
Kawasaki disease is an acute, febrile systemic vasculitis of
early childhood in which coronary artery aneurysms may
develop in up to 25% of untreated children. Tomisaku
Kawasaki saw his first case in January 1961, which he
presented as an emergent disease called mucocutaneous
ocular syndrome.22 Subsequently, coronary artery thrombosis
was found at autopsy of a child previously diagnosed as
having mucocutaneous ocular syndrome who died suddenly
and unexpectedly. Kawasaki disease is now the most common cause of acquired pediatric heart disease in the developed world.23 Future research may produce new insight into
the nature of the disease.
In 1990, Sato described a syndrome of an acute onset of
peculiar asynergy, which consisted of hypokinesis or akinesis
from the mid portion to the apical area and hyperkinesis of the
basal area on contrast left ventriculogram without coronary
artery stenosis.24 The syndrome was called tako-tsubo cardiomyopathy because the end-systolic left ventriculogram looks
like a tako-tsubo, an octopus pot or trap used in Japan. This
syndrome initially was thought to be restricted to Japan but
has now been shown to be more universal. It is often
precipitated by emotional or physical stress, but the precise
cause remains unclear.
In closing, it is our hope that this issue provides a clear
exposition of the current state of cardiovascular disease in
Asia and provides readers with a better understanding of
some of these diseases, with an emphasis on therapy and
insight into specific problems that face patients suffering
from cardiovascular disease in Asia and throughout the
world.
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Sasayama
Disclosures
None.
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KEY WORDS: Editorials
䡲
Asia
䡲
heart disease
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