Epidemiology and clinical management of cardiomyopathies and heart failure in China

Epidemiology and clinical management of

cardiomyopathies and heart failure in China

H Jiang,J Ge

Department of Cardiology,

Zhongshan Hospital,Shanghai

Medical College,Fudan

University,Shanghai,China

Correspondence to:

Professor J Ge,Department of

Cardiology,Zhongshan Hospital,

Shanghai Medical College,

Fudan University,Shanghai,

China.200032;

ge.junbo@https://www.360docs.net/doc/ef18375574.html,

Accepted21November2008

Published Online First

23March2009

ABSTRACT

Heart failure(HF),a syndrome of clinical symptoms and

signs,is the most serious and the final outcome of all

heart diseases and as in other parts of the world it is a

common cause for admission to hospital in the Chinese

population.In this review the epidemiological data on

cardiomyopathies,HF and current treatment for chronic

HF among people living in China are summarised.

EVOLUTION OF CARDIOMYOPATHIES

CLASSIFICATION AND ITS INCIDENCE IN CHINA

The classification of cardiomyopathies was proposed

by the World Health Organization(WHO)/

International Society and Federation of Cardiology

Task Force(ISFC)in1995.1They were classified as

dilated cardiomyopathy(DCM),hypertrophic cardi-

omyopathy(HCM),restrictive cardiomyopathy

(RCM)and arrhythmogenic right ventricular cardi-

omyopathy(ARVC).In1999,the Chinese Medical

Association cardiovascular branch and editorial board

of the Chinese Journal of Cardiology suggested that the

WHO’s recommendations of1995should be the

diagnostic standard of cardiomyopathies in China.2

In2006,the American Heart Association(AHA)

issued3‘‘Contemporary definitions and classification

of the cardiomyopathies’’.The cardiomyopathies are

now classified by the pathophysiology or,if possible,

by aetiological/pathogenetic factors and they are

divided into two major groups:primary cardiomyo-

pathies(genetic,non-genetic,acquired),which are

solely or predominantly confined to heart muscle;

secondary cardiomyopathies,which show pathologi-

cal myocardial change as part of a large number of

generalised systemic(multiorgan)disorders.This

completely renovated the WHO/ISFC classification.

In the same year,the Chinese Medical Association

cardiovascular branch and editorial board of the

Chinese Journal of Cardiology organised an expert panel

on myocardial https://www.360docs.net/doc/ef18375574.html,bining evidence from

large-scale clinical trials from Europe and the United

States,and China’s evidence-based findings and

conclusions,they suggested4that primary cardio-

myopathies be classified into DCM,HCM,RCM,

ARVC,and unclassified cardiomyopathies should

include left ventricular non-compaction,but dilated

cardiomyopathy resulting from myocarditis should

belong to secondary cardiomyopathies.It has been

recognised that arrhythmias and conduction system

diseases(ion channelopathies)have an obvious

genetic background,such as long and short QT

syndrome,Brugada syndrome,etc,but at this time

they were not classified into primary cardiomyopa-

thies,which differs from the AHA classification.

A potentially fatal form of local cardiomyopathy

in China is called Keshan disease(KD).To the best of

our knowledge,it was reported for the first time in

Zhang Yunfu Tuen Keshan counties of Heilongjiang

province of China in1935.Research showed that

similar to dilated cardiomyopathy,KD occurred in a

transitional zone between the north east and the

south west.In addition,large epidemiological,

anatomical pathology and clinical laboratory studies

also indicated that this disease is a local cardiomyo-

pathy.The aetiology is unknown,but selenium

deficiency may be involved.About45000people in

14locations of12provinces were surveyed during

2000–4,5and it was found that potential KD had an

annual rate of3.8%,but the chronic KD detection

rate was0.8%.In2005,10413people in22locations

of12provinces were surveyed.The incidence of

latent and chronic KD in surveillance locations was

3.5%and0.6%,respectively,and patients with KD

were estimated to be between4.82and5.81million

in China,with no significant difference in morbidity

compared with2004.KD might be classified as a

‘‘mitochondrial cardiomyopathy’’endemic in China.

The incidence of DCM in the United States and

elsewhere is36.5per100000subjects.6In Nanjing,7

from1985to1989,275new cases of cardiomyopathy

were collected from2098175residents aged,60,

who were clinically diagnosed in outpatient and

inpatient departments of14hospitals,and the overall

incidence was2.6per100000person-years,which

increased from1.7per100000in1985to3.3per

100000in1989and increased progressively with age.

The average annual incidences of DCM and HCM

were both1.3per100000,while the incidence of

cardiomyopathy among men was3.0per100000,

which was significantly higher than the 2.2per

100000rate among women especially noted with

HCM.In a population-based echocardiography study

performed among8080adults(4064men and4016

women)from nine communities across nine pro-

vinces in China from October2001to February20028

the age-and sex-adjusted prevalence of HCM was

about80per100000adults,while DCM was19per

100000.HCM and DCM are not rare in China.

According to these estimations,the prevalence in

China is similar to the average rate of the whole

world;there are at least1million cases of HCM in

China,comparable to the prevalence of HCM of17/

100000,170/100000in Japan and America.69

The incidences of ARVC and RCM in the Chinese

population have rarely been reported.Fung and

Sanderson10studied11patients with arrhythmo-

genic right ventricular cardiac disease,and found

that the most common symptoms were palpitations

(73%)and dizziness(46%).Six(55%)of the

arrhythmic patients had spontaneous ventricular

tachycardia,and one(9%)had ventricular fibrillation

and cardiac arrest.Seven patients(64%)had an

Global burden of cardiovascular disease

abnormal electrocardiogram,of whom,two(18%)had a family history of ARVC or premature sudden cardiac death,and five (45%)showed right ventricle dilatation without left ventricular dysfunction on echocardiography.Nine of these patients(90%) had right ventricular wall thinning or fibrofatty replacement on magnetic resonance imaging(MRI);MRI has more value in the diagnosis of ARVC.

INCIDENCE OF HEART FAILURE IN CHINA

In1996,the estimated incidence of heart failure(HF)in China was3.8/1000among women and3.0/1000among men aged.45 years,and it was the12th leading cause of hospitalisation in Hong Kong.11In1997,136203patients(56%female)were surveyed12in Hong Kong.The mean age of the female patients was77.5and of the male patients72.4,and the overall incidence of HF was0.7per 1000population.In those aged.85years,the incidence of HF was 20per1000women and14per1000men,which was similar to another study from Hong Kong,in which730patients with HF were identified and studied.13In that study the majority were female(56%),while the mean ages of the female and male patients were75.6and70.6,respectively.The main identifiable causes of HF were hypertension(37%),ischaemic heart disease (31%),valvular heart disease(15%),cor pulmonale(27%), idiopathic dilated cardiomyopathy(4%)and others(10%). Among women,hypertension was the most common cause in all ages,while among men aged,70,ischaemic heart disease was equal to hypertension(36%and35%,respectively). Investigations made by the Shanghai Investigation Group of HF14in1980,1990and2000,based on2178hospitalised patients with congestive heart failure(CHF),found that the aetiology of HF had shifted from mainly rheumatic valvular disease to coronary heart disease during the past two decades.Rheumatic valvular disease had fallen from46.8%to8.9%,while coronary heart disease had increased from31.1%to55.7%.In2000 coronary heart disease was the first cause of HF,accounting for 55.7%;hypertension was the second,accounting for13.9%; while rheumatic valvular disease was8.9%and DCM7.5%.

To evaluate the current status of HF in some parts of China, data of CHF were taken from42hospitals in different cities of China.15A total of10714patients with HF were enrolled,all of whom were admitted to hospital in1980,1990and2000;the majority(56.7%)were male,more than60%of the total population were aged.60and the mean(SD)hospital stay was 35.1(43)days,31.6(34.1)days,21.8(25.6)days(p,0.001), respectively,in1980,https://www.360docs.net/doc/ef18375574.html,mon causes of HF were coronary heart disease,rheumatic valvular heart disease and hypertension.Again it was noted that from1980to2000,the incidence of coronary heart disease and hypertension had risen from36.8%and8%to45.6%and12.9%,respectively,the rate of rheumatic valvular heart disease had fallen from34.4%to18.6%, while DCM was6.4%versus7.6%and congenital heart disease was3.5%versus3.2%in1980and2000,respectively.Deaths from HF as a percentage of total cardiovascular disease mortality had changed little in3years—39.9%,37.7%and41.1%,respectively—and the main causes of death in HF were pump failure(59%), arrhythmia(13%),sudden cardiac death(13%).

Gu et al reported16a large-scale epidemiological survey,in which a total of15518adults had been surveyed from20urban and rural areas in10provinces of China in2000,five in the north,including Beijing,Jilin,Shaanxi,Qinghai and Shandong, and five in the south,including Jiangsu,Hubei,Fujian,Guangxi and Sichuan(bounded by the Yangtze;fig1),with equal numbers from the urban and rural populations and equal numbers of men and women.The result showed that the prevalence of CHF was0.9%for the general population,0.7% and1.0%for the men and the women,respectively.The women had CHF more frequently than the men,and the prevalence of HF in China was lower than in Western countries.According to this research,currently,there are about four million patients, aged35–74years,with HF in China,and the prevalence of CHF among people aged35–44was0.4%,people aged.55was 1.3%—that is to say the prevalence of CHF increased substantially with age.The risk of CHF was higher in the north(1.4%)than in the south(0.5%),and higher in urban

Figure1Clinical centre of the epidemiological

survey.

Global burden of cardiovascular disease

(1.1%)than in rural(0.8%)areas in China,which is consistent with the geographical distribution of coronary heart disease and hypertension.

Urban populations in China account for only one tenth of the total population,so,the majority of patients with HF are treated in primary hospitals.17In the study by Cao et al total of 2100people from2066local hospitals of17areas had been studied in China,and the results indicated that the three main causes of CHF were coronary heart disease(57.1%),hyperten-sion(30.4%)and rheumatic valvular disease(29.6%).However in some place(Yunnan,Guizhou,Hainan),chronic pulmonary heart disease was also a main cause of CHF(up to26%),while the leading cause of HF in Qinghai province was Plateau heart disease(53.2%),as it is located in the plateau.The survey suggested that the prevalence of HF in China is lower than in Western countries(in the USA it is1.5%,2.0%). Additionally,in contrast to Western countries,the prevalence among women was higher than among men,which could be accounted for by the different causes of HF between them.The proportion of the patients with rheumatic valvular disease in China is higher than in Western countries,and the incidence of rheumatic valvular disease among women was significantly higher than that of men.The prevalence of CHF increased substantially with ageing,which is consistent with the data in other countries.Although the causes of HF vary between cities in China,coronary heart disease,hypertension,rheumatic valvular disease and cardiomyopathy were the major causes of cardiovascular disease,and tuberculosis pericarditis and pul-monary heart disease accounted for the remainder(table1). Given all this,prevention of CHF in China should focus not only on the effective prevention of coronary heart disease and hypertension but also on the prevention of rheumatic valvular disease and chronic lung disease.

TREATMENT OF PATIENTS WITH HEART FAILURE IN CHINA Pharmacological treatment

A retrospective study18of5189patients admitted to hospital with HF from1973to2002in two centres of Tian Jin showed that,among all patients,use of nitrates was80.0%,diuretics 71.8%,digitalis68.1%,angiotensin conversion enzyme inhibi-tors(ACEI)52.2%,and b blockers(BB)19.5%. Furthermore,data15from42hospitals in different cities of China in1980,1990and2000were analysed.A total of10714patients with HF were enrolled—56.7%were men,mean(SD)ages were 63.1(16.1)years for men and67.8(16.5)for women,and60%were aged.60years.Diuretics,nitrates and digitalis were still dominant drugs in hospitals with the total proportion of55.4%,43.2%, 48.2%,respectively.The use of digitalis had decreased(51.7%, 45.5%,40.3%),while the use of B

B and ACEI had increased sharply from8.5%and14.0%in1980to19.0%and40.4%in2000, https://www.360docs.net/doc/ef18375574.html,pared with1990,the use of aldosterone antagonists had increased from8.4%to20%in2000(table2). Survival has improved as the times from diagnosis to the final death of patients with HF were33.6,37.1and40.5months in 1980,1990and2000,respectively.The other investigation carried out by the Shanghai HF Investigation Group14of2178cases from 12hospitals showed that medical treatment has remained mainly conventional over the past20years,such as diuretics,nitrates and digitalis,which accounted for77.1%,74.4%,60.0%.ACEI and BB were70.8%and25.0%in2000,respectively.In1990,the rate of use of dihydropyridine calcium antagonists had reached41.3%, but fell to14.2%https://www.360docs.net/doc/ef18375574.html,e of angiotensin receptor blockers (ARBs)started in2000was11.5%(table2).

A cross-sectional study was initiated in16medical centres in 2000and the results showed that19the rate of use of ACEI and B

B in Shanghai was61.0%and27.2%,respectively,while24.4% and70.0%of the patients who were considered sensitive to ACEI and BB did not take these drugs.Thus,the use of these drugs in the majority of small hospitals and community hospitals regretfully deviated from the guidelines.

Another study of2100patients from2066primary hospitals20of 17areas in China in2006found that the use of diuretics in all classes of CHF was90%,the rate of digitalis use was60%,the rate of large-dose digitalis(>0.25mg/day)was10%,use of BB and ACEI was 40%and80%,respectively.What was disappointing was that target doses were reached in only1%and2%of cases,respectively. The use of ARBs was5%and spironolactone50%(table2). Research in Mianyang,Sichuan province showed21that drug use has improved from2004since the treatment guide for CHF was issued;ACEI and BB were used for59.2%and60.1%,with nitrates up to56.3%and calcium antagonists to20.1%.In the past20years,traditional medicine had still been the main treatment for HF,with diuretics remaining one of the most commonly used drugs.

ACEI are currently underused in China,and few reach target doses,which may be because of the proportion of patients with rheumatic valvular disease.In addition,the use of nitrates may be more relevant to coronary heart disease,but a considerable number of patients without coronary heart disease have also

Table1Causes of heart failure in China

Survey site Year Patients

(n)

Causes of heart failure

Hypertension

(%)

Ischaemic

heart disease

(%)

Valvular

heart disease

(%)

Cor pulmonale

(%)

Idiopathic dilated

cardiomyopathy

(%)

Congenital heart

disease

(%)

Hong Kong131995730373115274–

Shanghai14198021788.531.146.8– 6.0–199010.340.624.2– 6.9–

200013.955.78.9–7.5–

42Hospitals in different cites1519801756836.835.5– 6.4 3.5 1990218110.433.837.0–7.4 3.1 2000677712.945.621.0–7.6 3.2

Primary hospitals of

China17

2004210030.457.129.626.0*––

*Only for patients in primary hospitals in Yunnan province,Guizhou province and Hainan province in China.

Global burden of cardiovascular disease

used them.BB are less used,perhaps because of the frequent coexistence of pulmonary heart disease.

Stem cell therapy

In1994,scholars of Washington University reported in the ‘‘Science’’journals the first case of treatment of myocardial infarction in animals by cell transplantation.Soonpaa who carried out the first myocardial cell transplantation,confirmed that myocardial cell transplantation is feasible.In2000,Ruijin Hospital in Shanghai published in the China Medical Journal an experimental study of cultured autologous myoblast for the treatment of acute myocardial infarction.Fudan University affiliated to Zhongshan Hospital,and Beijing University affiliated to the Third Hospital conducted the‘‘15’’national research.22 Since2003,they have conducted clinical research into bone marrow stem cell transplantation in the treatment of coronary heart disease,ischaemic heart disease and HF,and recently,China has also carried out23clinical trials of the treatment of myocardial infarction of nearly600patients with bone marrow-derived cells. However,stem cell therapy in China is still in the clinical research stage,and there is no clinical norm of stem cell transplantation. The Chinese government will provide12million yuan for cell transplantation research in the treatment of heart disease. Currently,there are three million patients with myocardial infarction in China,24with an increase of600000new patients https://www.360docs.net/doc/ef18375574.html,pared with Western countries,Chinese coronary artery disease is more serious and is treated later;for such patients,conventional revascularisation is often poor,and cell transplantation could become effective ways to improve the quality of life and prolong life.

Cardiac resynchronisation therapy(CRT)

CRT is a new treatment for patients with DCM with severe congestive HF.Although the first use of CRT in China was in1999, there have been only500cases in which it has been used up to the end of2005.There may be many reasons for this,such as a shortage of doctors who have mastered pacing technology,electrophysiol-ogy knowledge and some interventional treatment technology; ignorance of the fact that CRT can be very effective in improving heart function in patients with HF;and unacceptable cost. Implantable cardioverter-defibrillator(ICD)

The causes of death for HF are deterioration of cardiac failure and/or sudden cardiac death(SCD),and the latter is caused by the most malignant ventricular arrhythmia(ventricular tachy-cardia and ventricular fibrillation).Narang et al reported25that SCD is considerable for patients with mild to moderate HF, accounting for.50%of the total deaths,besides,among721 surveyed patients with CHF in Japan.26SCD accounted for40% of the total deaths,and therefore,prevention of SCD is an effective way to reduce the mortality due to HF.Ten years of an international clinical trial demonstrated that an ICD is the most effective prevention of SCD.

Use of ICDs is still in the initial stage in China,and although clinical use of ICDs was started in1992,in China major trauma thoracic surgery was complex,so that only about10patients received this technology in5years.In recent years,owing to the development of transvenous systems,the number of patients implanted with an ICD has gradually increased,reaching about 400by the end of2003.

Cardiac transplantation

Heart transplants are a mature technology in China and elsewhere.The first heart transplant in China was carried out in April1978in Guangchi Hospital,which is affiliated to the Second Medical College of Shanghai.It was also the first case of orthotopic heart transplant in Asia.However,this patient died of acute rejection109days after the operation.Orthotopic heart transplantation was then carried out in Taipei‘‘National’’Taiwan University Hospital in July1987.Currently,the longest survival time of these patients is more than15years,for a patient who was operated on in the Second Affiliated Hospital of Harbin Medical University in April1992,and is still alive. According to incomplete statistics,more than400patients had received a heart transplant in the mainland of China by2007, among whom more than200were operated on in Zhongshan Hospital of Shanghai with a1-year survival rate of about90%, 3-year survival rate of about80%,5-year survival rate of about 70%.In December2005,Zhongshan Hospital of Shanghai completed one heart–lung transplant,this patient not only survived,but lived for the longest time among patients operated on in China.Currently,China’s heart transplant operations have been less affected by the lack of a donor,traditional values and the high cost of operation than formerly.

The heart assist device

Heart assist devices include:an intra-aortic balloon pump,a left/right ventricular assist device(such as Thoratec,Novacor,

Table2Pharmacological treatment in China

Survey site Years Patients(n)Pharmacological treatment

Nitrates(%)Diuretics(%)Digitalis(%)ARB(%)ACEI(%)

Spironolactones

(%)BB(%)

Calcium

antagonist(%)

Tianjin181973–8254230.358.761.3–– 5.99.014.8 1983–92125370.667.871.6–24.210.18.335.2

1993–2002339491.475.467.9 4.070.923.125.321.6

42Hospitals in different cites151980175644.763.751.70.414.010.08.5 6.1 1990218136.070.245.5 1.426.48.49.516.4 2000677753.048.640.3 4.540.420.019.010.5

Shanghai141980217874.477.160.0–0.6– 6.8–1990–38.9– 5.741.3

200011.570.8–25.014.2 Primary hospitals in

17areas of China20

20062100–90605805040–BB,b blocker;ACEI,angiotensin converting enzyme inhibitor;ARB,angiotensin receptor blocker.

Global burden of cardiovascular disease

Heartmate,Jarvik2000),a biventricular assist device and an artificial heart(Jarvik-7-70,Cardio West,etc).An intra-aortic balloon pump and extracorporeal membrane oxygenation have been widely used in the clinics of China and have achieved satisfactory clinical results.But other heart assist device have more complications,high mortality and increased cost,so their use in clinics is limited and only individual cardiac surgery centres have reported a few cases.

CONCLUSIONS AND FUTURE CHALLENGES

The epidemiology of cardiomyopathies and HF in China has its own characteristics.In the1970s,the causes of HF were mainly rheumatic valvular disease,but as we can see,this situation has moved to coronary heart disease and hypertension.Although rheumatic valvular disease and congenital heart disease have declined markedly as a proportion of cases of HF,rheumatic valvular disease and pulmonary heart disease still account for a considerable number of cases in China.As in the developed countries,the mean age of HF is rising.Although the prevalence of HF in China is lower than in Western countries,in view of China’s large population,the fast ageing of this population,and 130million people with hypertension,with low rates of treatment,patients with HF need to receive high attention. Conventional drugs still constitute the essential treatment of HF.Diuretics remains one of the most commonly used drugs for CHF in China.The usefulness of BB and ACEI in the treatment of CHF has been gradually recognised and accepted by clinicians,so they are more frequently used;however,they are still not fully used and rarely to the target https://www.360docs.net/doc/ef18375574.html,e of ACEI has not been well standardised in China.In light of this,the Chinese Medical Association Cardiovascular Disease Branch formulated their ‘‘China ACEI expert consensus’’based on the consensus of ACEI use from the European Society for Cardiology(ESC),and the latest evidence-based medical research into China’s national conditions. They announced on17March2006that the use of digitalis, calcium channel blockers and traditional vasodilator drugs (nitrates)is too high.Although the ACC/AHA and the ESC guidelines for CHF do not recommend the use of calcium channel blockers for systolic dysfunction in CHF,they are still being used in a certain numbers.Surveys have shown that nitrates,except for a small number of myocardial ischaemia treatments,are mainly used for HF,which is not in line with all the guidelines.The history of using ARBs is short,and treatment experience and evidence-based medicine were insufficient,which may lead to their lower usage.In short,there is still a great gap between clinical treatment and guidelines for CHF,which need our further efforts. The Cardiovascular Branch of the Chinese Medical Association issued a proposed standard treatment for CHF in January2002in the Chinese Journal of Cardiovascular Disease.27 With better management of HF,patients are living longer and enjoying a better quality of life.It is necessary to unify the management of patients according to the guide,by establish-ment of an HF clinic,implementation of education and standard treatment,completion of follow-up of treatment status of patients,so as to improve drug usage,the target dose and long-term prognosis and enable patients with HF to receive greater benefits.

To progress and to integrate our research into the wider world,we need more cooperation and interaction with scientists throughout the world,keeping in mind the clinical conditions of our country.

Competing interests:None declared.

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Global burden of cardiovascular disease

doi: 10.1136/hrt.2008.150177

2009 95: 1727-1731 originally published online March 23, 2009

Heart

H Jiang and J Ge

cardiomyopathies and heart failure in China

Epidemiology and clinical management of

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Epidemiology (7514 articles)Drugs: cardiovascular system

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