CV Risk and Lipids in Asia: Epidemiology

1. CV Risk and Lipids in Asia: Epidemiology

2. The Burden of CVD in Asia: Stroke Deathsby Country, 2002 2 Cardiovascular disease (CVD), including stroke and coronary heart disease (CHD), is a leading cause of mortality in the East Asia and Pacific region, according to 2002 World Health Organization (WHO) statistics. For example, in China, stroke was responsible for more than 1.5 million deaths and CHD led to more than 700,000 deaths in 2002 alone. WHO CVD Atlas. 2002. Deaths from stroke. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_16_death_from_stroke.pdf. Accessed March 7, 2011. WHO CVD Atlas. 2002. Deaths from coronary heart disease. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_14_deathHD.pdf. Accessed March 7, 2011. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442. Cardiovascular disease (CVD), including stroke and coronary heart disease (CHD), is a leading cause of mortality in the East Asia and Pacific region, according to 2002 World Health Organization (WHO) statistics. For example, in China, stroke was responsible for more than 1.5 million deaths and CHD led to more than 700,000 deaths in 2002 alone. WHO CVD Atlas. 2002. Deaths from stroke. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_16_death_from_stroke.pdf. Accessed March 7, 2011. WHO CVD Atlas. 2002. Deaths from coronary heart disease. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_14_deathHD.pdf. Accessed March 7, 2011. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442.

3. The Burden of CVD in Asia: CHD Deaths by Country, 2002 3 Cardiovascular disease (CVD), including stroke and coronary heart disease (CHD), is a leading cause of mortality in the East Asia and Pacific region, according to 2002 World Health Organization (WHO) statistics. For example, in China, stroke was responsible for more than 1.5 million deaths and CHD led to more than 700,000 deaths in 2002 alone. WHO CVD Atlas. 2002. Deaths from stroke. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_16_death_from_stroke.pdf. Accessed March 7, 2011. WHO CVD Atlas. 2002. Deaths from coronary heart disease. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_14_deathHD.pdf. Accessed March 7, 2011. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442. Cardiovascular disease (CVD), including stroke and coronary heart disease (CHD), is a leading cause of mortality in the East Asia and Pacific region, according to 2002 World Health Organization (WHO) statistics. For example, in China, stroke was responsible for more than 1.5 million deaths and CHD led to more than 700,000 deaths in 2002 alone. WHO CVD Atlas. 2002. Deaths from stroke. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_16_death_from_stroke.pdf. Accessed March 7, 2011. WHO CVD Atlas. 2002. Deaths from coronary heart disease. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_14_deathHD.pdf. Accessed March 7, 2011. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442.

4. Age-Standardized Stroke and CHD DeathRates by Country, 2002 4 Age-standardized mortality rates for stroke are elevated in East Asian Pacific countries and are generally higher than in Western countries. East Asian countries have lower CHD mortality rates than do Western countries, but South Asian and some Southeast Asian countries have age-standardized mortality rates for CHD that are comparable to or higher than those of Western countries. Ueshima H, Sekikawa A, Miura K, et al. Cardiovascular disease and risk factors in Asia: a selected review. Circulation. 2008;118:2702-2709. Age-standardized mortality rates for stroke are elevated in East Asian Pacific countries and are generally higher than in Western countries. East Asian countries have lower CHD mortality rates than do Western countries, but South Asian and some Southeast Asian countries have age-standardized mortality rates for CHD that are comparable to or higher than those of Western countries. Ueshima H, Sekikawa A, Miura K, et al. Cardiovascular disease and risk factors in Asia: a selected review. Circulation. 2008;118:2702-2709.

5. Stroke Type in China Sino-MONICA-Beijing project indicate from 1984 to 2004 the incidence of hemorrhagic stroke declined by 1.7% annually the incidence of ischemic stroke increased by 8.7% annually Stroke subtypes in urban areas 5 Epidemiologic studies show that ischemic stroke in Asia is becoming more common than hemorrhagic stroke. Results from the Sino-MONICA-Beijing project indicate that from 1984 to 2004 the incidence of hemorrhagic stroke declined by 1.7% and the incidence of ischemic stroke increased by 8.7% annually. Studies in Shanghai and Beijing in 2000 documented that ischemic stroke was the dominant type of stroke. In Shanghai, 70% of total stroke was ischemic and 27.4% intracranial hemorrhage. In Beijing, 78% of total stroke was ischemic and 18.9% intracranial hemorrhage. Liu M, Wu B, Wang W-Z, et al. Stroke in China: epidemiology, prevention, and management strategies. Lancet Neurology. 2007;6:456-64. Jiang B, Wang W-Z, Chen H, et al. Incidence and trends of stroke and its subtypes in China: results from three large cities. Stroke. 2006;37:63-68. Zhao D, Liu J, Wang W, et al. Epidemiological transition of stroke in China: twenty-one–year observational study from the Sino-MONICA-Beijing Project. Stroke. 2008;39:1668-1674. Epidemiologic studies show that ischemic stroke in Asia is becoming more common than hemorrhagic stroke. Results from the Sino-MONICA-Beijing project indicate that from 1984 to 2004 the incidence of hemorrhagic stroke declined by 1.7% and the incidence of ischemic stroke increased by 8.7% annually. Studies in Shanghai and Beijing in 2000 documented that ischemic stroke was the dominant type of stroke. In Shanghai, 70% of total stroke was ischemic and 27.4% intracranial hemorrhage. In Beijing, 78% of total stroke was ischemic and 18.9% intracranial hemorrhage. Liu M, Wu B, Wang W-Z, et al. Stroke in China: epidemiology, prevention, and management strategies. Lancet Neurology. 2007;6:456-64. Jiang B, Wang W-Z, Chen H, et al. Incidence and trends of stroke and its subtypes in China: results from three large cities. Stroke. 2006;37:63-68. Zhao D, Liu J, Wang W, et al. Epidemiological transition of stroke in China: twenty-one–year observational study from the Sino-MONICA-Beijing Project. Stroke. 2008;39:1668-1674.

6. Projected Stroke and CHD Increase to2030: Effect of Population Aging andRisk-Factor Changes in China 6 A computer model (CHD Policy-China, a Markov model of CVD in the adult Chinese population) was used to estimate annual CHD and stroke event rates in China from 2010 to 2030 using simulations based on aging and population growth alone and, in addition, based on projected changes in systolic blood pressure, total cholesterol, diabetes, and smoking. Demographic changes expected to occur in China from 2010 to 2030 are forecasted to cause a rise of greater than 50% in annual CHD and stroke events. Much of the projected increase is due to aging and population growth alone. Additional events are attributed to trends in systolic blood pressure, total cholesterol, diabetes, and smoking. Data for the model come from the International Collaborative Study of Cardiovascular Disease in Asia Study for risk-factor trends; various other Chinese studies for stroke incidence, mortality, and case-fatality rates; and the China Multiprovincial Cohort Study for stroke and CHD hazard ratios. Moran A, Gu D, Zhao D, et al. Future cardiovascular disease in China: Markov model and risk factor scenario projections from the Coronary Heart Disease Policy Model— China. Circ Cardiovasc Qual Outcomes. 2010;3:243-252. A computer model (CHD Policy-China, a Markov model of CVD in the adult Chinese population) was used to estimate annual CHD and stroke event rates in China from 2010 to 2030 using simulations based on aging and population growth alone and, in addition, based on projected changes in systolic blood pressure, total cholesterol, diabetes, and smoking. Demographic changes expected to occur in China from 2010 to 2030 are forecasted to cause a rise of greater than 50% in annual CHD and stroke events. Much of the projected increase is due to aging and population growth alone. Additional events are attributed to trends in systolic blood pressure, total cholesterol, diabetes, and smoking. Data for the model come from the International Collaborative Study of Cardiovascular Disease in Asia Study for risk-factor trends; various other Chinese studies for stroke incidence, mortality, and case-fatality rates; and the China Multiprovincial Cohort Study for stroke and CHD hazard ratios. Moran A, Gu D, Zhao D, et al. Future cardiovascular disease in China: Markov model and risk factor scenario projections from the Coronary Heart Disease Policy Model— China. Circ Cardiovasc Qual Outcomes. 2010;3:243-252.

7. Burden of Diabetes in Asia 7 Data from the International Diabetes Federation for 2007 show the number of persons worldwide with diabetes by age group and deaths attributable to diabetes in adults by region. The estimated prevalence of diabetes in the Western Pacific region (which includes China) is 7.6% (total population 1,468,598,000). The estimated prevalence of diabetes in the Southeast Asia region (includes India) is 6% (total population 770,350,000). Importantly, diabetes in Asian countries occurs in younger individuals than it does in Western countries. Key: EMME, Eastern Mediterranean/Middle East; SACA, South America/Central America; SEA, Southeast Asia (comprises Bangladesh, Bhutan, India, Maldives, Mauritius, Nepal, and Sri Lanka). Western Pacific comprises Australia, Brunei Darussalam, Cambodia, China, Hong Kong, Macau, Cook Islands, Fiji, French Polynesia, Guam, Indonesia, Japan, Kiribati, Korea (Democratic People’s Republic of), Korea (Republic of), Lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia (Federal States of), Mongolia, Myanmar, Nauru, New Caledonia, New Zealand, Niue, Palau, Papua New Guinea, Philippines, Samoa, Singapore, Solomon Islands, Taiwan, Thailand, Timor-Leste, Tokelau, Tonga, Tuvalu, Vanuatu, and Vietnam. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301:2129-2140. Data from the International Diabetes Federation for 2007 show the number of persons worldwide with diabetes by age group and deaths attributable to diabetes in adults by region. The estimated prevalence of diabetes in the Western Pacific region (which includes China) is 7.6% (total population 1,468,598,000). The estimated prevalence of diabetes in the Southeast Asia region (includes India) is 6% (total population 770,350,000). Importantly, diabetes in Asian countries occurs in younger individuals than it does in Western countries. Key: EMME, Eastern Mediterranean/Middle East; SACA, South America/Central America; SEA, Southeast Asia (comprises Bangladesh, Bhutan, India, Maldives, Mauritius, Nepal, and Sri Lanka). Western Pacific comprises Australia, Brunei Darussalam, Cambodia, China, Hong Kong, Macau, Cook Islands, Fiji, French Polynesia, Guam, Indonesia, Japan, Kiribati, Korea (Democratic People’s Republic of), Korea (Republic of), Lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia (Federal States of), Mongolia, Myanmar, Nauru, New Caledonia, New Zealand, Niue, Palau, Papua New Guinea, Philippines, Samoa, Singapore, Solomon Islands, Taiwan, Thailand, Timor-Leste, Tokelau, Tonga, Tuvalu, Vanuatu, and Vietnam. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301:2129-2140.

8. High Cumulative Incidence of Stroke inAsians With Type 2 Diabetes 8 The Action in Diabetes and Vascular Disease (ADVANCE) study was a multinational clinical trial that included over 11,000 participants with type 2 diabetes from 20 countries. A post hoc analysis of the ADVANCE patients focused on 3 groups of countries defined by geography and level of economic development (Asia, Eastern Europe, and established market economies) and examined variation in rates of major complications, hospital utilization, and costs for patients from these different areas. Compared with Eastern Europe and established market economies, the incidence of major cerebrovascular events was higher than that of coronary events in the Asian diabetic population. Clarke PM, Glasziou P, Patel A, et al; on behalf of the ADVANCE Collaborative Group. Event rates, hospital utilization, and costs associated with major complications of diabetes: a multicountry comparative analysis. PLoS Med. 2010;7:e1000236. The Action in Diabetes and Vascular Disease (ADVANCE) study was a multinational clinical trial that included over 11,000 participants with type 2 diabetes from 20 countries. A post hoc analysis of the ADVANCE patients focused on 3 groups of countries defined by geography and level of economic development (Asia, Eastern Europe, and established market economies) and examined variation in rates of major complications, hospital utilization, and costs for patients from these different areas. Compared with Eastern Europe and established market economies, the incidence of major cerebrovascular events was higher than that of coronary events in the Asian diabetic population. Clarke PM, Glasziou P, Patel A, et al; on behalf of the ADVANCE Collaborative Group. Event rates, hospital utilization, and costs associated with major complications of diabetes: a multicountry comparative analysis. PLoS Med. 2010;7:e1000236.

9. Increase in Age-Standardized Mean Total Cholesterol Levels in East and Southeast Asia and Pacific Region, 1980-2008 9 Global mean total cholesterol levels changed little between 1980 and 2008, decreasing by less than 0.1 mmol/L per decade in men and women. In contrast, in East and Southeast Asia and the Pacific region, mean total cholesterol levels in men (shown on the left) and women (shown on the right) were estimated to increase by 0.08 and 0.09 mmol/L per decade, respectively, from 1980 to 2008. Trends in mean serum cholesterol were determined in an analysis of data from published and unpublished health surveys and epidemiologic studies from 199 countries and territories in 21 subregions, which were grouped into 7 merged regions. Farzadfar F, Finucane MM, Danaei G, et al; on behalf of the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Cholesterol). National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants. Lancet. 2011;377:578-586.Global mean total cholesterol levels changed little between 1980 and 2008, decreasing by less than 0.1 mmol/L per decade in men and women. In contrast, in East and Southeast Asia and the Pacific region, mean total cholesterol levels in men (shown on the left) and women (shown on the right) were estimated to increase by 0.08 and 0.09 mmol/L per decade, respectively, from 1980 to 2008. Trends in mean serum cholesterol were determined in an analysis of data from published and unpublished health surveys and epidemiologic studies from 199 countries and territories in 21 subregions, which were grouped into 7 merged regions. Farzadfar F, Finucane MM, Danaei G, et al; on behalf of the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Cholesterol). National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants. Lancet. 2011;377:578-586.

10. Relationship of CHD Mortality With Usual Total Cholesterol by Age: Prospective Studies Collaboration 10 The Prospective Studies Collaboration was a collaborative meta-analysis combining data from 61 existing prospective studies involving a total of 1 million participants from Europe, North America, Australia, Israel, China, and Japan. During 12.7 million person-years of follow-up, there were more than 55,000 vascular deaths (12,000 stroke, 34,000 ischemic heart disease [IHD], and 10,000 other vascular). A decrease of 1 mmol/L in total cholesterol was associated with about a one-half, one-third, and one-sixth lower IHD mortality in both sexes at ages 40 to 49, 50 to 69, and 70 to 89, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. Although the proportional differences in risk decrease with age, the absolute effects of cholesterol on annual IHD mortality rates are much greater at older than at younger ages. Overall, 1 mmol/L lower total cholesterol reduced IHD risk by one-third. Prospective Studies Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet. 2007;370:1829-1839. The Prospective Studies Collaboration was a collaborative meta-analysis combining data from 61 existing prospective studies involving a total of 1 million participants from Europe, North America, Australia, Israel, China, and Japan. During 12.7 million person-years of follow-up, there were more than 55,000 vascular deaths (12,000 stroke, 34,000 ischemic heart disease [IHD], and 10,000 other vascular). A decrease of 1 mmol/L in total cholesterol was associated with about a one-half, one-third, and one-sixth lower IHD mortality in both sexes at ages 40 to 49, 50 to 69, and 70 to 89, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. Although the proportional differences in risk decrease with age, the absolute effects of cholesterol on annual IHD mortality rates are much greater at older than at younger ages. Overall, 1 mmol/L lower total cholesterol reduced IHD risk by one-third. Prospective Studies Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet. 2007;370:1829-1839.

11. Association of Stroke Mortality With Usual Total Cholesterol by Age: ProspectiveStudies Collaboration 11 With regard to stroke mortality, the Prospective Studies Collaboration found that increases in usual total cholesterol were weakly associated with total stroke mortality for participants aged 40 to 59 years but that little association existed for older participants. Likewise, a decrease in total cholesterol of 1 mmol/L was associated with a small decrease in stroke mortality for the youngest age group studied, but no real change in stroke mortality was seen with similar decreases in cholesterol for patients in the older age groups. Prospective Studies Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet. 2007;370:1829-1839. With regard to stroke mortality, the Prospective Studies Collaboration found that increases in usual total cholesterol were weakly associated with total stroke mortality for participants aged 40 to 59 years but that little association existed for older participants. Likewise, a decrease in total cholesterol of 1 mmol/L was associated with a small decrease in stroke mortality for the youngest age group studied, but no real change in stroke mortality was seen with similar decreases in cholesterol for patients in the older age groups. Prospective Studies Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet. 2007;370:1829-1839.

12. Relationship of Cholesterol Level to CV Mortality in Asians: Asia PacificCohort Studies Collaboration 29 cohorts 352,033 individuals 283,544 Asians 68,489 Australians/New Zealanders 2 million person-years of follow-up 4841 cardiovascular deaths 12 The Asia Pacific Cohort Studies Collaboration (APCSC) is a meta-analysis of prospective observational studies in the Asia Pacific region. Its objective was to determine the hazard ratios of major cardiovascular diseases based on total cholesterol levels. The combined data included 29 cohorts, with 2 million person-years of follow-up of 352,033 individuals, the majority of whom were from Asia. A total of 4841 cardiovascular deaths were recorded in the study population. Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.The Asia Pacific Cohort Studies Collaboration (APCSC) is a meta-analysis of prospective observational studies in the Asia Pacific region. Its objective was to determine the hazard ratios of major cardiovascular diseases based on total cholesterol levels. The combined data included 29 cohorts, with 2 million person-years of follow-up of 352,033 individuals, the majority of whom were from Asia. A total of 4841 cardiovascular deaths were recorded in the study population. Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.

13. Association Between Usual CholesterolLevel and CHD Death or Nonfatal MI:Asia Pacific Cohort Studies Collaboration 13 This study found a continuous positive association between usual cholesterol levels and the risk for CHD that persisted after adjustment for age, sex, blood pressure, and smoking. Higher usual cholesterol levels were associated with higher risk of death from CHD as well as with higher risk of combined outcome of nonfatal myocardial infarction (MI) or death from CHD in the entire study population. Each increase of 1 mmol/L in cholesterol level equated to about a 35% (95% CI, 26%-44%) increase in risk of coronary death, as well as a 45% (95% CI, 35%-55%) increase in the risk of the combined outcome of coronary death or nonfatal myocardial infarction. Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572. This study found a continuous positive association between usual cholesterol levels and the risk for CHD that persisted after adjustment for age, sex, blood pressure, and smoking. Higher usual cholesterol levels were associated with higher risk of death from CHD as well as with higher risk of combined outcome of nonfatal myocardial infarction (MI) or death from CHD in the entire study population. Each increase of 1 mmol/L in cholesterol level equated to about a 35% (95% CI, 26%-44%) increase in risk of coronary death, as well as a 45% (95% CI, 35%-55%) increase in the risk of the combined outcome of coronary death or nonfatal myocardial infarction. Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.

14. Association Between Usual CholesterolLevel and Stroke: Asia Pacific CohortStudies Collaboration 14 The study found a weak positive association between cholesterol and combined risk of both fatal and nonfatal stroke risk but no association between total cholesterol level and stroke mortality. Each increase of 1 mmol/L in total cholesterol was associated with a 7% (95% confidence interval [CI], 0.9%-14%) increase in fatal or nonfatal stroke. Compared with those in the lowest fifth of usual cholesterol level, the risk of fatal or nonfatal stroke among individuals belonging to the highest fifth was increased by about 20% (hazard ratio [HR] = 1.2; 95% CI, 1.1-1.3). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572. The study found a weak positive association between cholesterol and combined risk of both fatal and nonfatal stroke risk but no association between total cholesterol level and stroke mortality. Each increase of 1 mmol/L in total cholesterol was associated with a 7% (95% confidence interval [CI], 0.9%-14%) increase in fatal or nonfatal stroke. Compared with those in the lowest fifth of usual cholesterol level, the risk of fatal or nonfatal stroke among individuals belonging to the highest fifth was increased by about 20% (hazard ratio [HR] = 1.2; 95% CI, 1.1-1.3). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.

15. Association Between Usual CholesterolLevel and Ischemic Stroke: Asia PacificCohort Studies Collaboration 15 The relationship between usual cholesterol and the risk for ischemic stroke was different from that of usual cholesterol and hemorrhagic stroke. Although there appeared to be a positive association between cholesterol and the risk of fatal ischemic stroke, it was not statistically significant. There was a significant relationship between usual cholesterol and the risk of fatal or nonfatal ischemic stroke: each 1 mmol/L higher level of usual cholesterol was associated with a 25% (95% CI, 13%-40%) greater risk of fatal or nonfatal ischemic stroke. Compared with the lowest fifth of usual cholesterol levels, the risk for this combined outcome was about 50% higher for those belonging to the highest fifth (HR = 1.5; 95% CI, 1.3-1.8). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572. The relationship between usual cholesterol and the risk for ischemic stroke was different from that of usual cholesterol and hemorrhagic stroke. Although there appeared to be a positive association between cholesterol and the risk of fatal ischemic stroke, it was not statistically significant. There was a significant relationship between usual cholesterol and the risk of fatal or nonfatal ischemic stroke: each 1 mmol/L higher level of usual cholesterol was associated with a 25% (95% CI, 13%-40%) greater risk of fatal or nonfatal ischemic stroke. Compared with the lowest fifth of usual cholesterol levels, the risk for this combined outcome was about 50% higher for those belonging to the highest fifth (HR = 1.5; 95% CI, 1.3-1.8). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.

16. Association Between Usual CholesterolLevel and Hemorrhagic Stroke: AsiaPacific Cohort Studies Collaboration 16 Although there was evidence of an inverse association between usual cholesterol levels and risk of hemorrhagic stroke mortality, the excess risk appeared to occur mainly in those with the lowest quintiles of cholesterol (below 5.0 mmol/L). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572. Although there was evidence of an inverse association between usual cholesterol levels and risk of hemorrhagic stroke mortality, the excess risk appeared to occur mainly in those with the lowest quintiles of cholesterol (below 5.0 mmol/L). Zhang X, Patel A, Horibe H, et al; Asia Pacific Cohort Studies Collaboration. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563-572.

17. Summary Stroke is the leading cause of death in the East Asia and Western Pacific region CV risk factors and CV mortality are projected to increase Increased cholesterol levels are a major cause of the high risk for ischemic stroke in Asian Pacific countries 17 Stroke and CHD are the leading causes of death in the East Asia and Western Pacific regions. With sociodemographic changes in these areas, cardiovascular risk factors and mortality rates are projected to increase, whereas they are decreasing in more developed countries. Increasing cholesterol levels are a major cause of the increasing risk of ischemic stroke and CHD in Asian Pacific countries. Stroke and CHD are the leading causes of death in the East Asia and Western Pacific regions. With sociodemographic changes in these areas, cardiovascular risk factors and mortality rates are projected to increase, whereas they are decreasing in more developed countries. Increasing cholesterol levels are a major cause of the increasing risk of ischemic stroke and CHD in Asian Pacific countries.