Trends in the prevalence of heart diseases over a ten-year period from single-center observations based on a large echocardiographic database

Trends in the prevalence of heart diseases over a ten-year period from single-center observations based on a large echocardiographic database 从单中心大型超声心动图数据分析近十年中国 心脏疾病患病率的变化趋势 1 first-author 1 2 2 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:cheng.leilei@zs-hospital.sh.cnjbge@zs-hospital.sh.cn †E-mail:cheng.leilei@zs-hospital.sh.cnjbge@zs-hospital.sh.cn cheng.leilei@zs-hospital.sh.cn 2 2 1 1 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:cheng.leilei@zs-hospital.sh.cnjbge@zs-hospital.sh.cn †E-mail:cheng.leilei@zs-hospital.sh.cnjbge@zs-hospital.sh.cn cheng.leilei@zs-hospital.sh.cn Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai 200032, China There is a paucity of data regarding trends in the incidence of heart disease in China during recent years. Using a large echocardiography database in our center, we analyzed trends in the prevalence of several common heart diseases from Dec. 2003. This study retrospectively analyzed the echocardiographic database in our Department from 2003 to 2012. A total of 385 682 cases were included in the study. The prevalence of rheumatic heart disease decreased over the 10-year period, from 4.04% in 2003 to 3.06% in 2012 ( P < 0.01). Infective endocarditis also decreased, from a mean prevalence of 0.37% in July 2003 to 0.27% in Dec. 2008 ( P < 0.001). The prevalence of hypertrophic cardiomyopathy, which includes 20% apical hypertrophic cardiomyopathy and 20% hypertrophic obstructive cardiomyopathy, was about 1.8%. The prevalence of the three most common adult congenital heart diseases (CHDs) decreased by about 10% from July 2003 to Dec. 2008 (all P < 0.001). The prevalence of moderate pulmonary arterial hypertension (PAH) or left ventricular systolic dysfunction (LVSD) decreased during the 10-year period ( P < 0.001), but there was no change in the prevalence of severe PAH or LVSD ( P > 0.05). The present study indirectly demonstrates that the prevalence of several common heart diseases in China has declined in recent years. 目的 2 中国心脏疾病近年患病率趋势变化的相关研究较少，本研究利用复旦大学附属中山医院心血管病研究所中心大型的超声心动图数据，观察2003年至2012年心脏疾病患病率的变化。 创新点 2 本研究间接地反映近十年来我国心脏疾病患病率趋势变化的情况。 方法 2 回顾性地分析了本中心2003年至2012年的超声心动图数据，共纳入了385682名患者。 结论 2 从2003年至2012年，风湿性心脏病和感染性心内膜炎的患者率明显下降；2003-2007年期间包括房间隔缺损、室间隔缺损和动脉导管未闭的先天性心脏病的患病率较2008-2012年明显下降；重度肺动脉高压、重度左室收缩功能不全和肥厚型心肌病的患病率在十年间没有明显变化。 Prevalence Trends Heart diseases Epidemiology 患病率 趋势 心脏疾病 流行病学 Introduction 1 From 1990 to 2005 the total number of deaths from cardiovascular disease (CVD) globally increased from 14.4 million to 17.5 million (World Health Organizatio 2005 2005 ). Today CVD is the largest single contributor to global mortality and will continue to dominate mortality trends in the future. Notably over 80% of deaths from CVD occur in low and middle income countries (World Health Organization 2009 2009 ). The global disease burden will likely shift from infectious diseases to chronic diseases within the next few decades. China has experienced an epidemiological shift from infectious to chronic diseases in a much shorter time than many other countries (Yang et al. 2008 2008 ). In China the CVD burden is an important public health issue. The number of Chinese with CVD is estimated at 230 million individuals (NCCD 2010). Moreover CVD accounts for 41% of deaths from all causes and is the leading cause of death in China (He et al. 2005 2005 ; Li et al. 2014 2014 ). However data regarding the trends in the prevalence of heart disease in recent years are lacking. Our center the Shanghai Institute of Cardiovascular Diseases (Shanghai China) is one of the three largest heart research centers in China. The objective of our study was to analyze trends in the prevalence of several common heart diseases from 2003 to 2012 using a large echocardiographic database at our center Materials and methods 1 Data analysis 2 This analysis used the echocardiographic database of outpatients who were referred to our department from 2003 to 2012. For patients who underwent echocardiography (ECG) examination more than once within one year we used the first result or the final definitive diagnostic result. Only 2-dimensional (2D) transthoracic echocardiograms were used for analysis (2D imaging M-mode imaging Doppler imaging). 3D-echocardiograms tissue Doppler images and transesophageal echocardiograms were excluded. The echocardiographic diagnosis was based on recommendations of the American Society of Echocardiography (Zoghbi et al. 2003 2003 ; Douglas et al. 2011 2011 ). Patients younger than 18 years were excluded. The prevalence of a disease was calculated as the ratio of the number of patients with the disease to the total annual number of patients. The study followed the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of Zhongshan Hospital Fudan University (Shanghai China). Diseases for analysis 2 Valvular heart diseases (VHDs) 3 Valvular heart diseases (VHDs) VHDs were classified into rheumatic heart disease (RHD) non-rheumatic VHD and post valve surgery. We analyzed only aortic and mitral valve abnormalities; tricuspid and pulmonary valve abnormalities were not included in the analysis. Minor valve regurgitation was not regarded as VHD because it may occur in many healthy patients but minor valve stenosis was included. Infectious endocarditis was also included as a type of VHD. Cardiomyopathy 3 Cardiomyopathy included hypertrophic cardiomyopathy (HCM), non-compaction of the ventricular myocardium, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy. Ventricular cardiomyopathy and restrictive cardiomyopathy were initially diagnosed by ECG, but the final diagnosis of the disease was made by reviewing the medical records and other examinations. HCM was classified into three types: apical HCM, hypertrophic obstructive cardiomyopathy (HOCM), and hypertrophic non-obstructive cardiomyopathy (HNOCM). Dilated cardiomyopathy was not included in the analysis because its diagnosis cannot be based solely on ECG. Congenital heart disease (CHD) 3 We analyzed four of the most common CHDs: atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), and bicuspid aortic valve (BAV). Pulmonary arterial hypertension (PAH) and left ventricular systolic dysfunction (LVSD) 3 We enrolled patients with moderate PAH (pulmonary artery systolic pressure (PASP), 50–69 mmHg) or severe PAH (PASP, ≥70 mmHg), where PASP was calculated as the sum of the tricuspid jet gradient. Also, PAH was divided into CHD associated PAH and other types of PAH. LVSD patients had a left ventricular ejection fraction between 30% and 45% (moderate) or <30% (severe). Statistical analysis 2 Continuous variables are presented as the mean±standard deviation (SD) and categorical variables as percentages. The prevalence of diseases was compared using the χ 2 test. P < 0.05 was considered to represent statistical significance. The relative change in prevalence of disease between the first and second 5-year periods was calculated as follows: (prevalence in Dec. 2008−prevalence in July 2003 2003 )/prevalence in July 2003×100%. We defined a change in relative value greater than 10% as a marked change, while a difference of less than 10% was regarded as not significant. Statistical analyses were performed using the SPSS 13.0 software package (SPSS Inc., Chicago, Illinois, USA). Results 1 A total of 385 682 cases were included in the study. Demographic characteristics of patients are given in Table 1 1 . The proportion of male patients was about 50% each year, ranging from 49.12% to 52.32%. Year Number of case Male (%) Age (year) Total number of outpatient visits (person-time) Percentage of outpatient undergoing ECG (%) 2003 11 086 51.19 49.38±17.88 80 856 13.71 2004 14 656 52.32 54.39±16.06 103 526 14.16 2005 23 655 51.00 54.28±16.06 153 420 15.42 2006 28 210 50.54 54.81±16.36 184 755 15.27 2007 36 926 49.12 55.21±16.19 244 555 15.10 2008 46 414 49.94 55.47±18.61 293 538 15.81 2009 53 145 49.49 55.76±16.10 334 517 15.89 2010 54 247 51.42 55.87±15.84 375 271 14.45 2011 55 597 50.56 57.08±15.69 394 918 14.08 2012 61 746 51.80 57.10±16.50 423 561 14.57 The mean age was (54.97±17.35) years. The proportion of patients undergoing ECG remained at 15% each year, while outpatient visits increased every year, from 80 856 in 2003 to 423 561 in 2012. The trends in the prevalence of heart diseases during the 10-year period are shown in Table 2 2 . RHD, rheumatic heart disease; IE, infective endocarditis; VHD, valvular heart disease; HOMC, hypertrophic obstructive cardiomyopathy; HNOMC, hypertrophic non-obstructive cardiomyopathy; ApHCM, apical hypertrophic cardiomyopathy; HCM, hypertrophic cardiomyopathy; ARVD, arrhythmogenic right ventricular cardiomyopathy; RCM, restrictive cardiomyopathy; NCVM, non-compaction of ventricular myocardium hypertrophic; ASD, atrial septal defect; VSD, ventricular septal defect; PDA, patent ductus arteriosus; BAV, bicuspid aortic valve; CHD, congenital heart disease; PAH, pulmonary arterial hypertension; LVSD, left ventricular systolic dysfunction. The relative change value of prevalence of disease between the first 5 years and last 5 years. Statistics values for comparisons of prevalence of disease between the first 5 years and last 5 years 2 Disease 12 Prevalence of several common heart diseases (%) 2 Change * * (%) 2 P ** ** 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 First 5 years Last 5 years  RHD 4.04 5.49 3.73 3.71 3.43 3.11 2.91 3.10 3.05 3.06 3.87 3.04 −21.47 <0.001  IE 0.47 0.48 0.27 0.41 0.31 0.27 0.20 0.29 0.30 0.31 0.35 0.26 −25.56 <0.001  Post valve surgery 5.16 5.04 4.72 3.38 4.11 4.32 4.38 4.36 4.62 4.40 4.18 4.42 5.79 0.002  Non-RHD VHD 4.66 5.15 5.01 4.27 4.27 4.33 3.82 4.64 4.54 4.65 4.67 4.33 −7.68 0.006  HOCM 0.32 0.42 0.37 0.37 0.33 0.29 0.37 0.42 0.48 0.45 0.37 0.40 8.41 0.008  HNOCM 0.89 1.35 1.08 1.23 0.95 0.94 0.95 1.11 1.15 0.99 1.11 1.04 −6.31 0.064  ApHCM 0.39 0.33 0.34 0.32 0.25 0.16 0.29 0.52 0.33 0.69 0.30 0.33 10.01 0.202  Total of HCM 1.60 2.10 1.79 1.92 1.53 1.39 1.61 2.05 2.17 2.14 1.78 1.76 −1.12 0.784  ARVD 0.00 0.00 0.00 0.00 0.01 0.01 0.00 0.01 0.01 0.02 0.00 0.01 67.96 0.370  RCM 0.00 0.01 0.02 0.01 0.01 0.02 0.02 0.05 0.03 0.06 0.01 0.03 216.17 <0.001  NCVM 0.02 0.05 0.02 0.04 0.03 0.02 0.05 0.08 0.06 0.04 0.04 0.05 36.83 0.016  ASD 3.10 2.89 2.42 2.34 2.20 2.23 2.26 2.03 2.19 2.34 2.38 2.27 −5.90 <0.001  VSD 2.11 1.88 1.40 1.47 1.27 1.45 1.28 1.15 1.12 1.21 1.44 1.24 −13.73 <0.001  PDA 0.78 0.76 0.59 0.57 0.53 0.53 0.52 0.55 0.48 0.54 0.59 0.52 −11.52 0.017  ASD+VSD+PDA 5.99 5.53 4.40 4.39 4.00 4.21 4.07 4.09 3.80 4.09 4.41 3.94 −10.82 <0.001  BAV 0.65 0.85 0.61 0.74 0.55 0.62 0.74 0.79 0.90 1.08 0.65 0.72 9.24 0.058  CHD associated PAH 1.71 1.30 1.14 1.22 1.02 0.91 0.85 0.82 0.83 0.97 1.14 0.85 −25.65 <0.001  Other types of PAH 7.73 9.40 5.50 7.58 6.82 5.70 3.64 6.22 5.98 6.06 7.09 5.39 −24.01 <0.001  Moderate PAH 7.48 8.54 6.64 7.09 6.18 5.09 4.79 5.21 5.01 5.31 6.87 5.02 −26.87 <0.001  Severe PAH 1.96 2.16 1.53 1.71 1.66 1.52 1.59 1.83 1.81 1.72 1.72 1.69 −1.37 0.638  Moderate LVSD 4.26 4.23 4.27 4.19 3.44 3.22 3.34 3.33 3.64 3.12 3.94 3.39 −14.20 <0.001  Severe LVSD 0.92 0.96 0.96 0.76 0.66 0.61 0.91 0.89 0.90 1.17 0.79 0.84 5.04 0.256 VHD 2 There was a trend towards decreasing prevalence of RHD over the 10-year period, from 4.04% in 2003 to 3.06% in 2012 ( P < 0.01). Infective endocarditis also decreased, from an average prevalence of 0.37% in July 2003 to 0.27% in Dec. 2008 ( P < 0.001). There was no clear trend in the percentage of patients with non-rheumatic VHD (ranging from 3.82% to 5.15%) and patients having undergone valve surgery (ranging from 3.38% to 5.16%). Cardiomyopathy 2 The prevalence of HCM, which included 20% apical HCM and 20% HOCM, was about 1.8%. There was no obvious change in the prevalence of HCM or its subgroups over the 10-year period. Other types of cardiomyopathy, including arrhythmogenic right ventricular cardiomyopathy, restrictive cardiomyopathy, and non-compaction of ventricular myocardium, were rather rare (0–0.08%). CHD 2 The prevalence of the three most common CHDs, ASD, VSD, and PDA, decreased by about 10% from the first to the second five-year period (all P < 0.001, Table 2 2 ); the prevalence of another common CHD, BAV, did not change markedly (about 0.7%). PAH and LVSD 2 The prevalence of CHD-associated PAH (or other types of PAH) and moderate PAH decreased during the 10-year period ( P < 0.001), while that of severe PAH did not change significantly (1.74% in July 2003, 1.71% in Dec. 2008; P =0.697). Similarly, the average prevalence of patients with moderate LVSD declined over the 10-year period, from 4.26% in 2003 to 3.12% in 2012 ( P < 0.001), while that of severe LVSD remained unchanged (0.80% in July 2003, 0.85% in Dec. 2008; P =0.261). Discussion 1 The Department of Cardiology, Shanghai Institute of Cardiovascular Diseases (Shanghai, China), which treats patients from all over the nation, is one of the three largest and most recognized heart research centers in China. There are more than 10 000 inpatient and 300 000 outpatient visits per year. Thus, the patients and their respective data reasonably reflect the trends in the prevalence of heart disease within the country as a whole. A total of 385 682 cases were included in this study. The main findings were as follows: (1) the prevalence of RHD decreased over the 10-year period, from 4.04% in 2003 to 3.06% in 2012; (2) HCM was not rare and apical HCM was common (20%); however, other types of cardiomyopathy were rather uncommon; (3) When comparing the average prevalence of the first 5-year period with that of the last 5-year period, the prevalence of the three most common adult CHDs decreased by about 10%; (4) the prevalence of patients with moderate PAH or LVSD decreased during the 10-year period, while there was no change in the prevalence of severe PAH or LVSD. RHD remains a significant health burden in China. The prevalence of chronic RHD is estimated to be 186/100 000 adults, which is 10 times higher than that in industrialized countries, such as Canada and Japan (Zhimin et al., 2006 2006 ). The prevalence of acute rheumatic fever and RHD has been declining since the 1950s (Chen et al., 2003 2003 ). Our study showed that RHD accounted for 3%–5% of outpatient visits; furthermore, the prevalence of RHD had continued to decline over the 10-year period of the study. Infective endocarditis also decreased, but the percentage of patients with non-rheumatic VHD and of patients having undergone valve surgery did not change significantly. HCM is a global disease and is present in about 2 of every 1000 young adults in the USA (Maron et al., 1995 1995 ). In China, HCM is not so rare; the estimated prevalence is about 80 per 100 000 adults (Zou et al., 2004 2004 ). Apical HCM was first described in Japan (Sakamoto et al., 1976 1976 ), where it accounts for 13% to 25% of the entire HCM population (Eriksson et al., 2002 2002 ). In western countries it is less common, accounting for 3% to 11% of all HCM patients (Moro et al., 1995 1995 ; Eriksson et al., 2002 2002 ). Apical HCM was present in about 20% of the entire HCM population in our study, which is similar to the incidence in the Japanese population. Generally, HOCM is found in about 25% of patients with HCM (Wigle et al., 1985 1985 ). In the present study, 20% of HCM was HOCM. The overall incidence of CHD is 8.2/1000 total births in China (Yang et al., 2009 2009 ), which is similar to that of developed countries (Mitchell et al., 1971 1971 ). The most common types of CHD in newborns are VSD (34.0%), PDA (23.7%), and ASD (10.8%) (Mitchell et al., 1971 1971 ). Data on the size and composition of the adult CHD population are lacking, but can be assumed to be ever-changing. It is estimated that there are about 2.8 adults with CHD per 1000 of the population (Warnes et al., 2001 2001 ). In the present study, adult CHD was present in 5% of patients; the most common CHDs were ASD, VSD, BAV, and PDA. The prevalence of the three most common CHDs (ASD, VSD, and PDA) decreased over the 10-year period. There are two possible explanations for this phenomenon: first, patients with CHD are diagnosed and treated at a younger age due to the increasing availability and use of improved examination techniques; second, the incidence of live-born CHD has been significantly reduced through fetal ECG (Yang et al., 2009 2009 ). PAH was present in about 7%–9% of all patients, while LVSD was present in about 4%–5%. The prevalence of CHD associated with PAH decreased over the 10-year period. This may be due to the decline in the incidence of adult CHD and early treatment of this disease. Moderate PAH decreased, while severe PAH did not change. Similarly, the prevalence of patients with moderate LVSD decreased over the 10-year period, but there was no change in the prevalence of severe LVSD. There remains a lack of effective methods for treatment of severe PAH or LVSD. Further efforts should be made to prevent cardiovascular diseases from developing into severe PAH or severe LVSD. Limitations 1 There were several limitations of the study. First, this is a single center study and the results of the study may only broadly reflect the trends in the prevalence of heart diseases in China. Second, the epidemiological analysis was based on a patient population referred to our department; this is not a community population. Thus, the prevalence of heart diseases was not their true epidemiological prevalence. The prevalence of heart diseases in the present study only indirectly reflects the prevalence of heart diseases in the general population. Third, the diagnosis of heart diseases included in the study was based on ECG. Therefore, many other common diseases that could be diagnosed by clinical examination or other methods, such as arrhythmia, dilated cardiomyopathy, or coronary heart disease, were not analyzed in the present study. In conclusion, our study demonstrates a decreasing trend in the prevalence of RHD and infective endocarditis from 2003 to 2012. 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All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). 10.1631/jzus.B1500136 Project supported by the National Natural Science Foundation of China (Nos. 81400318 and 81300209) 2015-06-01 2015-11-30 2015-11-07 2022-01-05 Copyright © Zhejiang University and Springer-Verlag Berlin Heidelberg 2016 2016 Journal of Zhejiang University-SCIENCE B (Biomedicine and Biotechnology) 01 17