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. 2024 Jul 30;4(8):624-633.
doi: 10.1016/j.jacasi.2024.05.008. eCollection 2024 Aug.

Mortality, Cardiovascular Disease, and Their Associations With Risk Factors in Southeast Asia: A PURE Substudy

Aditya K Khetan  1 , Lia M Palileo-Villanueva  2 , Nafiza Mat-Nasir  3 , Rosnah Ismail  4 , Antonio Miguel Dans  5 , Marc Evans M Abat  6 , Shofiqul Islam  1 , Philip Joseph  1 , Darryl P Leong  1 , Koon K Teo  1 , Sumathy Rangarajan  1 , Salim Yusuf  1
Affiliations

Mortality, Cardiovascular Disease, and Their Associations With Risk Factors in Southeast Asia: A PURE Substudy

Aditya K Khetan et al. JACC Asia. .

Abstract

Background: The drivers of cardiovascular disease (CVD) and all-cause mortality may differ around the world. Regional-level prospective data can help guide policies to reduce CVD and all-cause mortality.

Objectives: This study examined the incidence of CVD and mortality in Malaysia and the Philippines and estimated the population-level risks attributable to common risk factors for each outcome.

Methods: This prospective cohort study included 20,272 participants from Malaysia and the Philippines. The mean follow-up was 8.2 years. The incidences of CVD and mortality rates were calculated for the overall cohort and in key subgroups. For each outcome, population-attributable fractions (PAFs) were calculated to compare risks associated with 12 modifiable risk factors.

Results: The mean age of the cohort was 51.8 years (59% women). Leading causes of mortality were CVD (37.9%) and cancer (12.4%). The incidence of CVD (per 1,000 person-years) was higher in the Philippines (11.0) than Malaysia (8.3), and CVD contributed to a higher proportion of deaths in the Philippines (58% vs 36%). By contrast, all-cause mortality rates were higher in Malaysia (14.1) than in the Philippines (10.9). Approximately 78% of the PAF for CVD and 68% of the PAF for all-cause mortality were attributable to 12 modifiable risk factors. For CVD, the largest PAF was from hypertension (24.2%), whereas for all-cause mortality, the largest PAF was from low education (18.4%).

Conclusions: CVD and cancer account for one-half of adult mortality in Malaysia and the Philippines. Hypertension was the largest population driver of CVD, whereas low education was associated with the largest burden of overall mortality.

Keywords: Southeast Asia; cardiovascular disease; modifiable risk factors; mortality.

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Conflict of interest statement

The PURE study is an investigator-initiated study that has received funding from the Population Health Research Institute, the Hamilton Health Sciences Research Institute, the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, the Canadian Institutes of Health Research’s Strategy for Patient Oriented Research, the Ontario SPOR Support Unit, and the Ontario Ministry of Health and Long-Term Care; has received unrestricted grants from AstraZeneca (Canada), Sanofi Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, and King Pharma; and has received funding from various national or local organizations in participating countries: Argentina: Fundacion ECLA (Estudios Clínicos Latino America); Bangladesh: Independent University, Bangladesh, and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases and ThinkTank Research Center for Health Development; Colombia: Colciencias (grants 6566-04-18062 and 6517-777-58228); India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia (grants 100-IRDC/BIOTEK 16/6/21 [13/2007] and 07-05-IFN-BPH 010), Ministry of Higher Education of Malaysia (grant 600-RMI/LRGS/5/3 [2/2011]), MARA Technological University, Kebangsaan University Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the United Nations Relief and Works Agency for Palestine Refugees in the Near East, International Development Research Centre (Canada); Philippines: Philippine Council for Health Research and Development; Poland: Polish Ministry of Science and Higher Education (grant 290/W-PURE/2008/0), Wroclaw Medical University; Saudi Arabia: Saudi Heart Association, Saudi Gastroenterology Association, Dr Mohammad Alfagih Hospital, The Deanship of Scientific Research at King Saud University (research group RG -1436-013); South Africa: The North-West University, SA and Netherlands Programme for Alternative Development, National Research Foundation, Medical Research Council of South Africa, The South Africa Sugar Association, Faculty of Community and Health Sciences; Sweden: grants from the Swedish state under the Agreement Concerning Research and Education of Doctors, the Swedish Heart and Lung Foundation, the Swedish Research Council, the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemason’s Foundation, and AFA Insurance; Turkey: the Metabolic Syndrome Society, AstraZeneca, Sanofi Aventis; United Arab Emirates: Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences and Dubai Health Authority. The external funders and sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; in the preparation, review, or approval of the manuscript; or in the decision to submit the manuscript for publication. Dr Yusuf has received support from the Marion W. Burke endowed chair of the Heart and Stroke Foundation of Ontario. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Major Causes of Mortality in the Southeast Asia Cohort The leading causes of death in the Southeast Asia cohort are shown in descending frequency. CVD = cardiovascular disease; GI = gastrointestinal.
Figure 2
Figure 2
PAF for Cardiovascular Events and All-Cause Mortality (A) Cardiovascular disease (CVD) events. (B) All-cause mortality. The population-attributable fraction (PAF) was mutually adjusted for 12 modifiable risk factors in addition to age, sex, and urban-rural location. Estimates for individual risk factors were truncated at a lower limit of 0 because this is the lowest threshold to demarcate a relationship with increased risk. Abdo = abdominal; HDL = high-density lipoprotein; HTN = hypertension.
Central Illustration
Central Illustration
Prospective Urban Rural Epidemiology Study Southeast Asia Findings The incidence of cardiovascular disease (CVD) and all-cause mortality in Southeast Asia (Malaysia and the Philippines), as well as their key drivers. DM = diabetes mellitus; HDL = high-density lipoprotein; HTN = hypertension; PAF = population-attributable fraction.
See this image and copyright information in PMC

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