European Heart Journal Supplements (2016) 18 (Supplement F), F2–F11 The Heart of the Matter doi:10.1093/eurheartj/suw030

Outline of the report on cardiovascular diseases in China, 2014 Chen Weiwei1, Gao Runlin1, Liu Lisheng1, Zhu Manlu1, Wang Wen1, Wang Yongjun2, Wu Zhaosu3, Li Huijun1, Zheng Zhe1, Jiang Lixin1, and Hu Shengshou1*, for the editorial Board† 1

National Center for Cardiovascular Diseases, 167 Beilishi Road, Xicheng District, Beijing 100037, China Beijing Tiantan Hospital, 6 Tiantan Xili, Chongwen District, Beijing 100050, China 3 Beijing Anzhen Hospital, 2 Anzhen Road, Beijing 100029, China 2

KEYWORDS Cardiovascular diseases (CVD); Risk factors; Prevalence; Mortality

The risk factors for cardiovascular diseases (CVDs) are more prevalent in the Chinese population, and therefore, increase the incidence of CVD. In general, CVD morbidity and mortality will remain an upward trend in the next 10 years. Cardiovascular disease is the leading cause of death in China, which accounts for .40% of deaths from any cause. The burden of CVD is substantial and has become an important public health issue. Measures for the prevention and treatment of CVD in China should be further enforced without delay. Since 2005, the National Center for Cardiovascular Diseases has organized experts of cardiology, neurology, nephrology, diabetes, epidemiology, community health, health economics, biostatistics, and other related fields to compile the annual Report on Cardiovascular Diseases in China. The report aims to provide a timely review of the trend of the epidemic of CVD and to assess the progress of prevention and control of CVD. We present an abstract from the Report on Cardiovascular Diseases in China (2014), including trends in CVD, morbidity and mortality of major CVD, up-to-date assessment of risk factors, as well as health resources for CVD, and a profile of medical expenditure, with the aim of providing evidence for decision making in CVD prevention and control programmes in China, and of delivering the most authoritative information on CVD prevention and control for all citizens.

Introduction Major and profound changes have taken place in China over the past 30 years. Rapid socioeconomic progress has exerted a great impact on lifestyle. An epidemic of cardiovascular disease (CVD) in China is emerging as a result of lifestyle changes, urbanization, and the accelerated process of ageing. The incidence of CVD is continuously increasing and will remain an upward trend in the next decade. Cardiovascular disease is the leading cause of death for Chinese in both urban and rural area. Nowadays, 44.8% of

* Corresponding author. Tel: +86 10 88396412, Fax: +86 10 88204205, Email: [email protected] † Members of the Editorial Board are given in Appendix.

deaths in rural area and 41.9% of deaths in urban area are caused by CVD in China.1 The burden of CVD remains heavy and has become a major public health issue. Effective strategies should be enforced urgently for the prevention and treatment of CVD under the supervision of the government.

Prevalence and mortality of cardiovascular disease Prevalence of cardiovascular disease In China, the prevalence of CVDs is continuously increasing. Currently, an estimated 290 million individuals suffer from CVD, of which 270 million have hypertension, .7 million

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Outline of the report on cardiovascular diseases in China

Figure 1

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Mortality of cardiovascular disease in urban and rural Chinese population (China: 1990–2013).

Figure 2 Major causes of death in rural population (%) (China: 2013).

have had a stroke, 2.5 million have had a myocardial infarction, 4.5 million have heart failure, 5 million have pulmonary heart disease, 2.5 million have rheumatic heart disease, and 2 million have congenital heart disease. One of five Chinese adults is afflicted by CVD.

Mortality of cardiovascular disease In 2013, the mortality rate due to cardiovascular diseases was 293.69 per 100 000 persons in rural area and 259.40 per 100 000 persons in urban area (Figure 1). 44.8% of deaths in rural areas and 41.9% of deaths in urban areas were caused by CVD, higher than those of cancer or any other diseases (Figures 2 and 3). Two out of five deaths were caused by CVD.1 The increase in CVD mortality is mainly attributed to the increase in the mortality of ischaemic heart disease (IHD). On the basis of death data from the National Disease Surveillance Point System between 2004 and 2011, the standardized mortality rate from IHD rose significantly in people aged over 35 years in all areas, with an annual increase of 5.00% in men and 3.65% in women. For both men and women, the mortality rate due to IHD increased faster in rural population than in urban population. The standardized mortality from IHD for rural population became higher than that of urban populations in 2011, though it was lower than that of urban population in 2004.2 Death from cerebrovascular diseases is one of the main reasons of affecting Chinese life expectancy. Data from the National Disease Surveillance Point System

Figure 3

Major causes of death in urban population (%) (China: 2013).

demonstrated, after excluding cerebrovascular-related deaths, the calculated life expectancy increased by 2.26 years in 2010, with 1.79 and 2.41 years for urban and rural areas, respectively. Ninety-seven per cent of the increase was attributable to the removal of cerebrovascular deaths in people aged over 40 years. The mortality of cerebrovascular diseases was lower in 2010 than in 2005. The reduction degree was significantly larger in urban areas than in rural areas.3

Risk factors of cardiovascular diseases Hypertension Results from the Global Burden of Disease 2010 (GBD 2010) show that there are 2 million premature deaths per year in China maybe attributable to the elevated blood pressure, and the medical costs of hypertension therapy are as high as RMB 36.6 billion annually.4 According to a National Survey in 2002, the prevalence of hypertension among Chinese adults aged 18 years and older was 18.8%.5 The prevalence shows an upward tendency in recent years. It is higher in northern areas than in southern areas. In some northern areas, the prevalence is as high as 30%.6 The prevalence of hypertension in both males and females increases from 1979 to 2002. The difference in hypertension prevalence between urban and rural population is shrinking; in 1979, the rates were 10.8 vs. 6.2%, respectively, whereas in 2002, the rates were 19.3 vs. 18.6%.5

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China Health and Nutrition Survey indicated that the incidence of hypertension increased from 2.9/100 personyears (1991–97 cohort) to 5.3/100 person-years (2004–09 cohort).7 The detection rate of high-normal blood pressure among Chinese adults is increasing. According to a survey in 2002, the detection rate was 34% in Chinese adults aged .18 years, which represented 300 million people nationwide, with a higher rate in males than in females. It is reported that, compared with normotensives, the risk in subjects with high-normal blood pressure is increased by 56% for stroke, 44% for coronary heart disease, and 52% for all CVD.8 According to a survey in 13 provinces from 2009 to 2010 among 50 171 subjects aged at least 18 years, the awareness, treatment, and control rates as well as the treatment–control rate hypertension were 42.6, 34.1, 9.3, and 27.4%, respectively, higher than those in 2002 (30.2, 24.7, 6.1, and 25.0%, respectively). Additionally, all rates were higher in females than in males, and higher in urban than in rural areas.6 Blood pressure levels among children and adolescents of different ages and genders are increasing. The China Health and Nutrition Survey from 1991 to 2009 showed that the prevalence of hypertension among children and adolescents had been continuously increasing, from 7.1% in 1991 to 13.8% in 2009.9 Secondary hypertension is the main cause of hypertension among hospitalized children (52.0%). The age of children with secondary hypertension is lower than that of children with primary hypertension. Renovascular hypertension is the leading cause of secondary hypertension, accounting for one-third to two-thirds of all cases. Recent studies have found that drug-related hypertension has become the second most common cause of secondary hypertension, accounting for 18.3% of all cases.10,11

Smoking Smoking rate According to the Global Adult Tobacco Survey (GATS)-China Project in 2010,12 the overall smoking rate in men aged over 15 years was 62.8%, with a current smoking rate of 52.9%, which representing 340 million male smokers and 290 million male current smokers. The overall smoking rate in women was 3.1% (2.4% of current smokers); the number of female smokers was 16.39 million, including 10.46 million current smokers. The total number of smokers was estimated to be 356 million among subjects aged over 15 years. The overall smoking rate was significantly higher in rural residents than in urban residents (29.8 vs. 26.1%). The Global Youth Tobacco Survey (GYTS) 2014 China Program13 covered 31 provinces and 155 117 students aged 13–15 years old. The results indicated that the overall tobacco use rate among Chinese students was 6.9%. 18.8% students had tried smoking (28.9% for boys and 7.7% for girls). Among those who reported ever trying cigarettes, 82.3% smoked a whole cigarette for the first time before 13 years of age. 71.8% of current smokers had tried to quit. More than half of the students reported to have been exposed to second-hand smoking in indoor public places (57.2%) or schools (54.5%).

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Smoking cessation The smoking cessation rate rose from 9.42% in 1996 to 11.5% in 2002, and then to 16.9% in 2010. The number of people who stopped smoking increased by 15 million. In 2010, the GATSChina project reported that 16.1% of current smokers intended to quit smoking within the next 12 months.12 The rate of smoking relapse has increased, from 10.5% in 1996 to 32.5 and 33.1% in 2002 and 2010, respectively. A multi-province/city cohort study on cardiovascular disease risk factors employed a 10 year follow-up of 30 000 individuals aged 35–64 years old. The study demonstrated that smoking was an independent risk factor for acute coronary heart disease and acute ischaemic stroke. 19.9% of acute coronary heart disease events and 11.0% of acute ischaemic stroke events were attributed to smoking.14 Based on data from a 10 year multicentre prospective study among 26 607 Chinese, the excess risk of all types of stroke among male current smokers (Hazard ratio: 1.39) was mainly due to a significantly elevated risk of ischaemic stroke.15

Dyslipidemia A National Survey in 201016 showed that the prevalence rates of total cholesterol (TC) ≥6.22 mmol/L among males and females aged 18 years and older were 3.4 and 3.2%, respectively, and the prevalence rates of triglyceride (TG) ≥2.26 mmol/L among males and females were 13.8 and 8.6%, respectively. Males aged 45–59 and females above 60 had the highest prevalence rates of hypercholesterolaemia. China National Diabetes and Metabolic Disorder Study in 2007 and 2008 revealed that among Chinese men and women aged 20 years and older, the prevalence rates for TC ≥ 6.22 mmol/L were 8.7 and 9.3%, respectively; the awareness rates were 27.6 and 20.7%, respectively; the treatment rates were 21.4 and 14.0%, respectively; the control rates were 18.3 and 11.2%, respectively; and the treatment–control rates were 88.1 and 78.4%, respectively.17 Among 12 040 Chinese with dyslipidemia in 2011, 39% received lipid-lowing therapies, with the majority using statins. The percentage reaching low-density lipoprotein cholesterol (LDL-C) target was only 25.8%. Only 19.9 and 21.1% patients with high-risk and very high-risk cardiovascular disease factors reached LDL-C target levels.18 The results of DYSlipidemia International Study-China (DYSIS-China) showed that 88.9% of hospitalized patients were administrated statins in 2012. Among all patients who received statin therapy, 38.5% did not reach the LDL-C target level, and patients with high or very high risk tended to achieve the LDL-C target level at a lower rate.19

Diabetes mellitus According to a survey in a nationally representative sample of 98 658 Chinese adults in 2010, the overall prevalence of diabetes was estimated to be 11.6% in the Chinese adults .18 years of age.20 The prevalence among men was 12.1%, and among women was 11.0%. The newly diagnosed

Outline of the report on cardiovascular diseases in China

diabetes was 8.1% (8.5% in men and 7.7% in women). The prevalence of previously diagnosed diabetes was 3.5% (3.6% in males and 3.4% in females). The prevalence of diabetes was higher in urban residents. In addition, the prevalence of prediabetes was estimated to be 50.1% in Chinese adults (52.1% in men and 48.1% in women). Among patients with diabetes, only 30.1% (29.7% in males and 30.5% in females) were aware of their condition, only 25.8% (25.5% in males and 26.2% in females) received treatment for diabetes, and only 39.7% (40.7% in males and 38.6% in females) of those treated have their condition controlled to target levels. The awareness, treatment, and management rates for diabetes were higher in urban areas than in rural areas, and higher in developed and medium developed areas than in underdeveloped areas. The 3B (blood glucose, blood pressure, and blood lipids) Study21 enrolled 25 817 adults with type 2 diabetes at 104 hospitals. The study found only 5.6% achieved the target goals for control of blood glucose, blood lipids, and blood pressure. The results of China Da Qing Diabetes Prevention Study showed that, compared with control participants, those in the combined lifestyle intervention groups had a 51% lower incidence of diabetes during 6 year active intervention period and a 43% lower incidence over the 20 year period. Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group.22 After 23 year follow-up, the incidence of cardiovascular, all-cause mortality, and diabetes in intervention group were all lower than those of the control group by 41%, 29% (Figure 4), and 45%, respectively.23

Overweight and obesity In the past 10 years, the prevalence of overweight and obesity showed an upward trend. The 2010 China Chronic Disease Monitoring Program reported that the prevalence of overweight, obesity, and central obesity reached 30.6, 12.0, and 40.7%, respectively.24,25 The prevalence of overweight and obesity among children and adolescents is also on the rise. Five national surveys on

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the health status of Chinese students were conducted from 1985 to 2010. The overweight and obesity rates for children and adolescents in 2010 increased by 8.7 and 38.1 times, respectively, in comparison with those in 1985.26

Physical inactivity Results from the Chinese Health and Nutrition Survey showed a significantly decreasing trend in physical activity in residents aged 18–49 years old. Compared with data from 1997, total physical activity in 2009 has decreased by 29% in males and by 38% in females.27 The 2010 China Chronic Disease Surveillance Program reported that the proportion of people who participated in regular exercise was only 11.9%, and the proportion was much lower among younger adults in the 25–44 year age group.28

Diet and nutrition The China Health and Nutrition Survey29 revealed that the total caloric intake significantly declined, but the percentage of total caloric intake from fat was much higher than the level recommended, while the percentage of total caloric from carbohydrates decreased. As a consequence, the dietary cholesterol intake increased. Although the dietary calcium intake increased slightly, it was only half of the recommended level. The daily intake of salt was much higher than the level recommended by dietary guidelines. The consumption of vegetables, fruits, and vitamin C was also insufficient. The proportion of children with the Western dietary pattern has increased, and the Western dietary pattern is becoming one of the important factors for unbalanced nutrition.30 The risk of obesity and hypertension is clearly elevated among children with the Western dietary pattern. The results from the INTERHEART study showed a lower risk of acute myocardial infarction (AMI) in people with higher vitamin and mineral diet scores. A higher risk of AMI was found in people with higher fat and protein scores.31

Figure 4 China Da Qing Diabetes Prevention Study: the accumulative all-cause mortality during 23 years (1986–2009).

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Metabolic syndrome According to the 2002 China Health and Nutrition Survey, the prevalence of metabolic syndrome in adults aged over 18 years was 6.6% (as diagnosed by China Diabetes Society criteria) or 13.8% (as diagnosed by U.S. National Cholesterol Education Program’s Adult Treatment Panel III criteria).

Cardiovascular diseases Cerebrovascular disease (stroke) The Ministry of Health has conducted a national health service survey every 5 years since 1993. The prevalence of cerebrovascular disease in China presents an upward trend; it is higher in urban areas than in rural areas. According to data from the China Health and Family Planning Statistics Yearbook 2014,1 the mortality of cerebrovascular disease from 2003 to 2013 was higher in rural than in urban population, as well as higher in men than in women. The mortality of cerebrovascular disease in 2013 was 125.56 per 100 000 in urban population and 150.17 per 100 000 in rural population (Figure 5). Based on the 2010 Sixth Population Census data, it was estimated that 835 800 urban residents and 1 012 100 rural residents died of cerebrovascular disease in 2013. The China National Stroke Registry demonstrated that the adherence to antihypertensive medicines among patients with stroke was poor, which increased the risk of stroke recurrence;32 the rate of warfarin use was low. An anticoagulant was insufficient in stroke patients with atrial fibrillation (AF).33

Sixth Population Census data, it was projected that there were 10 315 900 subjects with IHD in Mainland China in 2008. The mortality of coronary heart disease increased from 2002 to 2013. According to the data from the China Health and Family Planning Statistics Yearbook 2014,1 the coronary heart disease mortality in 2013 was 100.86 per 100 000 for urban population and 98.68 per 100 000 for rural population (Figure 6). These rates have both increased in comparison with the mortality in 2012 (urban: 93.17 per 100 000; rural: 68.62 per 100 000). Overall, the coronary heart disease mortality was higher in the urban than in the rural populations, and higher in males than in females. The mortality of AMI shows an increasing trend. The AMI mortality is higher in the urban than in the rural population. Since 2005, the AMI mortality in the rural population has increased rapidly. In 2013, the AMI mortality rate in rural areas exceeded that in urban areas (Figure 7). According to the data from National Health and Family Planning Commission of Percutaneous Coronary Intervention (PCI) network reporting system, the number of PCI cases in Mainland China has steadily increased. The total number of PCI cases in 2013 was 454 505. The China PEACE-Retrospective AMI study35 analysed 13 815 STEMI admissions in 2001, 2006, and 2011. The results showed that between 2001 and 2011, rates of hospital admission for STEMI per 100 000 people increased, from 3.5 in 2001, to 7.9 in 2006, to 15.4 in 2011(Figure 8). There were significant increases in the use of aspirin and clopidogrel within 24 h of hospital admission. Despite an increase in the use of primary PCI, the proportion of patients not receiving reperfusion has not significantly changed. b-Blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers remained very underused. The in-hospital mortality rate has not decreased significantly.

Coronary heart disease Arrhythmia Based on the data from the 2008 Fourth Family Health Survey,34 the overall prevalence of IHD was 7.7‰ (15.9‰ in urban areas and 4.8‰ in rural areas). According to the 2010

Figure 5

According to an epidemic survey in 2004,36 the age adjusted prevalence of AF was 0.77% in participants aged

Trends in stroke mortality (China: 2003–13).

Outline of the report on cardiovascular diseases in China

Figure 6

Figure 7

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Trends of coronary heart disease mortality in urban and rural population (China: 2002–13).

Trends of acute myocardial infarction mortality in urban and rural population (China: 2002–13).

35–59 years (0.78% in men and 0.76% in women). After adjusted for age and gender, the study revealed that myocardial infarction, left ventricular hypertrophy, obesity, and alcohol consumption were all associated with an increased risk of AF. A retrospective study of hospitalized patients from cardiology departments in 22 provincial hospitals showed that 26.8% of all the patients had cardiac arrhythmia. Among all of the patients, AF is the most common arrhythmia (35.0%), followed by paroxysmal supraventricular tachycardia (28.0%), sick sinus syndrome (11.9%), and premature ventricular contractions (11.6%).37 According to the 2013 Ministry of Public Health Website Registry data, 51 752 pacemakers were implanted in 2013,

indicated a 5% increase compared with that in 2012 (49 502 cases). Among the indications for cardiac pacing therapy, 51.0% were for sick sinus syndrome and 39.0% were for atrioventricular block. Implantation volume for implantable cardioverter defibrillator (ICD) was 1 903 cases in 2013, which indicated an increase of 15.2% compared with that in 2012, and dual chamber ICD accounted for 32.0%. Radiofrequency catheter ablation volume was 83 450 cases in 2013, increased of 13.5% in comparison with that in 2012. Of the radiofrequency catheter ablation carried out in 2013, 17.7% were for the treatment of AF. A survey with a 1-year follow-up among 678 718 people from July 2005 to June 2006 found that the incidence of sudden cardiac death in China was 41.8/100 000, with a higher rate

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Figure 8 Hospital admissions for STEMI in China.

in men than in women (44.6/100 000 vs. 39.0/100 000), and the incidence increased with age. There are 544 000 sudden cardiac deaths occur annually in China.38,39

Heart failure The prevalence of chronic heart failure in Chinese adults aged 35–74 was 0.9%(0.7% in males and 1.0% in females). The prevalence increased with age. It was higher in northern China than in southern China (1.4 vs. 0.5%), and higher in urban than in rural areas (1.1 vs. 0.8%).40 In the recent 30 years, the main cause for heart failure has changed from rheumatic valve heart disease to coronary heart disease.41 One recent retrospective survey over 15 years revealed that the 30 day mortality rate for hospitalized patients with chronic heart failure is 5.4%.42

Pulmonary arterial hypertension A national survey in 31 tertiary hospitals in China reported the following aetiologies of pulmonary arterial hypertension (PAH): congenital heart disease associated PAH (49.6%), idiopathic PAH (27.2%), connective tissue disease associated PAH (11.6%), and chronic thrombo-embolic PAH (11.6%).43 Results of one epidemiological study in seven provinces among people aged over 40 years in 2007 showed that the prevalence of chronic obstructive pulmonary disease (COPD) was 8.2%. The COPD prevalence was significantly higher in rural areas (8.8%) than in urban areas (8.8 vs. 7.8%), and higher in males than in females (12.4 vs. 5.1%). The estimated number of patients with COPD in China was 43 million.44 Chronic obstructive pulmonary disease ranked the fourth leading cause of death in urban areas and the third in rural areas. From 1990 to 2008, the COPD mortality declined annually.45

Cardiovascular surgery The number of cardiac surgeries increased over time in the past 10 years in China. There were 207 881 cases conducted

in 2013. Of these surgeries, 162 320 were performed on-pump. In 2013, a total of 85 578 congenital heart defect surgeries were performed in mainland China and Hong Kong, accounting for 41% of all cardiac and aortic surgeries. In 2013, 57 184 valvular surgeries, 37 861 coronary artery bypass grafts, 9032 aortic surgeries, 250 heart transplants (including 1 heart–lung transplant), and 541 extracorporeal membrane oxygenation adjuvant treatments were performed. The prevalence of congenital heart disease is dramatically various in different regions. Investigations into the spectrum of congenital heart diseases in different regions unanimously reported that ventricular septal defects, atrial septal defects, and patent ductus arteriosuses accounted for 75–80% of all congenital heart diseases. In 2012, the cumulative number of interventional treatment of congenital heart disease in Mainland China was 28 296 cases. The total amount of interventional treatment of congenital heart disease reached 80 000 cases from 2009 to 2012 (excluding military hospitals) according to data from online registry reported by the Statistical Information Center of National Health and Family Planning Commission. The total success rate was 97.69%, with 0.17% severe complications and 0.03% death.

Chronic kidney disease A chronic kidney disease (CKD) study among 47 204 adults in 13 different provinces and cities from September 2009 to September 2010 reported that the prevalence of CKD reached 10.8%, the adjusted prevalence of estimated glomerular filtration rate , 60 mL/min/1.73 m2 was 1.7%, and adjusted prevalence of albumin–creatinine ratio .30 mg/ g was 9.4%.46 The number of patients with CKD in China is estimated to be 120 million. The PATRIOTIC study47 found that the prevalence, awareness, and treatment rates of hypertension in elderly patients with CKD and hypertension in China were 82.0, 90.7, and 87.3%, respectively. The control rates were 29.6% for the target of ,140/90 mmHg and 12.1% for the target of ,130/80 mmHg.

Outline of the report on cardiovascular diseases in China

Peripheral vascular disease Lower extremity atherosclerotic disease (LEAD) and carotid atherosclerotic disease are commonly seen in middle-aged and elderly people. The prevalence of these diseases among those with major risk factors is particularly high and increases with age. Lower extremity atherosclerotic disease is detected in 30% of patients with cerebrovascular disease and in 25% with IHD. The mortality among patients with LEAD is much higher than those without LEAD at the same age, and is reversely correlated with ABI.48 The detection rate of carotid atherosclerotic plaques in adults between 43 and 81 years in Beijing is 60.3% (66.7% in males and 56.2% in females); carotid atherosclerotic plaques are mainly located at the enlargement part of carotid sinus.49

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Company, and has been served as a model of a functional community-based prevention programme. The risk of stroke can be reduced by 50% through successful control of hypertension. The Kailuan Limited Liability Company initiated a comprehensive hypertension management system in 2009. After 5 years, all hypertensive patients in the Kailuan Coil Mine were managed their condition, with the rates of awareness, treatment, and control of hypertension at 100, 100, and 52%, respectively. The average systolic blood pressure decreased by 12.29 mmHg, along with a 9.42 mmHg reduction in the average diastolic blood pressure. The number of sudden death decreased from 37 cases in 2008 to 2 cases in 2013.50,51

Costs of cardiovascular disease1,52,53 Community-based prevention and control of cardiovascular disease The first hypertension prevention and treatment centre in China was established in 1969 at the Capital Iron and Steel

Figure 9 Trend of total costs of hospitalization of cardiovascular disease (China: 2004–13). AMI, acute myocardial infarction; ICH, intracranial haemorrhage; CI, cerebral infarction.

Trends in hospitalization and discharge of cardiovascular disease In 2013, a total of 15.9962 million patients with cardiovascular or cerebrovascular diseases were discharged from hospitals, which accounted for 12.24% of the total hospital discharges. Of these, 7.6581 million were cerebrovascular disease patients, which accounted for 5.97% of the total hospital discharges. Among the 5.7295 million discharged patients with ischaemic CVD, 0.4936 million were diagnosed with AMI (35.82%), and 4.7196 million with cerebral infarction (29.50%). There were 2.3574 million patients diagnosed with hypertension (0.2030 million had an hypertensionrelated heart disease and/or kidney disease), 1.2680 million with intracranial bleeding, and 0.2511 million with rheumatic heart disease. 2.8142 million discharges were related to diabetes. From 1980 to 2013, hospital discharges for CVD in China increased by 9.51% per year, which was faster than the rate of increase in all-cause discharges (6.23% per year). The annual discharge rates for cerebral infarction, IHD, AMI, and intracranial haemorrhage all

Figure 10 Trend of the average expenses for per hospitalization of cardiovascular disease (China: 2004–13). AMI, acute myocardial infarction; ICH, intracranial haemorrhage; CI, cerebral infarction.

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increased more rapidly than the discharge rate of other CVD by 12.29, 11.66, 10.35, and 9.99%, respectively.

Hospitalization costs of cardiovascular disease Both the total costs of hospitalization and the average expenses for per hospitalization of CVD have increased over the past few years (Figures 9 and 10). In 2013, total hospitalization costs were RMB 11.47 billion for AMI, RMB 19.24 billion for intracranial haemorrhage, and RMB 39.81 billion for cerebral infarction. After adjusting for price inflation, the annual increase for the above diseases since 2004 was 33.46, 19.86, and 25.37%, respectively. The average expenses for per hospitalization of AMI, intracranial haemorrhage, and cerebral infarction was RMB 23 236.1, 15 171.8, and 8434.6, respectively. These costs have increased by 8.67, 6.50, and 2.28% annually since 2004. Conflict of interest: none declared.

Appendix National Center for Cardiovascular Diseases, China; Fuwai Hospital, Chinese Academy of Medical Sciences: Chen Weiwei, Fan Xiaohan, Gao Runlin, Gao Zhan, Gu Dongfeng, He Jianguo, Hu Shengshou, Jiang Lixin, Li Guangwei, Li Huijun, Li Wei, Li Ying, Liu Lisheng, Luo Xinjin, Ma Liyuan, Sui Hui, Wang Wen, Wang Zengwu, Zhang Jian, Zhang Shu, Zhang Yuhui, Zhao Liancheng, Zheng Zhe, Zhu Jun, Zhu Manlu; Beijing Tiantan Hospital: Du Wanliang, Wang Yilong, Wang Yongjun, Wu Di; Shanghai No.6 People’s Hospital: Jia Weiping; China PLA General Hospital: Li Xiaoying; Peking University First Hospital: Li Xiaomei, Wang Yu; Capital Institute of Pediatrics: Mi Jie, Dong Hongbo; Beijing Anzhen Hospital: Liu Jing, Wang Jinwen, Wang Wei, Wu Zhaosu, Yang Xiaohui, Yao Chonghua, Zeng Zhechun, Zhao Dong, Zuo Huijuan; PLA 306 Hospital: Xu Zhangrong; Chinese Center For Disease Control And Prevention: Chen Chunming, Yang Gonghuan; School of Public Health, Peking University Health Science Center: Chen Yude; Peking University People’s Hospital: Hu Dayi; Disease Prevention and Control Bureau, National Health and Family Planning Commission: Wang Bin, Wu Liangyou; Health Development Center, National Health and Family Planning Commission: Liu Kejun, Wang Mei; Information Center, National Health and Family Planning Commission: Rao Keqin; Zhejiang Hospital: Tang Xinhua; National Office for CVDs Prevention and Control: Wang Wenzhi; Peking Union Medical College Hospital: Zeng Zhengpei.

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