Coronary Artery Disease in Developing and Newly Industrialized Countries: A Scientific Statement of the International College of Cardiology

Abstract

Coronary risk factors such as hypertension, tobacco consumption, hypercholesterolemia and diabetes as well as coronary artery disease (CAD) have become a major health problem in developing and newly industrialized countries despite a moderate increase in fat intake and low rates of obesity. It is a paradox that in some of these countries the increased risk of people to diabetes and CAD, especially at a younger age, is difficult to explain by conventional risk factors. It is possible that the presence of new risk factors especially higher lipoprotein (a) (Lp(a)), hyperhomocysteinemia, insulin resistance, low high density lipoprotein cholesterol and poor nutrition during fetal life, infancy and childhood may explain at least in part, the cause of this paradox. The prevalence of obesity, central obesity, smoking, physical inactivity and stress are rapidly increasing in developing and newly industrialized countries due to economic development and affluence. Many countries in Eastern Europe (such as Slovakia, Poland, and Hungary) and Hong Kong, Singapore and Taiwan that are more affluent have greater prevalence of these adverse effects in comparison to less developed countries such as Philippines, China, Thailand, and Brazil. Hypertension, diabetes and CAD are very low in the rural population of India, China, and in the African sub-continent which has less economic development. However, in urban and immigrant populations of India and Chinese origin, the prevalence of hypertension (> 169/95, 12–20%), diabetes (6–18%) and CAD (7–14%) are significantly higher than they are in some of the developed countries. Mean serum cholesterol (180–200 mg/dl), obesity (5–8%) and dietary fat intake (25–30% en/day) are paradoxically not very high and do not explain the cause of increased susceptibility to CAD and diabetes in some South Asian countries. The force of lipid-related risk factors appear to be greater in these populations due to the presence of the above factors and results into CVD at a younger age in these countries. Available studies support the consensus that people of poor economic origin on rapid nutritional transition may develop CVD at a younger age. They should therefore have lower desirable limits of serum cholesterol, body mass index, dietary fat intake and should also decrease the new risk factors for prevention of CAD. These findings may require modification of the existing guidelines of the International Task Force for Prevention of CAD.