Cardiovascular Care in Malaysia: Role of NCVD Sunday 12th April 2015 2.10-2.30pm

1) To relate importance of NCVD / contribution of NCVD in Cardiovascular Care in Msia. 2) To motivate NCVD at participating sites to continue contributing data. Keep them inspired.

Cardiovascular Disease in the Country? What are the issues? Is CVD a problem? Issues – Prevalence, Incidence - Management - How are we doing? - as an individual - as a centre, - as a nation?

Cardiovascular Disease in the Country? Benchmark Compare to – another person - another centre - another country

Cardiovascular Disease in the Country? Are we doing enough? Can we do better?

Cardiovascular Disease in the Country? Data Quality data

Cardiovascular Disease is main cause of death in Ministry of Health hospitals, accounting for ~25% of all deaths.

National Cardiovascular Database NCVD - voluntary submission 2 databases - NCVD ACS - NCVD PCI. NCVD ACS NCVD PCI

National CV Disease Registry Acute Coronary Syndrome NCVD-ACS Registry 2006

National CV Disease Registry Percutaneous Coronary Intervention NCVD-PCI Registry

Data from NCVD Registry used in presentations & discussions - Status of CVD in Malaysia - Implications derived

Year 2006 2007 2008 Total Total N 3422 3646 2851 9919 Age, years Mean 59 Age group % 40 - <50 18% 19% 17% 50 - <60 31% 30% Ethnic group Malay 1684 (49%) 1740 (48%) 1426 (50%) 4850 (49%) Chinese 786 (23%) 853 (23%) 660 (23%) 2299 (23%) Indians 799 (23%) 847 (23%) 601 (21%) 2247 (23%) 49% Mean age: Global Registry of Acute coronary events (GRACE): 66 years, Malaysian NCVD Registry: 59 years.

National Health and Morbidity Surveys NHMS Malaysia % 1996 2006 2011 Overweight / Obesity 21.1 43.1 44.5 Smoking 24.8 21.5 23.1 Hypercholesterolaemia - 20.7 35.1 Hypertension 32.2 32.7 Diabetes 8.3 14.9 15.2    

Dyslipidaemia 33% Hypertension 61% Diabetes 43% NCVD-ACS Registry CV Risk factors 2006 (N=3392) 2007 (N=3640) 2008 (N=2839) 2009 (N=3594) 2010 (N=3401) Total (N=16,866) Dyslipidaemia 33 35 31 32 Hypertension 61 63 56 64 Diabetes 44 38 43 Family History of premature CVD 12 13 9 11 MI history 16 18 26 20 19 Documented CAD 15 14 17 New onset angina (< 2 weeks) 45 53 48 68 60 55 Chronic angina (onset > 2 weeks ago) 8 10 Peripheral vascular disease 1 Cerebrovascular disease 4 3 Current Smoker 34 BMI > 23kgm-2 75 74 73 76 Dyslipidaemia 33% Hypertension 61% Diabetes 43%

Presence of cumulative risk factors (Percentage), NCVD-ACS Registry, 2006-2010 47%

Cardiovascular Disease in Malaysia We Have to Prevent this Disease: Prevent Risk Factors: Obesity, Diabetes, High BP, High Cholesterol Detect Risk Factors early and treat early: Detect Heart Disease early and treat early: Before heart damage and scarring  Death and Disability

Myocardial Infarction AMI Most Effective Treatment: Timely Reperfusion: - Thrombolytic therapy - Angioplasty + stenting PPCI Before muscle damage becomes irreparable and permanent Thrombus Myocardial Infarction AMI Atherosclerosis is an ongoing process affecting mainly large- and medium-sized arteries; it can begin in childhood and progress throughout a person’s lifetime.1 Stable atherosclerotic plaques may encroach on the lumen of the artery and cause chronic ischemia, resulting in (stable) angina pectoris or intermittent claudication, depending on the vascular bed affected. Unstable atherosclerotic plaques may rupture, leading to the formation of a platelet-rich thrombus that partially or completely occludes the artery and causes acute ischemic symptoms.2 A large rupture typically results in the formation of a large thrombus that completely occludes the vessel, resulting in an acute vascular event. A smaller rupture may result in a mural thrombus that partially or transiently occludes the artery, causing acute ischemia and, in the long term, contributing to progression of atherothrombosis. References Jager A, Stehouwer CDA. Heart and Metabolism. Available at: www.heartandmetabolism.org/HMScardiac_metabolism.htm. Accessed March 3, 2003 Rauch U, Osende JI, Fuster V, et al. Ann Intern Med. 2001;134:224-38 Atherosclerosis

Door-to-Needle Time DTN Door-to-Balloon Time DTB Reperfusion Door-to-Needle Time DTN <30mins Door-to-Balloon Time DTB <90mins

Management of Patients Presenting with STEMI ECG Cardiac Biomarkers CHEST PAIN / EQUIVALENT Continuous ECG monitoring s/l GTN if no contraindication Aspirin / Clopidogrel / Analgesic Oxygen if SpO2 <95% Concomitant initial Mx Assessment for Reperfusion Onset of Symptoms <3hrs 3-12 hrs >12hrs Preferred Option PPCI** or Fibrinolytic Therapy PPCI*** Medical Therapy Second Option Fibrinolytic PPCI Subsequent Mx Consider PCI within 3-24 hrs of fibrinolytic -pharmacoinvasive Strategy PCI if ongoing ischaemia or haemodynamic instability **Preferred option in: - high-risk features - Contraindication to lytic therapy PCI time delay (DBT-DNT) < 60mins ***if DBT is within 90mins Concomitant Therapy Antithrombotics BB, ACE-I / ARB, Statins + Nitrates + Calcium antagonist

Timely Myocardial Reperfusion:  Improved clinical outcome Door-to-Needle DTN time: < 30 mins Door-to-Balloon DTB time: < 90 mins Timely Myocardial Reperfusion:  Improved clinical outcome   In-hospital mortality by half, from ~15% to ~7.5% Most patients in industrialized nations are now receiving the benefits of timely (early) reperfusion therapy.

Pre-hospital Triage in Transferring patients for PCI Zwolle PHIAT protocol (1998 - ) Pre-Hospital Infarct Angioplasty Triage 35 Ambulances + computer-assisted 12-lead tele-ECG, using algorithm Identification of a STEMI Ambulance nurse only, no physician Immediate transfer to Cathlab Rather than to nearest Hosp/CCU/ER PCI Centre Zwolle Referral Center Ambulance Transport Zwolle 1.400.000 Amsterdam Distance Range: 2 - 95 km Symptom-Ambulance 91 min Ambulance-Admission 49 min Door-Balloon 38 min Total 178’

“Physician-less’ System of Prehospital STEMI Diagnosis & Cath Lab Activation

STEMI Program: Singapore Dr Tan Huay Cheem MBBS, M Med(Int Med) MRCP(UK), FRCP(Edinburgh), FAMS, FACC, FSCAI Director, National University Heart Centre, Singapore Associate Professor of Medicine, Yong Loo Lin School of Medicine National University of Singapore President, Asia Pacific Society of Interventional Cardiology

STEMI Treatment Plan In Singapore Routine Fax & Transfer Nearest PCI Centres Call 995 995

Singapore Regional Health Systems (RHS) CGH TTSH JURONG KTPH OUTRAM Source: MOH, Dr Jennifer Lee presentation, 20090914 RH CH NH Polyclinics? FPs Home Care Rehab & support services Screening & Prevention Palliative NUHS 27 27

Reperfusion for STEMI In Singapore The number of STEMI cases which received ePCI increased from 1435 in 2012 to 1536 in 2013, while the number of STEMI cases which received thrombolysis increased from 2 in 2012 to 4 in 2013 in 2013 PPCI rate: 99.7%

Median Door-to-Balloon Time (min) ePCI Trends, 2007 - 2013 ePCI 2007 2008 2009 2010 2011 2012 2013 <90mins 367 478 841 840 906 1042 1184 >90mins 443 345 290 307 282 228 194 % within 90mins 45.3 58.1 74.4 73.2 76.3 82 85.9 Median Door-to-Balloon Time (min) 95 84 69 70 66 60 58 Excluding transfers, inpatient AMI

STEMI Management in Singapore: Conclusions Adoption of international benchmark of excellence (mortality rates, DTN/DTB time) for quality Formation of regional STEMI network as more hospitals are being set up Continual audit and review process between Ministry of Health, Emergency Services & Public Hospitals

National CV Disease Registry Acute Coronary Syndrome NCVD-ACS Registry 2006

NCVD-ACS 2006 – 2008 STEMI Treatment Fibrinolytic Therapy given=71%, Not given= 17% Given prior to transfer 16% Given at receiving centre 55% Not given, Contraindicated 4% Missed Lytic therapy 12% Patient refused 1% Primary PCI 7% Not given = 17% Missing data 5%

Door-to-needle and Door-to-balloon time distribution for patients with STEMI (by admission) NCVD ACS Registry, 2006 - 2008 Door to needle time (Recommended < 30 min) 2006 2007 2008 N 756 828 798 Mean ± SD 102 ± 142 91 ± 131 112 ± 194 Min, Max 2, 1349 1, 1435 1, 1440 Door to balloon time (Recommended < 90 min) 153 126 99 241 ± 295 215 ± 266 214 ± 260 35, 1440 25, 1410 11, 1195 Reference: W.A. Wan Ahmad, K.H. Sim. (Eds). Annual Report of the NCVD-ACS Registry, Year 2007 & 2008. Kuala Lumpur, Malaysia: National Cardiovascular Disease Database, 2010.

Outcomes for Patients with ACS by ACS Stratum, NCVD-ACS Registry, 2006-2008 GRACE Reg 7% 4% 3%

ACS Care in Malaysia, based on NCVD Registry Reperfusion strategy for STEMI patients: Mainly by fibrinolytic therapy (71%). Primary Angioplasty constitute about 7% In Malaysia, in-hospital and 30 days mortality rate is higher compared to Western Registry: In-hospital Mortality rate for STEMI is 10%. The 30-days mortality rate for STEMI is 14%. GRACE Registry: In-hospital Mortality rate for STEMI is 7%. ACTION Registry [US]: In-hospital Mortality rate for STEMI is 4%.

knowing the state of affairs with STEMI Care in Malaysia? What are we doing, knowing the state of affairs with STEMI Care in Malaysia?

Sunday 12th April 2015 Relevant STEMI Care personnel To discuss STEMI Network working

Symposium On Optimal Treatment For Acute Myocardial Infarction LUMEN GLOBAL SAVING LIVES FROM AMI LUMEN Meeting 2016 Kuala Lumpur, 9 – 10 Jan 2016 Symposium On Optimal Treatment For Acute Myocardial Infarction

1) To relate importance of NCVD / contribution of NCVD in Cardiovascular Care in Msia. 2) To motivate NCVD at participating sites to continue contributing data. Keep them inspired.

Thank You