Summary of the Annual Report of the NCVD-ACS Registry

Summary of the Annual Report of the NCVD-ACS Registry 2011-2013
Suggested citation: W.A. Wan Azman, K.H. Sim. (Eds). Annual Report of the NCVD-ACS Registry, Year Kuala Lumpur, Malaysia: National Cardiovascular Disease Database, 2015.

Authors Dr Omar Ismail, Hospital Pulau Pinang
Dr Alan Fong Yean Yip, Pusat Jantung Hospital Umum Sarawak Dr Chin Sze Piaw, Negeri Sembilan Chinese Maternity Hospital Dr Lee Chuey Yan, Hospital Sultanah Aminah Dr Wan Azman Wan Ahmad, University Malaya Medical Centre Dr Ahmad Syadi Mahmood Zuhdi, University Malaya Medical Centre Dr Imran Zainal Abidin, University Malaya Medical Centre Dr Ganiga Sridhar Srinivasaiah, University Malaya Medical Centre Dr Rafidah Abu Bakar, Institut Jantung Negara Dr Beni Isman Rusani, Institut Jantung Negara Dr Paras Doshi, Hospital Kuala Lumpur Dr Abdul Kahar Ghapar, Hospital Serdang Dr Mohd Sapawi Mohamed, Hospital Sultanah Nur Zahirah Dr Julian Tey Hock Chuan, Hospital Melaka Dr Tan Kin Leong, Hospital Tuanku Ja’afar

NCVD-ACS Registry Participating Hospitals
HTF HQEI HQEII HRPZ II HSB HPP HSNZ HRPB HTAA PJHUS UMMC IJN HKL HTAR HS HA Total SDP= 19 hospitals HTJ HSA *Each SDP started to contribute data at different time period *SDP: Source Data Provider HM NCVD-ACS Registry, Malaysia ( )

Chapter 1: CARDIAC SERVICES

Number and Density of Cardiologist in Malaysia by sector, 2014
Per 10,000 population Public 35 - Private 184 Total 219 0.073 Source: National Specialist Register as of 25 January 2015 * Indicator Demographics Malaysia 2013 was referred as the data for 2014 was not available at the publication of this report.

Comparison of Number and Density of Cardiologist in Malaysia by sector
between 2012 & 2014 Sector 2012 2014 Public (N) 32 35 Private (N) 154 184 Total 186 219 Per 10,000 population 0.06 0.073 Source: National Specialist Register as of 25 January 2015 * Indicator Demographics Malaysia 2013 was referred as the data for 2014 was not available at the publication of this report.

Number and Density of Cardiologist in Malaysia by state, 2014
Per 10,000 population Perlis Kedah 8 0.039 Pulau Pinang 33 0.200 Perak 14 0.057 Selangor & WP Putrajaya 34 0.058 WP Kuala Lumpur 72 0.418 Negeri Sembilan 3 0.027 Melaka 0.094 Johor 10 0.028 Pahang 0.051 Terengganu 2 0.017 Kelantan Sabah & WP Labuan 6 0.016 Sarawak 18 0.068

Comparison of Number and Density of Cardiologist in Malaysia by state, between 2012 & 2014
Per 10,000 population Perlis Kedah 7 0.04 8 0.039 Pulau Pinang 30 0.19 33 0.200 Perak 12 0.05 14 0.057 Selangor & WP Putrajaya 32 0.06 34 0.058 WP Kuala Lumpur 55 0.32 72 0.418 Negeri Sembilan 3 0.03 0.027 Melaka 0.09 0.094 Johor 9 10 0.028 Pahang 5 0.051 Terengganu 2 0.02 0.017 Kelantan 6 Sabah & WP Labuan 0.016 Sarawak 18 0.068

Sector Number Per 10,000 population
Number and Density of Hospital with Catheterisation Laboratory in Malaysia by sector, 2014 Sector Number Per 10,000 population Public 14 - Private 55 Total 69 0.023

Comparison of Number and Density of Hospital with Catheterisation Laboratory in Malaysia by sector, between 2012 & 2014 Sector 2012 2014 Public (N) 13 14 Private (N) 42 55 Total 69 Per 10,000 population 0.02 0.023 Source: National Specialist Register as of 25 January 2015 * Indicator Demographics Malaysia 2013 was referred as the data for 2014 was not available at the publication of this report.

Number and Density of Hospital with Catheterisation Laboratory in Malaysia by state, 2014
Per 10,000 population Perlis Kedah 6 0.029 Pulau Pinang 10 0.060 Perak 4 0.016 Selangor & WP Putrajaya 16 0.027 WP Kuala Lumpur 12 0.069 Negeri Sembilan 2 0.018 Melaka 3 0.035 Johor 0.011 Pahang 0.012 Terengganu 1 0.008 Kelantan Sabah & WP Labuan 0.005 Sarawak 5 0.019

Comparison of Number and Density of Hospital with Catheterisation Laboratory in Malaysia by state, between 2012 & 2014 2012 2014 State Number Per 10,000 population Perlis Kedah 4 0.02 6 0.029 Pulau Pinang 8 0.05 10 0.060 Perak 0.016 Selangor & WP Putrajaya 11 16 0.027 WP Kuala Lumpur 0.06 12 0.069 Negeri Sembilan 2 0.018 Melaka 3 0.04 0.035 Johor 0.01 0.011 Pahang 0.012 Terengganu 1 0.008 Kelantan Sabah & WP Labuan 0.0 0.005 Sarawak 5 0.019

Chapter 2: Patient Characteristics

N ACS admissions = 14,763

Mean age: 58.5 (12.2) years N ACS admissions = 14,763

N ACS admissions = 14,763

Hypertension 65% Diabetes 46%
CV Risk factors (N=16,866) 2011 (N=4,047) 2012 (N=4,589) 2013 (N=6,127) (N=14,763) Dyslipidaemia 33.0 39.2 36.4 37.0 37.4 Hypertension 61.0 67.0 65.6 63.2 65.0 Diabetes 43.0 46.2 46.6 45.0 45.8 Family History of premature CVD 11.0 14.5 13.2 12.4 MI history 19.0 22.0 20.8 16.2 19.2 Documented CAD 17.0 17.3 20.2 24.4 21.2 New onset angina (< 2 weeks) 55.0 61.4 57.6 56.4 58.2 Chronic angina (onset > 2 weeks ago) 11.4 9.6 9.4 9.9 Chronic Lung Disease 4.0 3.6 2.8 3.1 3.2 Renal disease 7.0 8.2 7.2 7.8 Peripheral vascular disease 1.0 1.2 0.8 0.6 Cerebrovascular disease 4.2 3.5 3.8 Heart Failure 8.6 5.3 Current Smoker 37.6 37.8 38.2 38.0 BMI > 23kgm-2 75.0 75.6 78.2 76.5 Hypertension 65% Diabetes 46%

Presence of cumulative risk factors (Percentage),
NCVD-ACS Registry,

Age-ethnic group distribution of male patients by ACS admission,
NCVD-ACS Registry,

Age-ethnic group distribution of female patients by ACS admission,
NCVD-ACS Registry,

Age-gender distribution of ACS patients with Diabetes,
NCVD-ACS Registry,

Age-gender distribution of ACS patients with Hypertension,
NCVD-ACS Registry,

Age-gender distribution of ACS patients with Dyslipidaemia,
NCVD-ACS Registry,

Type of cardiac presentation for patients with ACS (%) by admission,
NCVD-ACS Registry, 2006 2007 2008 2009 2010 2011 2012 2013 N 3,392 3,640 2,839 3,594 3,401 4,047 4,589 6,127 STEMI 42.0 46.0 54.0 47.0 53.0 50.8 52.0 50.0 NSTEMI 34.0 29.0 24.0 30.0 27.0 25.0 26.2 UA 22.0 17.0 22.2 23.3 23.8

Type of cardiac presentation for patients with ACS (%) by admission,
NCVD-ACS Registry,

Age group of patients by ACS stratum
NCVD-ACS Registry, Mean age (SD) for STEMI: 56.2 (12.0); NSTEMI: 60.8 (11.8) and UA: 60.8 (12.0)

Age-Gender distribution of patients by ACS stratum
NCVD-ACS Registry,

Ethnicity of patients by ACS stratum
NCVD-ACS Registry,

Co-morbidities by ACS stratum
NCVD-ACS Registry,

Chapter 3: Clinical Presentations and Investigations

Killip Classification by ACS stratum
NCVD-ACS Registry,

Killip Classification by Age group
NCVD-ACS Registry,

Pain to needle time by ACS admissions,
NCVD-ACS Registry, 2011 2012 2013 N 809 744 1062 2615 Median 160.0 210.0 195.0 185.0 IQR 170.0 200.5 180.0

Chapter 4: TREATMENT

Medication prescribed during the admission by ACS stratum,
NCVD-ACS Registry,

Medication prescribed among STEMI patient by Age Group,
NCVD-ACS Registry,

Medication prescribed among STEMI patient by Gender,
NCVD-ACS Registry,

Medication prescribed among STEMI patient by Ethnicity,
NCVD-ACS Registry,

Door to needle time by ACS admissions,
NCVD-ACS Registry, 2011 2012 2013 N 1009 960 1387 3356 Median 40.0 45.0 49.0 IQR 55.0 78.5 85.0 75.0 % of patients received who thrombolysis therapy ≤30mins 43.4 39.2 36.0

Door to balloon time by ACS admissions,
NCVD-ACS Registry, 2011 2012 2013 N 113 256 203 572 Median 120.0 113.5 104.0 111.0 IQR 133.0 164.0 119.0 139.0 % of patients with door to balloon time ≤90mins 33.6 36.8 41.8 38.0

Medication prescribed among NSTEMI/UA patient by Age Group,
NCVD-ACS Registry,

Medication prescribed among NSTEMI/UA patient by Gender,
NCVD-ACS Registry,

Medication prescribed among NSTEMI patient by Ethnicity,
NCVD-ACS Registry,

Type of treatment among STEMI patients by Age Group ,
NCVD-ACS Registry,

Type of treatment among STEMI patients by Gender ,
NCVD-ACS Registry,

Type of treatment among STEMI patients by Ethnicity ,
NCVD-ACS Registry,

Fibrinolytic Therapy by Type of hospitals,
NCVD-ACS Registry,

Chapter 5: OUTCOME

NCVD ACS In-Hospital Mortality and 30-day Follow UP
VS Outcome at discharge 30-day FU Year Outcome N % Alive 15531 92 14429 86 Died 1335 8 2437 14 2011 3729 92.2 3681 91.0 318 7.8 366 9.0 2012 4234 4173 355 416 2013 5670 92.6 5586 91.2 457 7.4 541 8.8 13633 92.4 13440 1130 7.6 1323 Outcome at discharge is similar but 30 day outcome has improve significantly

Outcome at discharge 30-day FU Young Middle age Elderly year Outcome N % Alive 906 97 7805 95 6820 88 886 7493 91 6050 78 Died 25 3 386 5 924 12 45 698 9 1694 22 2011 236 96.8 1896 94.8 1597 88.6 234 96.0 1883 94.2 1564 86.6 8 3.2 103 5.2 207 11.4 10 4.0 116 5.8 240 13.4 2012 300 97.8 2119 95.8 1815 87.6 299 97.4 2101 95.0 1773 85.6 7 2.2 92 4.2 256 12.4 2.6 110 5.0 298 14.4 2013 398 2889 2383 89.0 395 97.0 2859 94.0 2332 87.2 155 293 11.0 3.0 185 6.0 344 12.8 934 6904 95.2 5795 88.4 928 6843 94.4 5669 24 350 4.8 756 11.6 30 411 5.6 882 Outcome at discharge is similar but 30 day outcome has improve significantly

Outcome at discharge 30-day FU Male Female Year Outcome N % Alive 11876 93 3655 90 11157 87 3272 81 Died 947 7 388 10 1666 13 771 19 2011 2913 92.6 816 90.4 2882 91.6 799 88.6 232 7.4 86 9.6 263 8.4 103 11.4 2012 3381 93.2 853 88.8 3341 92.0 832 86.6 247 6.8 108 11.2 287 8.0 129 13.4 2013 4536 1134 89.8 4473 1113 88.2 329 128 10.2 392 149 11.8 10830 93.0 2803 89.6 10696 2744 87.8 808 7.0 322 10.4 942 381 12.2

Outcome at discharge 30-day FU Diabetes Non Diabetes Year Outcome N % Alive 6609 91 6490 93 5993 83 6115 88 Died 636 9 460 7 1252 17 835 12 2011 1587 91.2 1690 92.8 1559 89.4 1675 92.0 155 8.8 131 7.2 183 10.6 146 8.0 2012 1798 91.0 1885 93.2 1763 1864 92.2 176 9.0 138 6.8 211 159 7.8 2013 2322 90.4 2642 94.6 2273 88.6 2610 93.4 246 9.6 152 5.4 295 11.4 184 6.6 5707 90.8 6217 93.6 5595 89.0 6149 92.6 577 9.2 421 6.4 689 11.0 489 7.4

Outcome at discharge 30-day FU Hypertensive Non Hypertensive Year Outcome N % Alive 9470 92 4106 93 8658 84 3912 89 Died 846 8 289 7 1658 16 483 11 2011 2318 91.0 1044 94.4 2283 89.6 1035 93.6 229 9.0 62 5.6 264 10.4 71 6.4 2012 2562 91.6 1171 93.0 2519 90.0 1157 91.8 235 8.4 88 7.0 278 10.0 102 8.2 2013 3319 91.4 1758 94.6 3252 1743 93.8 311 8.6 99 5.4 378 114 6.2 8199 3973 94.2 8054 89.8 3935 93.2 775 249 5.8 920 10.2 287 6.8

Outcome at discharge 30-day FU Dyslipidaemia Non Dyslipidaemia Year Outcome N % Alive 5255 94 5623 92 4811 86 5269 Died 362 6 470 8 806 14 824 2011 1323 90.6 1667 93.4 1309 89.8 1643 92.0 136 9.4 118 6.6 150 10.2 142 8.0 2012 1435 1988 91.8 1412 1958 90.4 103 177 8.2 126 207 9.6 2013 1975 94.0 2730 1950 92.8 2678 90.2 128 6.0 240 153 7.2 292 9.8 4733 6385 92.2 4671 91.6 6279 90.8 367 535 7.8 429 8.4 641 9.2

30 day outcome is better at cardiologist centre
Outcome at discharge 30-day FU Physician Centre Cardiologist Centre Year Outcome N % Alive 5163 92 10368 4905 87 9524 85 Died 454 8 881 712 13 1725 15 2011 2839 92.2 890 92.0 2801 91.0 880 241 7.8 77 8.0 279 9.0 2012 3368 866 92.6 3315 90.8 858 91.8 286 69 7.4 339 9.2 8.2 2013 5031 639 92.8 4948 638 407 50 7.2 490 51 11238 92.4 2395 11064 2376 934 7.6 196 1108 215 30 day outcome is better at cardiologist centre

Outcome at discharge has improve in NSTEMI and UA more so for 30 day
30-day FU STEMI NSTEMI UA Year Outcome N % Alive 7340 90 4513 91 3678 97 7011 86 4020 81 3398 Died 790 10 445 9 100 3 1119 14 938 19 380 2011 1841 89.6 999 91.4 889 99.0 1813 88.2 985 90.0 883 98.4 214 10.4 95 8.6 1.0 242 11.8 109 10.0 15 1.6 2012 2120 88.8 1073 93.6 1041 2095 87.8 1053 91.8 1025 97.0 266 11.2 73 6.4 16 291 12.2 93 8.2 32 3.0 2013 2744 1478 92.2 1448 2709 88.6 90.4 1429 97.6 317 124 7.8 352 11.4 154 9.6 35 2.4 6705 89.4 3550 92.4 3378 98.8 6617 3486 90.8 3337 797 10.6 292 7.6 41 1.2 885 356 9.2 82 Outcome at discharge has improve in NSTEMI and UA more so for 30 day

Outcome at discharge 30-day FU STEMI w Fibrinolytic Therapy STEMI w/o Year Outcome N % Alive 5497 92 1843 86 5280 88 1731 81 Died 485 8 305 14 702 12 417 19 2011 1418 90.0 358 88.4 1402 89.0 349 86.2 159 10.0 47 11.6 175 11.0 56 13.8 2012 1521 90.2 551 85.6 1508 89.4 540 84.0 165 9.8 14.4 178 10.6 103 16.0 2013 2015 90.6 686 87.0 1990 676 209 9.4 13.0 234 113 4954 1595 86.8 4900 1565 85.2 533 242 13.2 587 272 14.8 Outcome at discharge and 30 days in STEMI patients without thrombolytic therapy are worse

Outcome at discharge 30-day FU STEMI w PCI STEMI w/o PCI Year Outcome N % Alive 1347 92 5470 90 1295 88 5215 86 Died 125 8 602 10 177 12 857 14 2011 376 93.8 1096 87.4 366 91.2 1087 86.8 25 6.2 157 12.6 35 8.8 166 13.2 2012 682 1235 87.6 673 90.0 1222 65 174 12.4 74 10.0 187 2013 987 92.2 1523 88.0 972 90.8 1504 87.0 83 7.8 206 12.0 98 9.2 225 13.0 2045 3854 87.8 90.6 3813 173 537 12.2 207 9.4 578 Outcome at discharge and 30 days in STEMI patients without PCI are worse

Year Outcome Outcome at discharge 30-day FU NSTEMI/UA w PCI NSTEMI/UA w/o PCI N % Alive 842 95 6170 94 803 91 5524 84 Died 41 5 406 6 80 9 1052 16 2007 248 96.8 1103 92.6 247 96.4 1090 91.4 8 3.2 89 7.4 3.6 102 8.6 2008 300 1387 95.4 297 1358 93.4 11 67 4.6 14 96 6.6 2009 402 97.2 2253 399 2211 93.6 12 2.8 110 15 152 6.4 950 4743 94.6 943 96.2 4659 93.0 31 266 5.4 38 3.8 350 7.0 Outcome at discharge and 30 days in NSTEMI/ UA patients without PCI are worse

Prognostic factors for death in hospital among STEMI patients, NCVD-ACS Registry, 2011-2013
Hazard ratio 95% CI p-value Age group, years 20 - <40 (ref) 655 1.00 40 - <60 4089 1.34 0.87 2.06 0.183 ≥60 2758 1.84 1.19 2.84 0.006 Gender Male (ref) 6397 Female 1105 1.27 1.04 1.55 0.019 *Ethnic group Malay (ref) 4318 Chinese 1262 0.85 0.70 1.03 0.102 Indian 1145 0.91 0.74 1.11 0.350 Others 777 0.62 0.45 0.86 0.005 Killip classification code I (ref) 4135 II 1366 1.25 0.98 1.59 0.066 III 342 1.94 1.46 2.57 <0.001 IV 983 3.52 4.35 Not stated/inadequately described 676 1.43 1.97 0.026 Percutaneous coronary intervention No (ref) 5031 Yes 2471 0.75 0.58 0.96 0.021 Cardiac catheterization 4689 2813 0.93 0.011

Factors N Hazard ratio 95% CI p-value TIMI risk score 0-2 (ref) 2241 1.00 3-4 2286 1.83 1.28 2.62 0.001 5-7 2322 3.43 2.43 4.84 <0.001 >7 653 6.39 4.39 9.30 Fibrinolytic therapy Not given (ref) 1875 Given 5627 0.78 0.67 0.91 0.002 Hypertension No (ref) 2774 Yes 4259 1.21 1.01 1.45 0.035 Unknown 469 0.70 0.43 1.12 0.134 Diabetes 3913 3016 1.06 0.90 1.24 0.507 573 1.47 0.99 2.16 0.052 Heart failure 6803 277 1.44 1.86 0.004 422 0.92 0.69 1.23 0.584 Family history of premature CVD 5326 957 0.95 0.73 0.706 1219 1.30 1.08 1.57 0.006

Prognostic factors for death in hospital among NSTEMI/UA patients, NCVD-ACS Registry, (Multivariate analysis) Factors N Hazard ratio 95% CI p-value Age group, years 20 - <40 (ref) 303 1.00 40 - <60 3165 8.52 1.18 61.37 0.033 ≥60 3793 15.84 2.21 113.64 0.006 *Ethnic group Malay (ref) 3141 Chinese 1912 1.04 0.81 1.35 0.738 Indian 1759 0.69 0.50 0.94 0.020 Others 449 0.97 0.59 1.59 0.901 Killip classification code I (ref) 3906 II 1002 1.47 1.05 2.06 0.024 III 296 2.80 1.88 4.16 <0.001 IV 370 7.51 5.65 9.99 Not stated/inadequately described 1687 0.93 0.65 1.31 0.664 Cardiac catheterization No (ref) 5115 Yes 2146 0.40 0.29 0.57 Hypertension 1703 5390 0.75 0.56 0.051 Unknown 168 0.37 2.29 0.867 Diabetes 3208 3787 1.24 0.084 266 1.11 0.54 2.26 0.773

Summary The number and density of registered Cardiologist in National Specialist Registry, Malaysia has slightly increased from 175 ( 6 pmp) to 219 ( 7.3 pmp) as compared to previous report. There is still uneven distribution of Cardiologists and Cardiac catheterization lab in Malaysia, more in West Coast especially in Klang Valley,Pulau Pinang and Melaka as compared to East Coast and Sabah.

Summary Malaysian ACS patients are younger compared to western registries, in particular among the STEMI sub-group. Indians and Malays were more likely to present with an ACS event at a younger age. The prevalence of hypertension, diabetes and dyslipidaemia remains consistently high over the three years period. Patients with NSTEMI/UA have higher prevalence of hypertension, diabetes and dyslipidaemia compared to STEMI whereas smoking is higher in STEMI.

Summary The spectrum of ACS presentations in year were almost similar compared to the registry in the year ; commonest being STEMI (50.8% vs 48.2%), followed by NSTEMI (26.0% vs 29.4%) and unstable angina (23.2%vs 22.4%). The STEMI cohort had higher mean total cholesterol and LDL-C compared to those with NSTEMI/unstable angina. Almost 70% of the STEMI and 41.4% of the NSTEMI/UA cohort were in the intermediate to high TIMI risk score group. There was an increasing trend observed in STEMI patients presenting with Killip IV compared to past registry (13.4% vs 6%). Median door to needle time (DNT) was 45 minutes and remain unchanged since 2009.

Summary Similar length of admission in CCU/ICU was observed in all ACS spectrums and age groups. Following STEMI, 75% received fibrinolytic therapy and 9.4% were treated with primary PCI. The median DTN was 45 minutes, slightly better than previous cohort ( ) % achieved the recommended DTN of 30 minutes. The median DTB was 111 minutes, slight better than the previous cohort ( ) which was 117 minutes. 38.0% achieved the recommended DTB time of 90 minutes. In NSTEMI/UA, male and younger patients tend to undergo more PCI compared to female and elderly patients. There was improvement in prescription of Aspirin (more than 95%) and Statin (about 92%) compared to the previous cohort ( ). However, the usage of beta blocker and ACE inhibitor remain the same.

Summary There was improvement in overall 30-day outcome compared to the last NCVD-ACS registry in STEMI remains as the highest risk of mortality. Advanced age, female gender and higher TIMI risk score and Killip class identified as predictors of mortality. Patients who received fibrinolytic therapy had better outcome than those who did not. Hospitals with cardiac catheterization facility registered lower in-hospital and 30-day mortality. Patients who underwent urgent cardiac catheterization and urgent PCI had better outcome than those who did not.

THANK YOU Prepared by National Cardiovascular Disease Database
c/o National Heart Association of Malaysia Level 1, Medical Academies of Malaysia 210 Jalan Tun Razak, Kuala Lumpur Tel: Fax: Website:

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