1. Cardiovascular Care in Malaysia: Role of NCVD
Sunday 12th April 2015 pm

2. 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.

3. 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?

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

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

6. Cardiovascular Disease in the Country?
Data
Quality data

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

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

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

10. National CV Disease Registry Percutaneous Coronary Intervention
NCVD-PCI Registry

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

12. 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.

13. 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    

14. 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%

15. Presence of cumulative risk factors (Percentage),
NCVD-ACS Registry,
47%

16. 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

18. 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: Accessed March 3, 2003
Rauch U, Osende JI, Fuster V, et al. Ann Intern Med. 2001;134:224-38
Atherosclerosis

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

20. 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

21. 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.

23. Pre-hospital Triage in Transferring patients for PCI
Zwolle PHIAT protocol ( )
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
Amsterdam
Distance Range: km
Symptom-Ambulance 91 min
Ambulance-Admission 49 min
Door-Balloon 38 min
Total 178’

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

25. 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

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

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

28. 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%

29. Median Door-to-Balloon Time (min)
ePCI Trends,
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

30. 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

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

32. 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%

33. Door-to-needle and Door-to-balloon time distribution
for patients with STEMI (by admission)
NCVD ACS Registry,
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.

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

35. 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%.

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

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

38. 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

39. 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.

40. Thank You