Cardiovascular Care in Malaysia:

Role of NCVD

Sunday 12th April 20152.10-2.30pm

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.

Issues – Prevalence, Incidence - Management

- How are we doing? - as an individual- as a centre, - as a nation?

What are the issues?

Is CVD a problem?

Cardiovascular Disease in the Country?

Cardiovascular Disease in the Country?

Benchmark Compare to – another person

- another centre - another country

Are we doing enough?

Can we do better?

Cardiovascular Disease in the Country?

Data

Quality data

Cardiovascular Disease in the Country?

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 59 59 59

Age group %

40 - <50 18% 19% 17% 18%

50 - <60 31% 31% 30% 31%

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%)Mean age: Global Registry of Acute coronary events (GRACE): 66 years, Malaysian NCVD Registry: 59

years.

49%

National Health and Morbidity Surveys NHMS Malaysia

% 1996 2006 2011Overweight / Obesity 21.1 43.1 44.5

Smoking 24.8 21.5 23.1

Hypercholesterolaemia - 20.7 35.1

Hypertension 20.7 32.2 32.7

Diabetes 8.3 14.9 15.2

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 35 32 33

Hypertension 61 63 56 64 61 61

Diabetes 44 44 38 44 44 43

Family History of premature CVD

12 13 9 9 13 11

MI history 16 18 13 26 20 19

Documented CAD 15 18 14 20 16 17

New onset angina (< 2 weeks)

45 53 48 68 60 55

Chronic angina (onset > 2 weeks ago)

15 11 8 12 10 11

Peripheral vascular disease

1 1 1 1 1 1

Cerebrovascular disease

4 3 3 3 4 4

Current Smoker 33 34 34 34 34 33

BMI > 23kgm-2 75 74 73 76 75 75

Hypertension 61%

Diabetes 43%

Dyslipidaemia 33%

NCVD-ACS Registry

Presence of cumulative risk factors (Percentage),

NCVD-ACS Registry, 2006-2010

None

1 risk factor

2 risk factors

3 risk factors

> 3 risk factors

0 5 10 15 20 25 30

5

19

29

27

2047%

Cardiovascular Disease in Malaysia

Prevent Risk Factors:

Obesity, Diabetes, High BP, High

CholesterolDetect Risk Factors early and treat

early:Detect Heart Disease early and treat

early:

Before heart damage and scarring

Death and Disability

We Have to Prevent this Disease:

Atherosclerosis

Myocardial Infarction

AMI

Thrombus

Most Effective Treatment: Timely Reperfusion: - Thrombolytic therapy - Angioplasty + stenting PPCI

Before muscle damage

becomes irreparable and permanent

Reperfusion

Door-to-Needle Time DTN<30mins Door-to-Balloon

Time DTB<90mins

**Preferred option in:- high-risk features- Contraindication to lytic therapy- PCI time delay

(DBT-DNT) < 60mins***if DBT is within 90mins

Assessment for

Reperfusion

Preferred Option

Second Option

Onset of Symptoms

ECGCardiac

Biomarkers

Concomitant initial Mx

Subsequent Mx

CHEST PAIN / EQUIVALENT

<3hrs

>12hrs

3-12 hrs

Fibrinolytic

PPCI

Continuous ECG monitorings/l GTN if no

contraindicationAspirin / Clopidogrel /

AnalgesicOxygen if SpO2 <95%

PPCI** or Fibrinolyt

ic Therapy

PPCI***

Medical Therapy

Consider PCI within 3-24 hrs of fibrinolytic

-pharmacoinvasive Strategy

PCI if ongoing ischaemia or

haemodynamic instability

AntithromboticsBB, ACE-I / ARB, Statins

+ Nitrates + Calcium antagonist

Concomitant Therapy

Management of Patients Presenting with STEMI

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.

Timely Myocardial Reperfusion:

Door-to-Needle DTN time:

< 30 mins

Door-to-Balloon DTB time:

< 90 mins

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 ZwolleReferral CenterAmbulance 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 CHEEMMBBS, M MED(INT MED) MRCP(UK), FRCP(EDINBURGH), FAMS, FACC, FSCAI

DIRECTOR, NATIONAL UNIVERSITY HEART CENTRE, SINGAPOREASSOCIATE 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

Call 995

995

Fax & Transfer Nearest

PCI Centres

Routine

27

Singapore Regional Health Systems (RHS)

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care CGHTTSHJURONG

KTPH

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care OUTRAM

Source: MOH, Dr Jennifer Lee presentation, 20090914

RH

CH

NHPolyclinics?

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care NUHS

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%

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

National CV Disease Registry Acute Coronary Syndrome

NCVD-ACS Registry

2006

NCVD-ACS 2006 – 2008 STEMI Treatment

Missing data 5%

N=11,634

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%

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)

2006 2007 2008

N 153 126 99

Mean ± SD 241 ± 295 215 ± 266 214 ± 260

Min, Max 35, 1440 25, 1410 11, 1195

Door-to-needle and Door-to-balloon time distribution for patients with STEMI (by admission)

NCVD ACS Registry, 2006 - 2008

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%

Reperfusion strategy for STEMI patients:

Mainly by fibrinolytic therapy (71%).

Primary Angioplasty constitute about 7%

ACS Care in Malaysia, based on NCVD Registry

GRACE Registry:• In-hospital Mortality rate for STEMI is 7%. ACTION Registry [US]:• In-hospital Mortality rate for STEMI is 4%.

• 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%.

What are we doing, knowing the state of affairs

with STEMI Care in Malaysia?

Sunday 12th April 2015

Relevant STEMI Care personnelTo discuss STEMI Network working

LUMEN GLOBALSAVING LIVES FROM AMI

Symposium On Optimal Treatment For Acute Myocardial Infarction

LUMEN Meeting 2016

Kuala Lumpur, 9 – 10 Jan 2016

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