ncvd-acs registry

NCVD-ACS REGISTRY

Annual Report of the Acute Coronary Syndrome (ACS) Registry, Malaysia 2006

NCVD-ACS Registry: Annual Report2006Published by: Clinical Research Centre, Ministry of Health Malaysia

Suggested citation:W.A. Wan Ahmad. K.H. Sim (Eds.). Annual Report of the NCVD-ACS Registry 2006. Kuala Lumpur. 2008


Chapter 1: Provision of Acute Coronary Care

Services in Malaysia


• In 2006, there are 73 coronary care units (CCU) in Malaysia

• The incidence of ACS admission was therefore 47.1 per 100,000 population in 2006

• The estimate of the incidence of coronary heart disease (CHD) in Malaysia is 141 per 100,000 population

• Over 4000 ACS being denied admission into its CCU in 2006. It has 30% shortfall in CCU beds


CCU CardiologistCCU

nursesCath. Lab

Cardiac surgical service

ACS admission

N(%) N(%) N(%) N(%) N(%) N(%)

Malaysia 73(100) 163(100) 559(100) 36(100) 27(100) 12,534(100)

By Sector

Private 32(44) 81(50) 176(31) 28(78) 20(74) 3,398(27)

MOH 37(51) 37(23) 305(55) 4(11) 4(15) 7,580(60)

IJN 1(1) 27(17) 13(2) 1(3) 1(4) 335(3)

University 3(4) 17(10) 65(12) 3(8) 2(7) 1,221(10)

Acute Coronary/ Cardiac Care Services and Admissions in Malaysia 2006


Current CCU beds

Bed occupanc

y rate

Use forall acute

Use for ACS

Use fornon

cardiac

ACS denied

*RBS if non cardiac

excluded

N(%) % % % %% of all

ACS(% shortfall)

Malaysia 414(100) 89 65 40 35

Sectors

Private 214(52) 83 51 27 49 48 132

MOH 169(41) 93 77 49 23 62 89

IJN 12(3) 83 36 26 64 53 171

University 19(5) 104 76 58 24 14 119

Utilization of Acute Coronary / Cardiac Services in Malaysia 2006

*RBS – Required bed strength


Utilization of Acute Coronary / Cardiac Services by Sectors in Malaysia 2006

52

41

3 5

83

93

83

104

27

49

26

58

48

6253

14

132

89

171

119

0

20

40

60

80

100

120

140

160

180

Private MOH IJN UniversitySDP

Per

cen

tag

e (%

)

Current bed Bed occup. rateUse for ACS ACS deniedRBS if non cardiac excluded

*RBS – Required bed strength


Cardiac Care provided for ACS in Malaysia 2006

ACS admits

Thrombolytic

Angiogram

PCI CABG

% % % % %

Malaysia 100 38 33 20 7

Sector

Private 27 25 64 43 16

MOH 60 44 19 11 3

IJN 3 59 77 40 12

University 10 30 27 11 2


050

100

150

200

250

PCI pmp

010

020

030

040

0

Coronary Angiogram pmp

0 2 4 6 8 10 12 14 16 18 20

Cardiologist pmp

Coronary Angiogram pmp PCI pmp

Distribution of Cardiologist per million populations (pmp) by state

Relationship between availability of cardiologist and provision of emergency Coronary angiogram and Percutaneous Coronary Intervention (PCI) for patients admitted with ACS

in Malaysia 2006


Sample Size = 3422 patientsregistered in year 2006


SGH

SAH

PH

*NHI*UMMC*KLH

NCVD-ACS Registry Participating Sites in 2006

RPZ II HTFH SBH

TJH

TAAH

TFH Tuanku Fauziah Hospital

SBH Sultanah Bahiyah Hospital

PH Penang Hospital

NHI National Heart Institute

UMMC University Malaya Medical Centre

KLH Kuala Lumpur Hospital

TJH Tuanku Ja’afar Hospital

SAH Sultanah Aminah Hospital

RPZ II H Raja Perempuan Zainab II Hospital

TAAH Tengku Ampuan Afzan Hospital

SGH Sarawak General Hospital

Chapter 2: Patient Characteristics


Age group, no. % (N = 3422)

20 - <30 23 (1)

30 - <40 143 (4)

40 - <50 621 (18)

50 - <60 1054 (31)

60 - <70 881 (26)

70 - <80 571 (17)

80 129 (4)

Age Group for patient with ACS, Malaysia 2006


Age Group for patient with ACS, Malaysia 2006

14

18

31

26

17

4

0

5

10

15

20

25

30

35 20 - <3030 - <4040 - <5050 - <6060 - <7070 - <80>80

Age Group

% o

f p

atie

nts


Gender, no. % (N=3422)

Male 2569(75)

Female 853 (25)

Gender distribution for patients with ACS, Malaysia 2006

75%

25%

MaleFemale


Ethnic group distribution for patients with ACS,

Malaysia 2006 Ethnic group, no. % (N= 3422)

Malay 1684 (49)

Chinese 786 (23)

Indian 799 (23)

Orang Asli 0 (0)

Kadazan 2 (0)

Melanau 0 (0)

Murut 0 (0)

Bajau 1 (0)

Bidayuh 28 (1)

Iban 48 (1)

Other Malaysian 37 (1)

Foreigner 37 (1)


49.2

23.0 23.3

1.4 1.1 1.1 0.8 0.1 0.0 0.0 0.0 0.00

10

20

30

40

50

60

Malay

ChineseIndian

Iban

Other Malaysia

n

Foreigner

Bidayuh

Kadazan

MelanauMurut

Bajau

Orang Asli

Ethnicity

% o

f pa

tien

tsEthnic group distribution for patients with ACS, Malaysia

2006


Other Coronary Risk Factors (N=4332) %

Smoking 40

Family history of premature cardiovascular disease 12

BMI > 23kgm-2

Mean, SD75

25.8 (4.4)

Other Coronary Risk Factors for patients with ACS, Malaysia 2006


Other Coronary Risk Factors for patients with ACS, Malaysia 2006

40

12

75

0

10

20

30

40

50

60

70

80

% o

f p

atie

nts

Smoking Family history ofpremature cardiovascular

disease

BMI > 23kgm-2

Risk Factors


Co-morbidities (N=3422) %

Dyslipidaemia 33

Hypertension 61

Diabetes 44

Myocardial infarction history 16

Documented CAD > 50% stenosis 15

Chronic angina (onset>2 weeks ago) 15

New onset angina <2 weeks) 45

Coronary artery disease* 64

*Coronary artery disease is defined as “Yes” on any of the following co-morbidities: 1) History of myocardial infarction, 2) Documented CAD >50% stenosis, 3) Chronic angina (onset more than 2 weeks ago), 4) New onset angina (less than 2 weeks).

Note: Percentage is to the nearest decimal point.

Co-morbidities of patients with ACS,

Malaysia 2006


Co-morbidities for Patients with ACS, Malaysia 2006 (N=3422)

33

61

44

16 15 15

45

64

0

10

20

30

40

50

60

70

Dyslipidaemia Hypertension Diabetes Myocardialinfarction

history

DocumentedCAD > 50%

stenosis

Chronicangina

(onset>2weeks ago)

New onsetangina <2weeks)

Coronaryartery

disease*

Co-morbidity for Patients with ACS

% o

f P

atie

nts


Age group Male Female

20 - <30 1 0

30 - <40 5 1

40 - <50 21 9

50 - <60 35 19

60 - <70 24 31

70 - <80 12 31

80 3 8

Age-gender distribution for patients with ACS,

Malaysia 2006


Age-gender Distribution for Patients with ACS, Malaysia 2006

15

21

35

24

12

30 1

9

19

31 31

8

0

5

10

15

20

25

30

35

40

20 - <30 30 - <40 40 - <50 50 - <60 60 - <70 70 - <80 ³80

Age Group (Years)

% o

f pa

tien

ts

Male

Female


Chapter 3: Clinical Presentation and Investigation


Cardiac Presentations of Patients with ACS

by ACS Stratum, Malaysia 2006 STEMI NSTEMI UA

N=1445 N=1132 N=845

Systolic blood pressure, mmHg

N 1428 1116 836

Mean, SD 134 (28) 145 (30) 146 (28)

Median, (min, max) 130 (60, 230) 142 (66, 230) 142 (60, 224)

Diastolic blood pressure, mmHg

N 1402 1087 823

Mean, SD 80 (17) 82 (17) 82 (15)

Median, (min, max) 80 (26, 120) 82 (19, 120) 82 (34, 120)

Heart rate at presentation, beats/min

N 1434 1122 838

Mean, SD 82 (21) 86 (23) 81 (19)

Median, (min, max) 80 (30, 180) 84 (29, 180) 79 (40, 166)


Kilip Classification Code for Patients with ACS by ACS Stratum, Malaysia 2006

16

5

4

20

56

29

3

7

18

43

42

0

2

12

45

0 10 20 30 40 50 60

IV

III

II

I

% o

f pat

ient

s

Kilip Classification Code

UA

NSTEMI

STEMI

Not Stated/ Inadequately

described

Cardiac Presentations of Patients with ACS by ACS Stratum, Malaysia 2006


STEMI (N=1445) NSTEMI (N=1132)Patients with any cardiac marker done, no. % 1402 (97) 1114 (98)Peak CK-MB, Unit/L, no. % 801 874

>25 681 (85) 457 (52)Peak CK, Unit/L, no. % 1325 970

>2x reference upper limits 999 (75) 364 (38)Peak TnT, no. % 183 446

Positive or >0.01 181 (99) 436 (98)Peak TnI, no. % 58 167

Positive or > reference upper limit/0.04 54 (93) 156 (93)

Cardiac Biomarkers Done for Patients with

ACS by ACS Stratum, Malaysia 2006


* The denominators are based on STEMI, N=1445 and NSTEMI, N= 1132.

Cardiac Markers Done for ACS Patients by ACS Stratum*, Malaysia 2006

8575

99 93

5238

98 93

0

20

40

60

80

100

120

Peak CK-MB Peak CK Peak T n T Peak T n I

Cardiac Markers Done

% o

f p

atie

nts

STEMI

NSTEMI


Acute coronary syndrome

stratum, no. %

Age group* Young Middle-

ageElderly

N=166 N=1675 N=1581

STEMI 113 (68) 803 (48) 529 (33)NSTEMI 28 (17) 469 (28) 635 (40)

UA 25 (15) 403 (24) 417 (26)

ACS Stratum for Patients with ACS by Age Group,

Malaysia 2006

*Young is defined as age from 20 to less than 40 years, middle-age is defined as age between 40 to less than 60 years and elderly is defined as 60 years and above



ACS Stratum of patients with ACS by age group, Malaysia 2006

68

48

33

17

28

40

15

24 26

0

10

20

30

40

50

60

70

80

Young Middle-age Elderly

Age Group (Years)

% o

f pati

ents

STEMI

NSTEMI

UA


Cardiac presentation of patients with ACS by gender, Malaysia 2006

Acute Coronary Syndrome Stratum,No. (%)

Male Female

N=2569 N=853

STEMI1230 (48) 215 (25)

NSTEMI779 (30) 353 (41)

UA560 (22) 285 (33)


ACS Stratum by gender, Malaysia 2006

48

30

2225

33

41

0

10

20

30

40

50

60

STEMI NSTEMI UA

ACS Stratum

% o

f p

atie

nts

Male

Female


Chapter 4:

Treatment


Summary of treatments for patients with ACS by ACS stratum, Malaysia 2006

No. (%) STEMI NSTEMI UA

N=1445 N=1132 N=845

Total admission days* N 1420 1104 830Mean, SD 6 (3) 6 (4) 5 (4)Median, (min, max) 5 (1,28) 5 (1,30) 4 (1,29)

Number of days on CCU N 1093 450 140Mean, SD 3 (3) 4 (3) 3 (3)Median, (min, max) 3 (1,26) 3 (1,24) 2 (1,20)


Fibrinolytic Therapy for ACS Patients with STEMI, Malaysia 2006

Fibrinolytic therapy for STEMI (N=1445) No . (%)Given 1018 (70)Not given 427 (30)

30 %

70 %

GivenNot given


Reasons Fibrinolytic Therapy Not Given to ACS Patients (N=1445) No. (%)Proceeded directly to primary angioplasty

117 (8)Contraindicated 70 (5)Missed thrombolysis 193 (13)Others* 47 (3)

*Not given–Others includes missing and refusalNote: Percentage is to the nearest decimal point.

Reasons Fibrinolytic Therapy Not Given to Patients with STEMI, Malaysia 2006


*Not given–Others includes missing and refusalNote: Percentage is to the nearest decimal point.

Reasons not given Fibrinolytic Therapy for ACS Patients with STEMI, Malaysia 2006

0.0

10.0

20.0

30.0

40.0

50.0

Proceeded directly toprimary angioplasty

Contraindicated Missed thrombolysis Others*

Reasons

Per

cent

age

(%)


Cardiac catheterization, no. % STEMI

(N=1445)NSTEMI (N=1132)

UA (N=845)

Yes298 (21) 251 (22) 106 (13)

No1106 (77) 858 (76) 727 (86)

Transferred to another centre 39 (3) 23 (2) 12 (1)

Cardiac Catheterization for Patients with ACS by ACS Stratum, Malaysia 2006


Cardiac Catheterization for Patients with ACS by ACS Stratum, Malaysia 2006

22

13

77 76

86

3 2 1

21

0

10

20

30

40

50

60

70

80

90

100

STEMI (N=1445) NSTEMI (N=1132) UA (N=845)

ACS Stratum

Per

cen

tage

(%

)

Yes

No

Transferred toanother centre


Percutaneous coronary intervention, no. % STEMI

(N=1445)NSTEMI (N=1132) UA (N=845)

Yes308 (21) 162 (14) 80 (9)

No1137 (79) 970 (86) 765 (91)

Percutaneous Coronary Intervention, for Patients with ACS by ACS Stratum, Malaysia 2006


Percutaneous Coronary Intervention, for Patients with ACS by ACS Stratum, Malaysia 2006

2114

9

7986

91

0

10

20

30

40

50

60

70

80

90

100

STEMI NSTEMI UA

AC S S tratum

% o

f pati

ents

YesNo


CABG, no. % STEMI (N=1445)

NSTEMI (N=1132)

UA (N=845)

Yes 10 (1) 42 (4) 15 (2)No

1435 (99) 1090 (96) 830 (98)

CABG for Patients with ACS by ACS Stratum,

Malaysia 2006


Chapter 5:

Outcomes


Overall outcomeOutcome In-hospital 30-day* No. % No. %Discharged / Alive 3186 93 2302 67Died 229 7 288 8Lost to follow-up NA NA 832 24Missing 7 0 0 0

*Including patients who died in-hospitalNote: Percentage is to the nearest decimal point.

Overall Outcomes for Patients with ACS, Malaysia 2006


Overall In-hospital and 30-day Outcomes for Patients with ACS, Malaysia 2006

93

7

67

8

24

0

10

20

30

40

50

60

70

80

90

100

Discharged / Alive Died Lost to follow-up

Outcome

% o

f p

atie

nts

In-hospital30-day


Outcome In-hospital 30-day*STEMI NSTEMI UA STEMI NSTEMI UA

No. % No. % No. % No. % No. % No. %Discharged /Alive 1312 91

1056 93 818 97 939 65 796 70 567 67

Died 129 9 75 7 25 3 158 11 92 8 38 4Lost to follow-up NA NA NA NA NA NA 348 24 244 22 240 28Missing 4 0 1 0 2 0 0 0 0 0 0 0

•*Including patients who died in-hospital.Note: Percentage is to the nearest decimal point.

Overall outcomes for patients with ACS by ACS stratum, Malaysia 2006


Overall In-Hospital Outcomes for Patients with ACS by ACS Stratum,

Malaysia 2006

91

90

703 0

93 97

0

20

40

60

80

100

120

Discharged /Alive

Died Lost to follow-up

Missing

Outcome

Per

cen

tag

e (%

)

STEMI

NSTEMI

UA


Overall Outcome after 30 Days Follow Up for Patients with ACS by ACS Stratum, Malaysia 2006

65

11

24

0

70

8

22

0

67

4

28

00

10

20

30

40

50

60

70

80

Discharged / Alive Died Lost to follow-up Missing

Outcome

Perc

enta

ge (%

)

STEMI

NSTEMI

UA


Overall outcomes for patients with STEMI by fibrinolytic therapy, Malaysia 2006

Outcome In-hospital 30-day*Fibrinolytic therapy Fibrinolytic therapyYes No Yes No

No. % No. % No. % No. %Discharged / Alive 940 92 372 87 686 67 253 59Died 74 7 55 13 90 9 68 16Lost to follow-up NA NA NA NA 242 24 106 25Missing 4 0 0 0 0 0 0 0

*Including patients who died in-hospital.Note: Percentage is to the nearest decimal point.


In-hospital Outcomes for Patients with ACS with STEMI by Fibrinolytic Therapy, Malaysia 2006

92

70

87

13

00

10

20

30

40

50

60

70

80

90

100

Discharged /Alive


Missing

Outcome

Per

cen

tag

e (%

)

Yes

No


Outcomes at 30 Days Follow up for Patients with ACS with STEMI by Fibrinolytic Therapy,

Malaysia 2006

67

9

24

0

59

16

25

00

10

20

30

40

50

60

70

80

Discharged /Alive


Missing

Outcome

Percen

tag

e (

%)

Yes

No


Overall outcomes for patients with STEMI by Percutaneous Coronary Intervention, Malaysia 2006

Outcome In-hospital 30-day*

Percutaneous coronary intervention Percutaneous coronary intervention

Yes No Yes No

No. % No. % No. % No. %

Discharged / Alive 283 92 1029 91 242 79 697 61Died 25 8 104 9 34 11 124 11Lost to follow-up NA NA NA NA 32 10 316 28Missing 0 0 4 0 0 0 0 0

*Including patients who died in-hospital.Notes: 1. Percentage is to the nearest decimal point.2. Percutaneous Coronary Intervention includes primary, rescue and facilitated intervention


In-hospital Outcomes for Patients with STEMI by Percutaneous Coronary Intervention at admission,

Malaysia 200692

80

91

90

0102030405060708090

100


In-hospital Outcomes for STEMI Patients

% o

f P

atie

nts

Yes

No


30-Day Outcomes for Patients with STEMI by Percutaneous Coronary Intervention at admission, Malaysia 2006

79

11 10

0

61

11

28

00

10

20

30

40

50

60

70

80

90


30-Day Outcomes for STEMI Patients

% o

f P

atie

nts

Yes

No


CABG, no. % STEMI (N=1445)

NSTEMI (N=1132)

UA

(N=845)

Yes 10 (1) 42 (4) 15 (2)

No 1435 (99) 1090 (96) 830 (98)

CABG for Patients with ACS by ACS Stratum,

Malaysia 2006


CABG for Patients with ACS by ACS Stratum, Malaysia 2006

14 2

9996 98

0

20

40

60

80

100

120

STEMI NSTEMI UA

ACS Stratum

% o

f p

atie

nts

Yes

No


Overall outcomes for patients with STEMI by pre-admission aspirin use, Malaysia 2006


Pre-admission aspirin use Pre-admission aspirin use

Yes No Unknown Yes No Unknown

No. % No. % No. % No. % No. % No. %

Discharged / Alive 200 88 885 92 227 90 128 56 660 68 151 60Died

27 12 76 8 26 10 33 15 95 10 30 12Lost to follow-up NA NA NA NA NA NA 66 29 210 22 72 28Missing

0 0 4 0 0 0 0 0 0 0 0 0

*Including patients who died in-hospital.



In-hospital Outcomes for Patient with STEMI by pre-admission Aspirin Use, Malaysia 2006

88

12

0

92

8

0

90

10

00

10

20

30

40

50

60

70

80

90

100


In-hospital Outcomes for STEMI Patients

% o

f P

atie

nts

Yes

No

Unknown


30-day Outcomes for Patients with STEMI by pre-admission Aspirin Use, Malaysia 2006

56

15

29

0

68

10

22

0

60

12

28

00

10

20

30

40

50

60

70

80


30-day Outcomes for STEMI Patients

% o

f P

atie

nts

Yes

No

Unknown


Overall outcomes for patients with NSTEMI/UA by Percutaneous Coronary Intervention, Malaysia 2006


Percutaneous coronary intervention Percutaneous coronary intervention

Yes No Yes No

No. % No. % No. % No. %

Discharged / Alive 233 96 1641 95 207 86 1156 67Died 9 4 91 5 12 5 118 7Lost to follow-up

NA NA NA NA 23 10 461 27Missing 0 0 3 0 0 0 0 0




Overall Outcomes for Patients with NSTEMI/UA by Percutaneous Coronary Intervention, Malaysia 2006

96

4 0

95

50

0

20

40

60

80

100

120


In-hospital Outcomes for NSTEMI/UA Patients

% o

f P

atie

nts

Yes

No


30-day Outcomes for Patients with NSTEMI/UA by Percutaneous Coronary Intervention, Malaysia 2006

86

510

0

67

7

27

00

20

40

60

80

100


30-day Outcomes for NSTEMI/UA Patients

% o

f P

atie

nts

Yes

No


Overall outcomes for patients with NSTEMI/UA by CABG, Malaysia 2006


CABG CABG

Yes No Yes No

No. % No. % No. % No. %

Discharged / Alive

49 86 1825 95 47 82 1316 69Died 8 14 92 5 8 14 122 6Lost to follow-up

NA NA NA NA 2 4 482 25Missing 0 0 3 0 0 0 0 0




In-hospital Outcomes for Patients with NSTEMI/UA by CABG, Malaysia 2006

86

140

95

5 00

20

40

60

80

100


In-hospital Outcomes for NSTEMI/UA Patients

% o

f P

atie

nts

Yes

No


30-day Outcomes for Patients with NSTEMI/UA by CABG, Malaysia 2006

82

14

40

69

6

25

00

10

20

30

40

50

60

70

80

90


30-day Outcomes for NSTEMI/UA Patients

% o

f P

atie

nts

Yes

No


The full report is available for download at

www.acrm.org.my/ncvd

http://www.acrm.org.my/ncvd

ncvd-acs registry

Documents

coronary care units

malaysiaannual report

cardiac excludedsdppercentage

cardiac excludedn

ccu bedsannual report

bed strengthannual report

acsacs deniedrbs

annual report2006published