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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