Transcript Cardiovascular Care in Malaysia: Role of NCVD

Cardiovascular Care
in Malaysia:
Role of NCVD
Sunday 12th April 2015
2.10-2.30pm
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.
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?
Cardiovascular Disease in the Country?
Benchmark
Compare to – another person
- another centre
- another country
Cardiovascular Disease in the Country?
Are we doing enough?
Can we do better?
Cardiovascular Disease in the Country?
Data
Quality data
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
59
59
59
59
40 - <50
18%
19%
17%
18%
50 - <60
31%
31%
30%
31%
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%)
Age, years
Mean
Age group %
49%
Ethnic group
Mean age:
Global Registry of Acute coronary events (GRACE): 66 years,
Malaysian NCVD Registry: 59 years.
National Health and Morbidity Surveys
NHMS Malaysia
%
Overweight / Obesity
1996
21.1
2006
 43.1
2011
44.5
Smoking
24.8
21.5
23.1
-
20.7
35.1
Hypercholesterolaemia
Hypertension
20.7
 32.2
32.7
Diabetes
8.3
 14.9
15.2
NCVD-ACS Registry
2006
2007
2008
2009
2010
Total
(N=3392)
(N=3640)
(N=2839)
(N=3594)
(N=3401)
(N=16,866)
Dyslipidaemia
33
35
31
35
32
33
Hypertension
61
63
56
64
61
61
CV Risk factors
Diabetes
Family History of
premature CVD
MI history
Documented CAD
New onset angina
(< 2 weeks)
Chronic angina
(onset > 2 weeks ago)
Dyslipidaemia 33%
44
44
38
44
44
43
12
13
9
9
13
11
Hypertension
61%20
15
18
14
20
19
16
17
68
60
55
12
10
11
16
45
18
53
13
48
Diabetes
43%
11
8
15
26
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
Presence of cumulative risk factors (Percentage),
NCVD-ACS Registry, 2006-2010
> 3 risk
factors
20
47%
3 risk
factors
27
2 risk
factors
29
1 risk
factor
19
5
None
0
5
10
15
20
25
30
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
Most Effective Treatment:
Timely Reperfusion:
Before muscle
damage
- Thrombolytic therapy
becomes irreparable
- Angioplasty + stenting PPCI
and permanent
Thrombus
Atherosclerosis
Myocardial
Infarction
AMI
Reperfusion
Door-to-Needle
Time DTN
<30mins
Door-to-Balloon
Time DTB
<90mins
Management of Patients Presenting with STEMI
ECG
Cardiac
Biomarkers
Concomitant
initial Mx
Assessment for
Reperfusion
Onset of
Symptoms
Preferred
Option
Second Option
Subsequent Mx
Concomitant
Therapy
CHEST PAIN / EQUIVALENT
Continuous ECG monitoring
s/l GTN if no contraindication
Aspirin / Clopidogrel / Analgesic
Oxygen if SpO2 <95%
<3hrs
3-12 hrs
>12hr
s
PPCI** or
Fibrinolytic
Therapy
PPCI***
Medical
Therapy
Fibrinolytic
Consider PCI within 3-24
hrs of fibrinolytic
-pharmacoinvasive
Strategy
PPCI
PCI if ongoing
ischaemia or
haemodynamic
**Preferred option in:
instability
Antithrombotics
BB, ACE-I / ARB, Statins
+ Nitrates + Calcium antagonist
- high-risk features
- Contraindication to lytic therapy
- PCI time delay
(DBT-DNT) < 60mins
***if DBT is within 90mins
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.
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
PCI Centre Zwolle
Referral Center
Ambulance Transport
Identification of a STEMI
1.400.000
Ambulance nurse only, no physician
Immediate transfer to Cathlab
Rather than to nearest
Hosp/CCU/ER
SymptomAmbulance 91 min
Zwolle
Amsterdam
Distance Range: 2 - 95 km
AmbulanceAdmission 49 min
Door-Balloon
38 min
Total
178’
“Physician-less’ System of Prehospital STEMI
Diagnosis & Cath Lab Activation
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
STEMI Treatment Plan In Singapore
Routine
Call 995
99
5
Fax &
Transfer
Nearest
PCI
Centres
Singapore Regional Health Systems (RHS)
CH
NH
Polyclinics
Screening &
Prevention
Palliative
Care
RH
Home
Care
FPs
Rehab &
support
services
CH
NH
Polyclinics
Screening &
Prevention
CH
Screening &
Prevention
Palliative
Care
RH
Home
Care
FPs
CH
NH
Polyclinics
RH
Home
Care
FPs
Rehab &
support
services
Screening &
Prevention
NH
RH
NUHS
Home
Care
FPs
Palliative
Care
Home
Care
Rehab &
support
services
NH
RH
OUTRAM
Palliative
Care
Home
Care
FPs
Screening &
Prevention
Palliative
Care
RH
CH
Polyclinics
Polyclinics?
Screening &
Prevention
FPs
Rehab &
support
services
CH
NH
Polyclinics
Palliative
Care
Rehab &
support
services
Rehab &
support
services
27
Source: MOH, Dr Jennifer Lee presentation, 20090914
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-toBalloon 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
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%
Missing data 5%
Not
given
= 17%
Door-to-needle and Door-to-balloon time distribution
for patients with STEMI (by admission)
NCVD ACS Registry, 2006 - 2008
Door to needle time
(Recommended < 30 min)
2006
2007
2008
N
756
828
798
102 ± 142
91 ± 131
112 ± 194
2, 1349
1, 1435
1, 1440
Door to balloon time
(Recommended < 90 min)
2006
2007
2008
N
153
126
99
241 ± 295
215 ± 266
214 ± 260
35, 1440
25, 1410
11, 1195
Mean ± SD
Min, Max
Mean ± SD
Min, Max
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%
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%.
What are we doing,
knowing the state of affairs with
STEMI Care in Malaysia?
Sunday 12th April 2015
Relevant STEMI Care personnel
To discuss STEMI Network working
LUMEN GLOBAL
SAVING LIVES FROM AMI
Symposium On Optimal Treatment For Acute Myocardial
Infarction
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