1. National Cardiovascular Disease Database (NCVD) 2009 Update NHAM ASM 2009 17 April 2009 National Cardiovascular Disease Database (NCVD) ACS Registry PCI Registy 2009 Update NHAM ASM 2009 17 April 2009 Dr SIM Kui-Hian – Chair NCVD Board Dr Robaayah Zambahari – Chair NCVD Board Dr Jeyaindran Tan Sri Sinnadurai – Chair ACS Registry Dr Hj Azhari Rosman – Chair ACS Registry Dr Rosli Mohd Ali – Chair PCI Registry Dr Wan Azman – Chair Publication

2. Rationale – NCVD Registries Are the population & the patients groups in Malaysia similar to those being investigated in the clinical trials? Are our hospitals following the guidelines set out by the expert committees? Are we seeing the same results and benefits of implementing evidence-based strategies? Which strategy will be the best value in terms of cost-effectiveness for the Ministry of Health?

3. Objectives - NCVD ACS Registry Determine the number & the time trend of ACS in Malaysia Determine the socio-demographic profiles of these patients to better identify the high-risk group in our Malaysian population Determine the efficiency of, and adherence to current treatment guidelines Determine the cost to the nation by cardiovascular disease and the cost effectiveness of treatment and prevention programs Stimulate and facilitate research of cardiovascular disease using this database No more ‘guestimate’

4. Milestones - NCVD Registries 15 Oct 2005 Approval of MOH-MRG 9 Dec 2005 1 st NCVD – ACS Registry Steering Comm 1 st Jan 2006 eNCVD online data capturing NCVD piloted in 6 centres Expanded to nation wide – state government hospitals 31 st March 2006 Officially launched by Director General of Health Malaysia @ 10 th ASM, National Heart Association of Malaysia 14 April 20071 st Annual NCVD @ 11 th NHAM ASM 19 Dec 2007ACS Report Writing Committee 4 April 20082 nd Annual NCVD @ 12 th NHAM ASM 7 Dec 20061 st NCVD - PCI Registry Steering comm 3 April 20081 st NCVD – CABGs Registry Steering Comm

5. Organization of NCVD ACS registry Sponsor Governance Board Expert Panel NCVD Registry Office Source Data Providers Users group

6. Supporting Staff Clinical Registry ManagerMs S Gunavathy Selvaraj Clinical Registry AssociateMs Noor Amirah Muhamad Ms Hamimatunnisa Johar Clinical EpidemiologistDr Jamaiyah Haniff Ms S Gunavathy Selvaraj ICT ManagerMs Celine Tsai Pao Chien Database AdministratorMs Lim Jie Ying Application DeveloperMs Amy R. Porle Network AdministratorMr Kevin Ng Hong Heng Mr Adlan Ab. Rahman Webmaster & PublisherMs Azizah Alimat Clinical Data ManagerMs Teo Jau Shya Biostatistics ConsultantsDr Hoo Ling Ping Ms Norhafizah Bt. Ab. Manan

7. eNCVD – real time report Accessible – Anywhere & Anytime

8. Key of success COLLABORATION joint sacrifices of Ministry Of Health’s hospitals Ministry of Education’s (university) hospitals Private hospitals Ministry of Health Malaysia

10. 2006 73 CCU in Malaysia Incidence of ACS admission 47.1 per 100,000 population Incidence of coronary heart disease (CHD) 141 per 100,000 population Over 4000 ACS being denied admission into its CCU 30% shortfall in CCU beds

11. Provision of ACS services in Malaysia 2006 Female 76.3 Male 71.8 0.7% > 65yo Per Capita USD7,000

12. Provision of ACS services in Malaysia ACS admissions 37 CCUs in MOH hospitals 60% 3 university hospitals’ CCUs 10% private sector 27% economically developed states like Penang, Perak, Selangor/Wilayah Persekutuan have disproportionately large number of ACS admissions less developed states (Kedah/Perlis, Terengganu, Sabah and Sarawak) were underserved Patients in private hospitals are more likely to receive invasive coronary interventions (emergency angiogram, PCI and CABG)

13. 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

14. Age-gender distribution male pts with ACS by ethnic group, Malaysia 2006

15. Age-gender distribution for female pts with ACS by ethnic group, Malaysia 2006

16. Age group (years) distribution for pts with ACS by ACS stratum, Malaysia 2006

17. Gender, no. % (N=3422) Male 2569(75) Female 853 (25) ACS Gender distribution Malaysia 2006

18. ACS Ethnic group distribution Malaysia 2006

19. Overall outcomes for pts with ACS, Malaysia 2006 in-hospital 30 days NCVD-ACSGRACENCVD-ACS ACS stratum 7% STEMI 9% 7%11% NSTEMI 7% 6%8% UA 3% 3% 4%

20. Overall outcomes for pts with ACS, Malaysia 2006 in-hospital mortality 30-day mortality elderly age group 10% 13% Female patients 8% 10% male patients 6% 8% diabetes 7% 10% without diabetes 5% 6%

21. Overall outcomes for pts with STEMI ACS, Malaysia 2006 in-hospital mortality 30-day mortality use of fibrinolysis 7% 9% No fibrinolysis13% 16% PCI 8%11% No PCI9%11% Prognostic factors higher Killip class, higher TIMI risk score, former or current cigarette smoking, family history of premature cardiovascular disease, dyslipidaemia, hypertension and diabetes mellitus. Older age

22. Report: NCVD-ACS Registry Annual report year 2006 Freely downloadable online at http://www.acrm.org.my/ncvd/publications.htm http://www.acrm.org.my/ncvd/publications.htm

23. N C V D ACS Registry Interim Analysis @ 9 April 2009

24. Patient Demographics : ACS by Age group Age (years)200620072008 Age (Mean ± sd)59.12 ± 12.0758.97 ± 11.958.89 ± 11.98 Results as of 28 th October 2008

25. ACS Patients by Gender 200620072008 Gender (%)N=3533N=3857N=1714 Male74.6775.8675.09 Female25.3323.7224.33 Results as of 28 th October 2008, n=9,104

26. ACS Patients by Ethnicity Results as of 28 th October 2008, n=9,104

28. CV Risk factors Dyslipidaemia33.90 % Hypertension61.30 % Diabetes43.48 % Family History of CVD12.77 % MI history16.76 % Documented CAD15.15 % New onset angina (< 2 wks)13.23 % Chronic angina (>2 wks)47.73 % Chronic Lung Disease3.45 % Renal disease7.14 % Peripheral vascular disease0.87 % Cerebrovascular disease3.84 % Heart Failure7.77 % 2008 (n=6,516) 43 % 57 % 23 % 68% 7.2% 10.3% 8.3% 11% GRACE 32.42 % 57.69 % 40.56 % 11.16 % 16.68 % 16.21 % 48.08% 11.29% 3.26 % 6.40 % 0.75 % 3.42 % 6.46 % 2009 (n=10,846)

29. TIMI Risk Score NSTEMI/UA (n=5,427) Results as of 9 th April 2009, n= 10,864

30. Given at this centre 60.81 % Given at another centre prior to transfer 12.41 % Not given - proceeded directly to primary angioplasty 7.25 % Not given - Missed Thrombolysis 12.48 % Not given - patient refusal 0.17 % Not given - Contraindicated 4.21 % Not Applicable 2.67 % Fibrinolytic Therapy Status Baseline (n= 4,705) Results as of 9 th April 2009, n= 10,864

31. Door to needle time Year 200620072008 Door to needle time 98.9 + 140.55 88.42 + 130.02 86.87 + 129.18 (Mean + SD) Results as of 28 th October 2008, n=9,104

32. Pharmacological Therapy Drug used/given during admission (%) DrugPre- admission DuringAfter discharge ASA52.2685.9869.78 ADP Antagonist20.5060.5347.08 GP Receptor inhibitor0.522.90 Unfrac Heparin1.2911.36 LMWH9.7550.64 Beta Blocker24.5161.7352.40 ACE Inhibitor18.8753.5745.08 Angiotensin II receptor blocker 4.607.356.32 Statin30.0383.9769.31 Results as of 9 th April 2009, n= 10,864

33. Follow Up at 30 days & 12 months Outcome Alive85.39% Death3.45 % Lost to FU8.98 % Transferred0.58 % Missing1.6 % 84.53 % 2.31 % 10.58 % 0.18 % 2.4 % Cause of death CVD55.31 % Non CVD10.62 % Others13.27 % Missing20.80 % 47.44 % 8.97 % 21.79 % 21.80 % 30days (n= 6,550) 1year (n= 3,374) n= 226n= 78

34. Cardiovascular readmission ACS STEMI NSTEMI UA Missing 3.89 % 14.51 % 14.90 % 53.73 % 16.86 % Heart Failure 0.49 % Revascularization 5.15 % PCI87.54 % CABG9.79 % Stroke 0.11 % 2.07 % 12.86 % 7.14 % 61.43 % 11.43 % 0.53% 3.11% 78.09 % 15.24 % 0.06 % 30days (n= 6,550) 1year (n= 3,374)

35. Outcome at Discharge Results as of 28 th October 2008, n=9,104

36. N C V D PCI Registry Interim Analysis @ 9 April 2009

37. Total PCI = 6,441 as of 30 th October 2008 Age (years)20072008 Age (Mean ± sd)56.7 ±10.156.72 ± 10.08 Patient Demographics : PCI by Age Group

38. PCI by Gender Gender (%) 20072008 N= 3,952N=2,482 Male81.2882.72 Female18.5517.16 Total PCI = 6,441 as of 30 th October 2008

39. Ethnicity (%) 20072008 N= 3,952N=2,482 Malay46.3847.34 Chinese25.5625.10 Indian23.5821.15 Other Malaysia3.985.52 PCI by Ethnicity Other Malaysian includes Punjabi, Iban, Kadazan Dusun, Melanau, Bidayuh, Other Sabahan and Other Sarawakian Total PCI = 6,441 as of 30 th October 2008

40. PCI Status by year Total PCI = 6,441 as of 30 th October 2008

41. Stent Used 20072008 Other stents refer to stents other than listed in the Reference Stent List Total Stent, n =10,152 as of 10 th of October 2008

42. Aspirin92.20 % Clopidogrel93.14 % Ticlopidine5.62 % Statin90.18 % Beta blocker71.01 % ACE inhibitor53.64 % ARB13.65 % Warfarin1.10 % Others68.71 % Medications at discharge Baseline (n=8,236) Total PCI = 8,236 as of 9 th April 2009

43. Outcome at Discharge of Notification Outcome (%) 20072008 N=3,952N=2,482 Alive3791 (95.93)2440 (98.31) Transferred2 (0.05)0 (0) Died38 (0.96)24(0.97) Missing121 (3.07)18 (0.72) Total PCI = 6,441 as of 30 th October 2008

44. 20072008 N=1,429N=1429N=428N=917N=107 Outcome (No., %) 30 Days FU6 Months FU1 Year FU30 Days FU6 Months FU1 Year Fu Discharged 1364 (95.45) 653 (96.03) 411 (96.03) 900 (98.15) 106 (99.07) N/A Transferred 1 (0.07) 0 (0) 0 (0) 2 (0.22) 0 (0) N/A Died 9 (0.63) 7 (1.03) 2 (0.47) 4 (0.44) 1 (0.93) N/A Lost to FU 55 (3.85) 20 (2.94) 15 (3.50) 11 (1.20) N/A Outcome at Follow up

45. NCVD Registries Population Public Health Disease Burden/ Risk Factors Hospital ACS/PCI/CABG Communities Rehabilitation My NCDsNCVD ACS Registry PCI Registry CABGs Registry Implantable devices Heart Failure

46. European Society of Cardiology

47. American College of Cardiology

48. www.crc.gov.my www.acrm.org.my/ncvd

49. Ta & G’day Acknowledgement Clinical Research Centre, HKL Datamed Computing Services Sdn. Bhd. ClinResearch Sdn. Bhd. National Heart Association of Malaysia Ministry of Health Malasyaia Participating centres – Nurses, Doctors