national cardiovascular disease database (ncvd) 2009 update nham asm 2009 17 april 2009 national...
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National Cardiovascular Disease Database National Cardiovascular Disease Database ((NCVDNCVD)) ACS Registry PCI Registy
2009 Update 2009 Update
NHAM ASM 2009NHAM ASM 200917 April 200917 April 2009
Dr SIM Kui-Hian – Chair NCVD Board Dr Robaayah Zambahari – Chair NCVD Board
Dr Jeyaindran Tan Sri Sinnadurai – Chair ACS RegistryDr Hj Azhari Rosman – Chair ACS Registry
Dr Rosli Mohd Ali – Chair PCI Registry
Dr Wan Azman – Chair Publication
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?
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’
Milestones - NCVD Registries 15 Oct 2005 Approval of MOH-MRG
9 Dec 2005 1st NCVD – ACS Registry Steering Comm
1st Jan 2006 eNCVD online data capturing
NCVD piloted in 6 centres
Expanded to nation wide – state government hospitals
31st March 2006 Officially launched by Director General of Health Malaysia
@ 10th ASM, National Heart Association of Malaysia
14 April 2007 1st Annual NCVD @ 11th NHAM ASM
19 Dec 2007 ACS Report Writing Committee
4 April 2008 2nd Annual NCVD @ 12th NHAM ASM
7 Dec 2006 1st NCVD - PCI Registry Steering comm
3 April 2008 1st NCVD – CABGs Registry Steering Comm
Organization of NCVD ACS registry
Sponsor
Governance Board
Expert Panel
NCVD Registry Office
Source Data Providers
Users group
Supporting Staff
Clinical Registry Manager Ms S Gunavathy Selvaraj Clinical Registry Associate Ms Noor Amirah Muhamad
Ms Hamimatunnisa Johar Clinical Epidemiologist Dr Jamaiyah Haniff
Ms S Gunavathy Selvaraj ICT Manager Ms Celine Tsai Pao Chien Database AdministratorMs Lim Jie Ying Application Developer Ms Amy R. Porle Network Administrator Mr Kevin Ng Hong Heng
Mr Adlan Ab. Rahman Webmaster & Publisher Ms Azizah Alimat Clinical Data Manager Ms Teo Jau Shya Biostatistics Consultants Dr Hoo Ling Ping
Ms Norhafizah Bt. Ab. Manan
eNCVD – real time report
Accessible – Anywhere & Anytime
Key of success
COLLABORATION
joint sacrifices of
Ministry Of Health’s hospitals
Ministry of Education’s (university) hospitals
Private hospitals
Ministry of Health Malaysia
• 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
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)
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-gender distribution male pts with ACS by ethnic group, Malaysia 2006
% o
f pa
tient
s
Male patients
0
10
20
30
40
Malay Chinese Indian Others*
20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 >=80
Age-gender distribution for female pts with ACS by ethnic group, Malaysia
2006 N
o. o
f pa
tient
s
Female Patients
0
30
60
90
120
150
Malay Chinese Indian Others*
20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 >=80
Age group (years) distribution for pts with ACS by ACS stratum, Malaysia 2006
% o
f pa
tien
ts
Age group0
10
20
30
STEMI NSTEMI UA
20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 >=80
Gender, no. % (N=3422)
Male 2569(75)
Female 853 (25)
ACS Gender distribution Malaysia 2006
75%
25%
MaleFemale
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
tsACS Ethnic group distribution
Malaysia 2006
Overall outcomes for pts with ACS, Malaysia 2006
in-hospital 30 days
NCVD-ACS GRACE NCVD-ACS
ACS stratum 7%
STEMI 9% 7% 11%
NSTEMI 7% 6% 8%
UA 3% 3% 4%
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%
Overall outcomes for pts with STEMI ACS, Malaysia 2006
in-hospital mortality 30-day
mortality
use of fibrinolysis 7% 9%
No fibrinolysis 13% 16%
PCI 8% 11%
No PCI 9% 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
Report:NCVD-ACS Registry Annual report year 2006
Freely downloadable online at http://www.acrm.org.my/ncvd/publications.htm
N C V DACS Registry
Interim Analysis@ 9 April 2009
Patient Demographics : ACS by Age group
Age (years) 2006 2007 2008
Age (Mean ± sd) 59.12 ± 12.07 58.97 ± 11.9 58.89 ± 11.98
Results as of 28th October 2008
17.96
27.01
3.53
0.480.71
3.89
16.6
29.77
26.63
3.99
17.37
0.44
4.18
17.1
29.75
5.00
17.14
29.46
26.85
17.08
3.93
0
5
10
15
20
25
30
35
20 - <30 30 - <40 40 - <50 50 - <60 60 - <70 70 - <80 >80
Age Group (Years)
% o
f p
atie
nts
2006
2007
2008
ACS Patients by Gender
2006 2007 2008
Gender (%) N=3533 N=3857 N=1714
Male 74.67 75.86 75.09
Female 25.33 23.72 24.33
Results as of 28th October 2008, n=9,104
3.43
46.51
4.45
23.35
49.08
22.98
4.43
22.8223.07
43.7
24.2724.62
0
10
20
30
40
50
60
Malay Chinese Indian Other Malaysia
Ethnicity
Pe
rce
nta
ge
(%
) o
f P
ati
en
ts 2006
2007
2008
ACS Patients by Ethnicity
Results as of 28th October 2008, n=9,104
AC S s tratum by year
41.21
26.13
0.28
20.92
30.57
5.06
15.05
25.38
32.68
43.4542.18
17.39
0
5
10
15
20
25
30
35
40
45
50
S TE MI NS TE MI UA Missing
AC S s tratum
Per
cent
age
(%)
2006 2007 2008
Results as of 28th October 2008, n=9,104
CV Risk factors
Dyslipidaemia 33.90 %
Hypertension 61.30 %
Diabetes 43.48 %
Family History of CVD 12.77 %
MI history 16.76 %
Documented CAD 15.15 %
New onset angina (< 2 wks) 13.23 %
Chronic angina (>2 wks) 47.73 %
Chronic Lung Disease 3.45 %
Renal disease 7.14 %
Peripheral vascular disease 0.87 %
Cerebrovascular disease 3.84 %
Heart Failure 7.77 %
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)
TIMI Risk Score NSTEMI/UA (n=5,427)
11.72
17.36
25.7623.55
1.290.17
14.09
6.06
0
5
10
15
20
25
30
0 1 2 3 4 5 6 7
TIMI Risk Score
Per
cen
tag
e (%
)
Results as of 9th April 2009, n= 10,864
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 9th April 2009, n= 10,864
Door to needle time
Year
2006 2007 2008
Door to needle time 98.9 +
140.5588.42 + 130.02
86.87 + 129.18
(Mean + SD)
Results as of 28th October 2008, n=9,104
Pharmacological Therapy
Drug used/given during admission (%)
Drug Pre-admission
During After discharge
ASA 52.26 85.98 69.78
ADP Antagonist 20.50 60.53 47.08
GP Receptor inhibitor 0.52 2.90
Unfrac Heparin 1.29 11.36
LMWH 9.75 50.64
Beta Blocker 24.51 61.73 52.40
ACE Inhibitor 18.87 53.57 45.08
Angiotensin II receptor blocker
4.60 7.35 6.32
Statin 30.03 83.97 69.31
Results as of 9th April 2009, n= 10,864
Follow Up at 30 days & 12 months
Outcome
Alive 85.39%
Death 3.45 %
Lost to FU 8.98 %
Transferred 0.58 %
Missing 1.6 %
84.53 %
2.31 %
10.58 %
0.18 %
2.4 %
Cause of death
CVD 55.31 %
Non CVD 10.62 %
Others 13.27 %
Missing 20.80 %
47.44 %
8.97 %
21.79 %
21.80 %
30days (n= 6,550) 1year (n= 3,374)
n= 226 n= 78
Cardiovascular readmission
ACS STEMI NSTEMI UA Missing
3.89 %14.51 %14.90 %53.73 %16.86 %
Heart Failure 0.49 %
Revascularization 5.15 %
PCI 87.54 %
CABG 9.79 %
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)
Outcome at Discharge
Results as of 28th October 2008, n=9,104
0.233.33
6.711.19
91.85
0.181.717.57
85.12
14.99
6.65
74.80
0
10
20
30
40
50
60
70
80
90
100
D is charged T rans ferred D ied Mis s ingOutc ome
Per
cen
tag
e(%
) of p
atien
ts
2006
2007
2008
N C V DPCI Registry
Interim Analysis@ 9 April 2009
Total PCI = 6,441 as of 30th October 2008
Age (years) 2007 2008
Age (Mean ± sd) 56.7 ±10.1 56.72 ± 10.08
Patient Demographics : PCI by Age Group
28.06
0.810.12
4.15
20.15
36.97
19.51
3.90.5
10.22
27.19
36.14
0.73
11.12
0
5
10
15
20
25
30
35
40
20 - <30 30 - <40 40 - <50 50 - <60 60 - <70 70 - <80 >80
Age Group (years)
% o
f p
ati
en
ts
2007 2008
PCI by Gender
Gender (%) 2007 2008
N= 3,952 N=2,482
Male 81.28 82.72
Female 18.55 17.16
Total PCI = 6,441 as of 30th October 2008
Ethnicity (%) 2007 2008
N= 3,952 N=2,482
Malay 46.38 47.34
Chinese 25.56 25.10
Indian 23.58 21.15
Other Malaysia 3.98 5.52
PCI by Ethnicity
Other Malaysian includes Punjabi, Iban, Kadazan Dusun, Melanau, Bidayuh, Other Sabahan and Other Sarawakian
Total PCI = 6,441 as of 30th October 2008
89.4
4.78 1.92 2.052.784.31 1.49
91.98
0
10
20
30
40
50
60
70
80
90
100
Elective Urgent Rescue Primary
PCI Status
Per
cen
tag
e (%
) o
f p
atie
nts
2007
2008
PCI Status by year
Total PCI = 6,441 as of 30th October 2008
Stent Used
2007 2008
Other stents refer to stents other than listed in the Reference Stent List
Total Stent, n =10,152 as of 10th of October 2008
61.34%30.39%
0.32%2.89% 5.06%
DE S B MS
B ioabs orbable A ntibody C oated
Others
2.30%1.69%
42.41% 53.59%
0.02%
D E S B MSB ioabs orbable Antibody C oatedO thers
Aspirin 92.20 %
Clopidogrel 93.14 %
Ticlopidine 5.62 %
Statin 90.18 %
Beta blocker 71.01 %
ACE inhibitor 53.64 %
ARB 13.65 %
Warfarin 1.10 %
Others 68.71 %
Medications at dischargeBaseline (n=8,236)
Total PCI = 8,236 as of 9th April 2009
Outcome at Discharge of Notification
Outcome (%)2007 2008
N=3,952 N=2,482
Alive 3791 (95.93) 2440 (98.31)
Transferred 2 (0.05) 0 (0)
Died 38 (0.96) 24(0.97)
Missing 121 (3.07) 18 (0.72)
Total PCI = 6,441 as of 30th October 2008
2007 2008
N=1,429 N=1429 N=428 N=917 N=107
Outcome
(No., %)30 Days FU 6 Months FU 1 Year FU 30 Days FU 6 Months FU 1 Year Fu
Discharged1364
(95.45)
653
(96.03)
411
(96.03)
900
(98.15)
106
(99.07)N/A
Transferred1
(0.07)
0
(0)
0
(0)
2
(0.22)
0
(0)N/A
Died9
(0.63)
7
(1.03)
2
(0.47)
4
(0.44)
1
(0.93)N/A
Lost to FU55
(3.85)
20
(2.94)
15
(3.50)
11
(1.20)N/A N/A
Outcome at Follow up
NCVD Registries
PopulationPublic Health
Disease Burden/Risk Factors
Hospital
ACS/PCI/CABG
Communities
Rehabilitation
My NCDs NCVD ACS RegistryPCI Registry
CABGs Registry
Implantable devicesHeart Failure
European Society of Cardiology
American College of Cardiology
www.crc.gov.my
www.acrm.org.my/ncvd
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