Transcript National Cardiovascular Disease Database

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
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
No more
Malaysian population
‘guestimate’
 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
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
 Clinical Registry Associate
 Clinical Epidemiologist




ICT Manager
Database Administrator
Application Developer
Network Administrator
 Webmaster & Publisher
 Clinical Data Manager
 Biostatistics Consultants
Ms S Gunavathy Selvaraj
Ms Noor Amirah Muhamad
Ms Hamimatunnisa Johar
Dr Jamaiyah Haniff
Ms S Gunavathy Selvaraj
Ms Celine Tsai Pao Chien
Ms Lim Jie Ying
Ms Amy R. Porle
Mr Kevin Ng Hong Heng
Mr Adlan Ab. Rahman
Ms Azizah Alimat
Ms Teo Jau Shya
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
•
•
Incidence of coronary heart disease (CHD)
•
•
47.1 per 100,000 population
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 for patient with ACS,
Malaysia 2006
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-gender distribution male pts with
ACS by ethnic group, Malaysia 2006
Malay
Indian
Chinese
Others*
40
% of patients
30
20
10
0
20-<30
30-<40
40-<50
50-<60
Male patients
60-<70
70-<80
>=80
Age-gender distribution for female pts
with ACS by ethnic group, Malaysia
2006
Malay
Indian
Chinese
Others*
150
No. of patients
120
90
60
30
0
20-<30
30-<40
40-<50
50-<60
Female Patients
60-<70
70-<80
>=80
Age group (years) distribution for pts with
ACS by ACS stratum, Malaysia 2006
STEMI
UA
NSTEMI
% of patients
30
20
10
0
20-<30
30-<40
40-<50
50-<60
Age group
60-<70
70-<80
>=80
ACS Gender distribution
Malaysia 2006
Male
Female
75%
25%
Gender, no. %
(N=3422)
Male
2569(75)
Female
853 (25)
ACS Ethnic group distribution
Malaysia 2006
60
50
49.2
% of patients
40
30
23.0
23.3
20
10
1.4
1.1
1.1
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0.0
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Overall outcomes for pts with ACS,
Malaysia 2006
in-hospital
NCVD-ACS
30 days
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
NCVD
ACS Registry
Interim Analysis
@ 9 April 2009
Patient Demographics : ACS by Age group
Age (years)
Age (Mean ± sd)
2006
2007
2008
59.12 ± 12.07 58.97 ± 11.9 58.89 ± 11.98
35
30
% of patients
2006
29.75
29.46
29.77
2007
27.01 26.85
26.63
2008
25
20
17.96
17.14
16.6
17.37
17.1
17.08
15
10
5
0.44
0.71 0.48
4.18 5.00
3.89
3.93
3.99 3.53
0
20 - <30
30 - <40
40 - <50
50 - <60
60 - <70
Results as of 28th October 2008
Age Group (Years)
70 - <80
>80
ACS Patients by Gender
2006
2007
2008
N=3533
N=3857
N=1714
Male
74.67
75.86
75.09
Female
25.33
23.72
24.33
Gender (%)
Results as of 28th October 2008, n=9,104
ACS Patients by Ethnicity
Percentage (%) of Patients
60
50
49.08
46.51
2006
2007
2008
43.7
40
30
22.98
24.62
23.07
22.82 24.27
23.35
20
4.43
10
3.43
4.45
0
Malay
Chinese
Indian
Ethnicity
Results as of 28th October 2008, n=9,104
Other Malaysia
A C S s tratum by year
50
45
43.45
41.21
42.18
2006
2007
2008
P erc entag e (% )
40
32.68
35
30.57
30
26.13
25
25.38
20.92
17.39
20
15.05
15
10
5.06
5
0.28
0
S TE MI
NS TE MI
UA
Missing
AC S s tratum
Results as of 28th October 2008, n=9,104
CV Risk factors
2008
(n=6,516)
2009
(n=10,846)
GRACE
Dyslipidaemia
33.90 %
32.42 %
43 %
Hypertension
61.30 %
57.69 %
57 %
Diabetes
43.48 %
40.56 %
23 %
Family History of CVD
12.77 %
11.16 %
MI history
16.76 %
16.68 %
Documented CAD
15.15 %
16.21 %
New onset angina (< 2 wks)
13.23 %
48.08%
Chronic angina (>2 wks)
47.73 %
11.29%
Chronic Lung Disease
3.45 %
3.26 %
Renal disease
7.14 %
6.40 %
7.2%
Peripheral vascular disease
0.87 %
0.75 %
10.3%
Cerebrovascular disease
3.84 %
3.42 %
8.3%
Heart Failure
7.77 %
6.46 %
11%
68%
TIMI Risk Score NSTEMI/UA
(n=5,427)
30
25.76
23.55
Percentage (%)
25
20
17.36
14.09
15
11.72
10
6.06
5
1.29
0.17
0
0
1
2
3
4
5
6
7
TIMI Risk Score
Results as of 9th April 2009, n= 10,864
Fibrinolytic Therapy Status
Baseline (n= 4,705)
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 %
Results as of 9th April 2009, n= 10,864
Door to needle time
Year
Door to needle
time
2006
2007
2008
98.9 +
140.55
88.42 +
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
Preadmission
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
4.60
7.35
6.32
30.03
83.97
69.31
Angiotensin II receptor
blocker
Statin
Results as of 9th April 2009, n= 10,864
Follow Up at 30 days & 12 months
Outcome
30days (n= 6,550)
1year (n= 3,374)
Alive
85.39%
84.53 %
Death
3.45 %
2.31 %
Lost to FU
8.98 %
10.58 %
Transferred
0.58 %
0.18 %
1.6 %
2.4 %
CVD
n= 226
55.31 %
n= 78
47.44 %
Non CVD
10.62 %
8.97 %
Others
13.27 %
21.79 %
Missing
20.80 %
21.80 %
Missing
Cause of death
Cardiovascular readmission
ACS
STEMI
NSTEMI
UA
Missing
30days (n= 6,550)
1year (n= 3,374)
3.89 %
2.07 %
14.51
14.90
53.73
16.86
%
%
%
%
12.86 %
7.14 %
61.43 %
11.43 %
Heart Failure
0.49 %
Revascularization
5.15 %
3.11%
87.54 %
78.09 %
9.79 %
15.24 %
0.11 %
0.06 %
PCI
CABG
Stroke
0.53%
Outcome at Discharge
100
P erc entag e(% ) of patients
90
80
91.85
85.12
2006
74.80
2007
70
2008
60
50
40
30
14.99
20
1.71 3.33
1.19
10
6.71 7.57 6.65
0.23
0
D is charg ed
T rans ferred
Outc ome
Results as of 28th October 2008, n=9,104
0.18
D ied
Mis s ing
NCVD
PCI Registry
Interim Analysis
@ 9 April 2009
Patient Demographics : PCI by Age Group
Age (years)
Age (Mean ± sd)
40
2007
2008
56.7 ±10.1
56.72 ± 10.08
36.97
36.14
2007
35
28.06
% of patients
30
2008
27.19
25
19.51
20
20.15
15
10.22
10
5
0
3.9
11.12
4.15
0.5 0.12
20 - <30 30 - <40 40 - <50 50 - <60 60 - <70 70 - <80
Age2008
Group (years)
Total PCI = 6,441 as of 30th October
0.81
0.73
>80
PCI by Gender
2007
2008
Gender (%)
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
PCI by Ethnicity
2007
2008
N= 3,952
N=2,482
Malay
46.38
47.34
Chinese
25.56
25.10
Indian
23.58
21.15
3.98
5.52
Ethnicity (%)
Other Malaysia
Other Malaysian includes Punjabi, Iban, Kadazan Dusun,
Melanau, Bidayuh, Other Sabahan and Other Sarawakian
Total PCI = 6,441 as of 30th October 2008
Percentage (%) of patients
PCI Status by year
100
90
80
70
60
50
40
30
20
10
0
89.4 91.98
2007
2008
4.78
Elective
4.31
Urgent
1.92 1.49
Rescue
PCI Status
Total PCI = 6,441 as of 30th October 2008
2.78 2.05
Primary
Stent Used
2007
DE S
B ioabs orbable
O thers
0.02%
42.41%
2008
B MS
Antibody C oated
DE S
B MS
B ioabs orbable
A ntibody C oated
O thers
1.69%
2.30%
53.59%
0.32%
2.89%
5.06%
61.34%
30.39%
Other stents refer to stents other than listed in the Reference Stent List
Total Stent, n =10,152 as of 10th of October 2008
Medications at discharge
Baseline (n=8,236)
Aspirin
92.20 %
Clopidogrel
93.14 %
Ticlopidine
5.62 %
Statin
90.18 %
Beta blocker
71.01 %
ACE inhibitor
53.64 %
ARB
13.65 %
Warfarin
Others
1.10 %
68.71 %
Total PCI = 8,236 as of 9th April 2009
Outcome at Discharge of Notification
Outcome (%)
Alive
Transferred
Died
Missing
2007
2008
N=3,952
N=2,482
3791 (95.93)
2440 (98.31)
2 (0.05)
0 (0)
38 (0.96)
24(0.97)
121 (3.07)
18 (0.72)
Total PCI = 6,441 as of 30th October 2008
Outcome at Follow up
2007
Outcome
(No., %)
Discharged
Transferred
Died
Lost to FU
2008
N=1,429
N=1429
N=428
N=917
N=107
30 Days FU
6 Months FU
1364
653
411
900
106
(95.45)
(96.03)
(96.03)
(98.15)
(99.07)
1
0
0
2
0
(0.07)
(0)
(0)
(0.22)
(0)
9
7
2
4
1
(0.63)
(1.03)
(0.47)
(0.44)
(0.93)
55
20
15
11
(3.85)
(2.94)
(3.50)
(1.20)
1 Year FU 30 Days FU 6 Months FU 1 Year Fu
N/A
N/A
N/A
N/A
N/A
NCVD Registries
Population
Public Health
Disease Burden/
Risk Factors
My NCDs
Hospital
Communities
ACS/PCI/CABG
Rehabilitation
NCVD
ACS Registry
PCI Registry
CABGs Registry
Implantable devices
Heart 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