It’s probably not news anymore that cardiovascular disease – most notably, coronary heart disease and stroke – are the top killers in Malaysia.
According to Institut Jantung Negara director and senior consultant cardiologist Tan Sri Dr Robaayah Zambahari, these conditions have been the number one cause of death in public hospitals since 2007.
In fact, such diseases of the circulation accounted for about one-quarter (24.7%) of deaths in both public and private hospitals in 2013, according to the latest Health Ministry statistics.
While cardiovascular disease is a common killer in many countries, Malaysia has its own particular pattern of disease, says Universiti Malaya consultant cardiologist Prof Datuk Dr Wan Azman Wan Ahmad.
Prof Wan Azman has served as the chief editor for four National Cardiovascular Database Annual Reports, which report data from two national registries – the Acute Coronary Syndrome (ACS) Registry and the Percutaneous Coronary Intervention (PCI) Registry.
He says: “Malaysian ACS patients are younger compared to Western registries, in particular, among the ST Segment Elevation Myocardial Infarctions (Stemi) subgroup.”
ACS is divided into Stemi (a classic heart attack with full thickness damage of heart muscle), non-Stemi (a heart attack with partial thickness damage of heart muscle) and unstable angina (UA, chest pain that occurs even at rest or with minimal exertion).
The mean age of Malaysian ACS patients is 58.5, compared to 66 in the Global Registry of Acute Coronary Events (involving 30 countries in the Americas and Europe), 65 in the Thai Acute Coronary Syndrome Registry, 56 in the Gulf Acute Heart Failure Registry (involving the Middle East countries) and 60 in the Kerala-ACS registry (in India).
He adds: “And about one-quarter (24.2%) of them are less than 50 years old, that is, they are at the prime of their lives.
“And the retirement age in Malaysia is 60 – they have at least 10 more years before retiring.”
In terms of ethnicity, Malays and Indians have a relatively higher level of hospital admission for ACS, compared to Chinese, shares Prof Wan Azman.
He adds: “Chinese tend to get acute coronary syndrome at a much older age compared to Malays and Indians.”
Gender-wise, there is a huge disparity between males and females, with females comprising only 21.2% of ACS admissions and 16% undergoing PCI.
PCI, as explained by Dr Robaayah, is one of the three treatment methods to improve blood flow to the heart in those with coronary artery disease (which leads to coronary heart disease).
It involves inserting a stent into the blocked coronary, or heart, artery to open it up again. (See The new stent on the block)
While Prof Wan Azman had no time during his presentation to go into the reasons why females comprise such a low percentage of ACS and PCI patients, some possibilities he listed were missed or delayed diagnosis, a higher instant death rate among female heart attack victims, and gender bias, as females have less risk of having heart disease until after menopause.
Risk and death
Another factor that makes Malaysian ACS patients stand out is the number of cardiovascular risk factors they have.
“Malaysian patients have a high prevalence of cardiovascular risk factors, in particular, hypertension, dyslipidaemia and diabetes,
“As Tan Sri (Dr Robaayah) mentioned, the more factors you have, the more risk of getting cardiovascular disease and the progression of the disease is much faster,” says Prof Wan Azman.
Around 44% of ACS patients have three or more cardiovascular risk factors, with the most widespread risk factors being obesity (77%), hypertension or high blood pressure (65%), diabetes (46%), smoking (38%) and dyslipidaemia or abnormal cholesterol levels (37%) – all of which are modifiable on the individual level.
He also notes that almost 70% of ACS patients have an intermediate or high Thrombolysis in Myocardial Infarction (Timi) risk score.
This score is used to predict the likelihood of further damage caused by artery obstruction or death in patients with non-Stemi and UA.
In addition, there is an increasing trend of patients being classified as Killip IV, with 13.4% patients having that classification in the latest 2011-2013 ACS report, compared to 6% previously.
The Killip classification predicts the chances of survival within 30 days in patients with an acute heart attack, with a higher class having a higher chance of dying. Killip IV is the highest class.
In fact, the mortality rates for ACS are still worrying, according to Prof Wan Azman.
“The other thing I want to highlight to you is that the in-hospital mortality following Stemi is still high in Malaysia. It’s 10.6%.
“And for non-Stemi in-hospital mortality, it’s 7.6%. So, it’s still high,”
However, he notes that the outcome for non-Stemi and UA cases has improved over the years, especially at the one month follow-up visit.
The latest available figures from the ACS Registry are sourced from 19 major public hospitals around the country during the period of 2011-2013, and the PCI Registry from 15 major public hospitals for the period of 2013-2014.
Both Dr Robaayah and Prof Wan Azman were speaking on the current status of cardiovascular disease and treatment in Malaysia at the Malaysian launch of the world’s first magnesium-based drug-eluting bioresorbable scaffold in Kuala Lumpur recently.