This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus mainly on prehospital and A&E setting. Issues that are conventionally under the care of the cardiologists are not discussed.

1. Handling
Cardiovascular
Emergencies
In
A
Malaysian
Hospital
(A
Personal
Reflec/on
on
Issues
and
Challenges
Ahead)
K
S
Chew
Senior
Lecturer/Emergency
Physician,
Emergency
Medicine
Department
UniversiC
Sains
Malaysia
16150
Kubang
Kerian,
Kelantan,
Malaysia

2. Disclaimer:
The
views
presented
here
are
of
my
own
personal
reflec/on
and
is
not
represen/ng
any
official
statement/opinion
from
the
Ministry
of
Heath
Malaysia

3. Malaysia
mulC-­‐ethnic,
mulC-­‐religion
country
consisCng
of
13
states
and
three
federal
territories.
Majority
of
the
Malaysian
populaCon
of
about
27
million
people
consists
of
the
Malays
(50.4%),
Chinese
(23.7%),
the
indigenous
groups
(11%)
and
the
Indians
(7.1%)

4. MALAYSIA HEALTH FACTS 2006 2007 2008
Life Expectancy: Male 71.8 years 71.7 years 71.7 years
Life Expectancy: Female 76.3 years 76.5 years 76.5 years
No of MOH Hospitals 128 (30,969) 130 (32,149) 130 (33,004)
(no of beds)
No of Private Hospitals NA 195 (11,291) 209 (11,689)
(no of beds)
No of MOH Clinics 807 806 802
No of MOH Community Clinics 1,919 1,927 1,927
Total no of Public Doctors 13,335 14,298 15,096
Total no of Private Doctors 8,602 9,440 10,006
Doctor : Population Ratio 1:1,214 1 : 1,145 1 : 1,105
Reference:
Health
Facts
2006,
2007
and
2008.
Ministry
of
Health,
Malaysia
Official
Website.
URL:
www.moh.gov.my

5. Top
Ten
Causes
of
HospitalizaCon
in
Malaysian
Ministry
of
Health
Hospitals
2008
1
Normal
Deliveries
13.99%
2
ComplicaCons
of
Pregnancy,
Childbirth
and
the
12.77%
Puerperium
3
Accidents
8.40%
4
Diseases
of
the
Respiratory
System
8.05%
5
Diseases
of
the
Circulatory
System
6.99%
6
CondiCons
OriginaCng
in
the
Perinatal
Period
6.78%
7
Diseases
of
the
DigesCve
System
5.37%
8
Ill-­‐defined
CondiCons
3.63%
9
Diseases
of
the
Urinary
System
3.49%
10
Malignant
Neoplasms
3.16%
Reference:
Health
Facts
2008.
Ministry
of
Health,
Malaysia
Official
Website.
URL:
www.moh.gov.my

6. Top
Ten
Causes
of
Deaths
in
Malaysian
Ministry
of
Health
Hospitals
2008
1
Heart
and
Pulmonary
CirculaCon
Diseases
16.54%
2
SepCcaemia
13.18%
3
Malignant
Neoplasms
11.21%
4
Pneumonia
9.28%
5
Cerebrovascular
Diseases
8.65%
6
Diseases
of
the
DigesCve
System
5.18%
7
Accidents
5.00%
8
CondiCons
OriginaCng
in
the
Perinatal
Period
3.97%
9
NephriCs,
NephroCc
Syndrome
and
Nephrosis
3.76%
10
Ill-­‐
defined
CondiCons
2.63%
Reference:
Health
Facts
2008.
Ministry
of
Health,
Malaysia
Official
Website.
URL:
www.moh.gov.my

7. Flow
Chart
of
The
Emergency
Management
of
Acute
Coronary
Syndrome
For PCI
Inter-facility transfer
Chest pain Call 999 EMS Response Triage Plan
Fibrinolysis
Patient’s Dispatch EMS EMS Transport Door to Needle time: 30 min
symptoms Arrival
1 min 12-lead ECG Door to Balloon time: 90 min
within 8
5 min after
min ? Pre-hospital thrombolysis Inter-facility transfer
onset
Advice S/L GTN
q5min, max 3
tablets
Cardiopulmonary Resuscitation Automated External Defibrillator

8. Reference:
Clinical
Prac/ce
Guidelines
Management
of
Acute
ST
Eleva/on
Myocardial
Infarc/on
2007.
Ministry
of
Health
Malaysia.
www.moh.gov.my

9. Issues
Related
To
EMS
AcCvaCon

10. PREVIOUS
EMERGENCY
AMBULANCE
CALL
SYSTEM
PRIOR
TO
2007
(LACK
OF
AN
INTEGRATED
RESPONSE
SYSTEM)
EMERGENCY
CALL
999
HOSPITAL
HEALTH
CLINIC
991
PHONE
NUMBER
PHONE
NUMBER
TELEKOM
OPERATOR
HOSPITAL
JPA
3
OPERATOR
HEALTH
CLINIC
PARAMEDIC
EMERGENCY
JPA
3
TEAM
DEPARTMENT

11. • SCll
plagued
with
the
problem
of
prank
calls.
• In
2007,
97%
of
the
2
million
emergency
calls
are
prank
calls.
• In
2008,
the
percentage
was
64%.
• Prank
callers
can
be
charged
under
SecCon
223
of
the
Malaysian
CommunicaCons
and
MulCmedia
Act
Chew
KS,
Idzwan
ZM,
Hisamuddin
NA,
Kamaruddin
J,
Wan
1998,
which
carries
a
fine
of
up
to
Aasim
WA.
Cardiopulmonary
Resuscita/on:
The
Short
RM50,000
or
up
to
five
years
jail
or
both.
Comings
In
Malaysia.
Malaysian
J
Med
Sciences.
2008;14(2):
23-­‐5.

12. Issues
Related
To
EMS
Response

13. Ambulance
Response
Time
Cities Mean Ambulance Response Time (min)
Kota Bharu 15.2
Kuala Lumpur 21.1
United Kingdom 7.0 – 14.0
Australia 7.0 – 11.0
Singapore ± 15.0
Ankara (Turkey) ±9
New York ± 11.4
Chicago ± 11.3
Shah
CH,
Ismail
IM,
Mohsin
SS.
Ambulance
response
/me
and
emergency
medical
dispatcher
program:
a
study
in
Kelantan,
Malaysia.
Southeast
Asian
J
Trop
Med
Public
Health
2008;
39
(6):1150-­‐4.
Chew
KS,
Idzwan
ZM,
Hisamuddin
NA,
Kamaruddin
J,
Wan
Aasim
WA.
Cardiopulmonary
Resuscita/on:
The
Short
Comings
In
Malaysia.
Malaysian
J
Med
Sciences.
2008;14(2):23-­‐5.

14. Bicycle
and
Motorcycle
Squad
Around
Klang
Valley
Vicinity
As
A
Stop-­‐Gap
Measure
Motorcycle
Squad
• Area
covers
100
–150
km
sq
• ‘Response
Time’
less
than
15
min
• Distance
less
than
10km
or
travel
Cme
less
15
min
• The
Advanced
Life
Support
Unit
type
complete
equipments
including:
AED,
Airway
Management
Set,
MedicaCons,
Oxygen
Tank,
CommunicaCon
Set

15. “One
Size
Fit
All”
in
FormulaCng
An
Emergency
Medical
Service
System
In
Malaysia???

17. Klinik
Desa
Bario
-­‐
Sarawak

18. KK
Pa
Dalih
–
Up
To
Ten
Hours’
Journey
On
Foot

20. Issues
Related
To
ResuscitaCon

21. Cardiopulmonary
ResuscitaCon
• Bystander
CPR
is
performed
in
9%
of
out
of
hospital
cardiac
arrest
in
a
local
study
in
2006.
• Chew
KS,
Mohd
Idzwan
Z,
Nik
Hishamudin
NA,
Wan
Aasim
WA,
Kamaruddin
J.
How
frequent
is
bystander
cardiopulmonary
resuscita/on
performed
in
the
community
of
Kota
Bharu,
Malaysia?
Singapore
Med
J.
2008
Aug;49(8):636-­‐9.

22. Willingness
of
Final
Year
Medical
and
Dental
Students
To
Perform
Bystander
CPR
Chew
KS,
Yazid
MNA.
The
willingness
of
final
year
medical
and
dental
students
to
perform
bystander
cardiopulmonary
resuscita/on
in
an
Asian
community
Int
J
Emerg
Med.
2008;1(4):
301-­‐09.

23. Willingness
of
Final
Year
Medical
and
Dental
Students
To
Perform
Bystander
CPR
Chew
KS,
Yazid
MNA.
The
willingness
of
final
year
medical
and
dental
students
to
perform
bystander
cardiopulmonary
resuscita/on
in
an
Asian
community
Int
J
Emerg
Med.
2008;1(4):
301-­‐09.

24. Unspoken
socio-­‐cultural
barriers
to
perform
bystander
CPR
with
mouth-­‐to-­‐mouth
venClaCon
among
our
mulC-­‐
ethnic,
mulC-­‐religious
community
Gender
difference
is
probably
one
of
these,
especially
among
the
female
respondents
(performing
bystander
CPR
on
a
male
vicCm)
Chew
KS,
Yazid
MNA.
The
willingness
of
final
year
medical
and
dental
students
to
perform
bystander
cardiopulmonary
resuscita/on
in
an
Asian
community
Int
J
Emerg
Med.
2008;1(4):301-­‐09.

26. Issues
Related
To
Automated
External
Defibrillator
in
Malaysia

29. Issues
Related
To
DefiniCve
Coronary
Care
Plan

30. Malaysian
NaConal
Cardiovascular
Disease
(NCVD)
Database
• In
2006,
there
are
73
coronary
care
units
(CCU)
in
Malaysia
• The
incidence
of
ACS
admission
was
therefore
47.1
per
100,000
populaCon
in
2006
• The
esCmate
of
the
incidence
of
coronary
heart
disease
(CHD)
in
Malaysia
is
141
per
100,000
populaCon
• Over
4000
ACS
being
denied
admission
into
its
CCU
in
2006.
It
has
30%
shoroall
in
CCU
beds
Chin SP, Jeyaindran S, Azhari R, Wan Azman WA, Omar I, Robaayah Z, Sim KH. Acute coronary syndrome
(ACS) registry--leading the charge for National Cardiovascular Disease (NCVD) Database. Med J Malaysia. 2008
Sep;63 Suppl C:29-36.

31. Overall
Outcomes
For
PaCents
With
STEMI
By
FibrinolyCc
Therapy,
Malaysia
2006
In-­‐hospital
30-­‐day*
Outcome
Fibrinoly=c
therapy
Fibrinoly=c
therapy
Yes
No
Yes
No
No.
%
No.
%
No.
%
No.
%
Discharged
/
Alive
940
92
372
87
686
67
253
59
Died
74
7
55
13
90
9
68
16
Lost
to
follow-­‐up
NA
NA
NA
NA
242
24
106
25
Missing
4
0
0
0
0
0
0
0
*Including
pa/ents
who
died
in-­‐hospital.
Note:
Percentage
is
to
the
nearest
decimal
point.
Annual
Report
of
the
Acute
Coronary
Syndrome
(ACS)
Registry,
Malaysia
2006

32. Streptokinase
Failure
• In
a
local
study
in
2008,
streptokinase
failure
rate
is
56.8%
• Mean
door-­‐to-­‐needle
Cme
is
104.9
min
• Other
factors
shown
to
significantly
associated
with
streptokinase
failure
include
– Anterior
locaCon
infarcCon
– History
of
Diabetes
– Hypertension
– High
total
white
cell
counts
– Lee
YY,
Tee
MH,
Zurkurnai
Y
et
al.
Thromboly/c
failure
with
streptokinase
in
acute
myocardial
infarc/on
using
electrocardiogram
criteria.
Singapore
Med
J
2008;
49
(4):304-­‐10.
Note:
Streptokinase
failure
in
this
study
is
based
solely
on
ECG
criteria
of
failure
of
STE
of
≥
50%
and
not
on
angiographic
confirma=on

33. NCVD-­‐PCI
Registry
Results
PCI
Status
Baseline
(n=8,236)
ElecCve
(n=7,439)
90.32
%
Staged
PCI
22.06
%
Urgent
(NSTEMI/UA)
4.66
%
Rescue
2.09
%
Primary
2.48
%
Missing
0.45
%
Cath/
PCI
in
same
seqng
(ad
hoc)
84.12
%
Na=onal
Cardiovascular
Disease
Database
(NCVD)

34. Percentage
Of
Stent
Type
By
Total
Number
Of
Stents
Used
(N=13,150)
*‘Other’
refers
to
stent
other
than
listed
in
the
Reference
Stent
List
Na=onal
Cardiovascular
Disease
Database
(NCVD)

35. Conclusion

36. Thank
You