saturday, 8 2017 - nham conference · i don’t do rocket-science research. ... social media)...

Annual Scientific Meeting 2017 Saturday, 8th April 2017

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Whither the heart of cardiology?

@ 2017

Don’t Miss Today!

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0915-1010 Symposium 11: NHAM-ACC Clarke Ballroom, Le Meridien 1200-1300 Symposium 16: NHAM-ESC Ballroom C, Hilton

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0955-1015 Special Lecture 3: Stroke Prevention in AF: Assessing Risk and How to Improve Practical Decision-making in Everyday Clinical Practice Ballroom C, Hilton

NHAM Past President Samuel Ong delivers a strong message at the Nik Zainal Memorial lecture

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Whilst cardiology has seen tremendous advancements in technology, all its practitioners must assess the appropriateness of procedures and perform them with integrity and compassion.

“The best practitioners have science in one hand, and the art of medicine in the other. The art of medicine involves integrity and compassion”, he said whilst delivering the oratory for the Nik Zainal Memorial Lecture at the opening morning of NHAM ASM 2017.

He was making reference to the huge advancements in interventional cardiology.

From the first PTCA performed in Malaysia in 1983 by Drs K T Singham and Anuar Masduki, he feels privileged to have witnessed first hand the giant leaps we have taken to refine and develop percutaneous intervention. He paid tribute to all the pioneers in coronary intervention and paraphrased Sir Isaac Newton, “If I can see a little further than others, it is by standing on the shoulders of giants.”

Amidst the relative ease and safety at performing PCI, he has expressed grave concerns as to whether all procedures are carried out with appropriate indications. The problem lies in the system where

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cardiologists are deciding on treatment and also performing the treatment themselves. The system is potentially open to abuse to perform unnecessary and potentially harmful interventions.

He cited multivessel disease with incomplete revascularization, where patients may be better off with a bypass operation. On the other end of the spectrum and perhaps even more worrying, is the phenomenon of asymptomatic patients or those without major demonstrable ischemia, being subjected to procedures with potential complications such as bleeding, stent thrombosis and instent restenosis.

The primary dictum in medicine is “First, do no harm.” An inappropriate procedure exposes patients to unnecessary risk, financial cost and also consigns them to a long period of necessary pharmacotherapy.

The presence of appropriate use criteria such as that published in Malaysia in 2015 should help to limit this phenomenon. However, Dr. Samuel Ong feels that this is not enough. Audits should be carried out at all centers to assess the appropriateness on the procedures of all operators. “If we do not put our house in order, others will soon step in to do so”.

“If we do not put our house

in order, others will

soon step in to do so”

~ Dr Samuel Ong

Dr Samuel Ong

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Seeing the bigger picture

American College of Cardiology (ACC) and European Society of Cardiology (ESC) lectures open

NHAM 2017

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Past president of the ACC Kim Williams and President of the European Society of Cardiology Jeroen Bax delivered two fascinating lectures on the opening morning all of NHAM 2017. Kim Williams delivered a lecture entitled “Hypertension in 2017”. He illustrated the scale of the problem in that 58% of Medicare patients aged over 65 have hypertension. The upshot of this was that 30% of their budget was spent on hypertension-related treatments and complications.

He cited figures that up to a third of Malaysians are hypertensive as “staggering” and indicated this will continue to be a major problem worldwide.

Considerable controversy has emerged since JNC 8 relaxed the targets for systolic blood pressure for those over 60 years of age to ≤150 mmHg. He showed earlier data that proved once blood pressure targets were reduced below 140 systolic, there was a significant decline in cardiovascular events. He demonstrated that a period of more of three years or more was needed to demonstrate significant reductions in stroke, and this may influence the findings of clinical trials.

He supported lower targets for BP control in African Americans, the elderly, those with left ventricular hypertrophy and dysfunction, diabetes and CKD. He argued that Asians should also probably fall in this group due to the increased risk of stroke.

The elderly were always a concern about over-treatment.

Nevertheless, a sub-group analysis of the recent SPRINT study, which subdivided the elderly participants into those who were fit, frail, or in between, all showed improved hazard ratios with intensive BP Control. The frail group benefit least, but the degree of benefit was still better in magnitude, than that seen in the entire study cohort.

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Concluding, he said the treatment should be individualized and “no one size fits all”. Another oft- neglected important component was lifestyle modification, in particular sodium reduction, exercise, smoking cessation and good nutrition practice.

Jeroen Bax presented the dizzying array of options available for “Comprehensive Imaging in Coronary Artery Disease”. Depending on the question being asked, there were different modalities available including echocardiography, nuclear imaging and magnetic resonance imaging.

The future may eventually lie with the imaging modality that provides the best simultaneous anatomical and functional information, such as cardiac MR.

Responding to a question concerning asymptomatic patients who present with abnormal imaging results on routine testing (an asymptomatic low-risk lady who presented with an abnormal coronary calcium scan), he made the statement that “it seems that our ability to see things is progressing faster then our clinical knowledge about what to do with the results.”

NHAM has been very fortunate to enjoy strong relationships with both the ACC and ESC. Malaysia was the first international chapter of the ACC. Every year without fail, representatives from both societies will attend NHAM to disseminate knowledge and promote further friendship and cooperation.

“America and Europe meet at NHAM”

Dr Jeroen Bax Dr Kim Williams

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Pulse@NHAM meet up with European Society of Cardiology (ESC) President Dr Jeroen Bax

An interview with Dr Jeroen Bax

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How do you find your trip to KL so far?

It is my 5th time to KL and every time I come here, it always takes me by surprised by how metropolitan the city has become. You guys got it good here.

With your frequent visits, why is it important to make ESC prominent in Asian cardiology conference?

Over the years, we have learnt to appreciate “one medicine doesn’t fit all” and there are growing number of evidence out there to support this notion. The people living in Asian or African continent for example, are challenged by different kinds of diseases compared to the people living in the Europe and it goes vice versa. So, what may work in Europe may not certainly fits other demographics, hence, it is important for ESC to meet directly with the key players from different region, establish good connections for collaborations that are not just for clinical use or research, but also provide avenue for oversees training, taking the advantage of what we can offer in Europe.

Being the president of ESC term 2016-2018, how do you plan to differentiate your seat from your predecessors?

The best key words I would like to be associated with are; “global” and “young”. I have the opportunity to work with people from different countries, races and background in my institution, so I can appreciate and experience the differences in culture. I also get to see them go back to their home country and build something out of it. It’s an achievement for me too. I envisioned ESC going global, making connections with different parts of the world so we can come together to face the “cardiovascular battle” together. ESC will also focus more on education and training so we can assist young cardiologists build up their career. I understand there are new generations coming in

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with different sets values and mindset; different from the traditional generation I am used to. I see it as a challenge to make cardiology training more adaptable to the changing generation.

Last question. Can you spare some pearls of wisdom to budding cardiologists out there?

Do clinics! It gets you to realize what is still not known and how you can apply evidence into clinical practice. I don’t do rocket-science research. Instead, I do research based on clinical questions I encounter during my clinical practice so it feels more relevant, not just for me but for others too.

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Social Media & Medicine Author: Dr. KOH Kok Wei @ECGTalk

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Dr. Beni Isman Rusani, a cardiologist in the National Heart Institute of Malaysia pursued his education at the Auckland Medical School and furthered his postgraduate at the Universiti Kebangsaan Malaysia. His journey to specialize in this field started during his service in Hospital Kajang when his dear friend Dr Hafidz Abd Hadi brought up the idea of sub-specializing in the field of cardiology.

Little did he know that this adventure would lead his path into the road less traveled – social media and medicine.

“The mainstream media is good. Unfortunately, is less effective than social media in reaching out to the public. Most often, it only serves as a one sided interaction,” said Dr Beni.

In this cyber era, we are getting more dependent on social media to engage with the public. There are already NGOs such as @medtweetmy, mythbuster on Twitter, Facebook and Instagram available as channels to spread useful and beneficial health advices.

However, our people shall be reminded to be mindful of the source of information they are reading or hearing from the media. The poorly regulated media resulted in masses of health advertisements and articles on ‘unproven’ supplements, herbs and health products floating around (in both mainstream and social media) luring the public to believe the untruth, to purchase the potentially harmful and highly priced products.

In fact, as a physician, Dr. Beni felt responsible to provide health information. Not providing diagnosis, but to dispel common health myths. He added, “Let

+ Check it out

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Where? Ballroom B, Level 8, Hilton When? Saturday, 8th April 2017, 1200-1330

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Symposium 15: Social Media, Consumer Technologies and Medicine

+ “The mainstream media

is good. Unfortunately, is less effective than social media in reaching out to the public. Most often, it

only serves as a one sided interaction”

~ Dr Beni Isman Rusani

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us not undermine the impact one can offer with just a little of effort to slot in this opportunity to give back to our people in the midst of our pre-occupied schedules”. Having said that, do be cautious of the potential legal implication surrounding the social media (PDPA and your privacy).

Now, the thought that crosses our minds, “what inspires him contribute in social media all these years?“

“It is the feedbacks from the public - stimulated much encouragement, self-satisfaction and fulfillment having to see the public benefited from the little health information and advices that I could share, Oh wait! Sometimes, my readers send me chocolates too,” he concluded our interview with a smile.

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Two big killers collide in the specialty of cardio oncology: cardiac disease and cancer. The results can be devastating for both doctor and patient. Treated or even potentially cured of one ailment, to only suffer a new disease. “Both cardiologists and oncologists must be more cognizant of this entity and we must screen and treat it” says Rahal Yusoff. His experience and expertise in echocardiography has proven invaluable in the treatment of this problem.

The most familiar entity is anthracycline cardiomyopathy. New agents such as trastuzumab, which can cause a reversible cardiomyopathy, now join this.

However, many oncological agents have potential to cause cardiotoxicity to a lesser degree.

“There is much more to this fledgling specialty than just the above. It also involves the management of marantic endocarditis, pericardial effusions and other early and late complications of chemotherapy, radiotherapy and cancer surgery. Radiotherapy associated coronary disease and the increased propensity for venous thromboembolism are further examples.”

The cardiotoxicity off doxorubicin is increased with doses greater than 400 to 500 mg/m2 and also at the extremes of age (<15 and >60 years old). Other high risk features include

+ “Both cardiologists and

oncologists must be more cognizant of this

entity and we must screen and treat it”

~ Dr Mohd Rahal Yusoff

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female sex, chest irradiation, pre-existing left ventricular dysfunction and concurrent comorbidities and risk factors such as hypertension.

Patients with breast cancer often receive both anthracyclines and trastuzamab treatment. Previous anthracycline therapy increases the risk of trastuzamab cardiomyopathy.

The cardiomyopathy was previously described as causing type 1 changes (irreversible, dose-related e.g.anthracycline) or type 2 (Reversible, non-dose related e.g. trastuzamab). We now know there is a gray zone and the dichotomy is not so clear.

Those identified to be at high-risk for cardiotoxicity should receive an ECG, an echocardiogram and troponin I measurement.

Corrected QT interval should be assessed on the ECG.

Assessment of left ventricular ejection fraction needs to be standardized using the biplane Modified Simpsons method and not eyeballing or M-mode. The preferable method, if available, would be 3-D echo ejection fraction.

Global longitudinal strain should be utilized if available. Unfortunately, in the real world many centres do not practice this. A lot of the data comes from academic units and there is a steep learning curve. Furthermore, there is a variability in the

Dr Mohd Rahal Yusoff

Cardio-oncology: the next frontier Rahal Yusoff tells Pulse@NHAM about the challenges and opportunities in the newest interface specialty in cardiology

+ Check it out LEARN MORE ABOUT CARDIO-ONCOLOGY @ NHAM 2017!

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Symposium 23: Cardio-Oncology When? 0830-0945 Sunday, 9 April

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Where? Ballroom C Join Rahal Yusoff, Choo Wai Sun and Cham Yee Ling to learn more

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measurement depending on the vendor strain algorithm. So, if checking global longitudinal strain it is vital to use the same machine when performing subsequent surveillance on the same patient

MRI would of course be an excellent option for left ventricular function assessment but accessibility and cost limits use.

If the patient is detected to be at increased risk of cardiomyopathy or actually develops cardiomyopathy, there are things both the oncologist and cardiologist can do.

There is evidence for the use of drugs such as enalapril, carvedilol and nebivolol. Further work continues to confirm and expand on further treatment options.

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Tell us about the new Guidelines on Primary and Secondary Prevention of Cardiovascular Disease, which you chaired These guidelines have been a long time in production. Since 2010 when they were first initialized in fact. They encompass a massive scope, and involved a whole spectrum of medical professionals: primary care, public health, physicians, cardiologists, endocrinologists and many more. Although we have a detailed discussion of secondary prevention, we also want to focus strongly on primary prevention in asymptomatic individuals. Primordial prevention even. We have recommendations that discuss this strategy from the time person is in school. There are programmes to reduce smoking rates such as IMFree and KOTAK. There are details of plans and legislation to reduce sale of unhealthy food in or near schools. In fact, we have a lot of good ideas and programs. The problem is that in Malaysia we have a lot of rules and regulations, but the implementation is very poor! As cardiologists we are mostly involved in secondary prevention. This is fine, but it has a relatively small reach to a small number of patients. To make a bigger impact we must target primary prevention. There are so many choices for risk calculators these days. Which one do these guidelines employ? Are we closer to a local calculator? And do we need one? We have decided to stick to the Franminghan risk calculator. This has actually been validated by independently by two independent local studies. Of course, it would be best if we had our own local calculator. Singapore and Thailand actually use the Framingham calculator but have modified it to their own population cohort. I believe that there are efforts to generate a local calculator in place. Should we assess the 10-year or lifetime cardiovascular risk? In middle aged and elderly subjects we should use the 10-year risk. However in the younger persons, we should use a more long-

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term calculation such as the vascular age risk. How do we utilize other markers of risk, such as family history, hsCRP and coronary calcium score? This becomes important in intermediate risk patients. Those with 10-year risk off 10 to 20%. In our guidelines, we mentioned that in this situation family history, abnormal ankle-brachial index, elevated hs-CRP and coronary calcification score of more than 300, may help to sway the decision to begin preventative treatment. There has been considerable controversy regarding targets for treatment of diabetes, blood pressure and cholesterol. Tell us about the targets specified in the guidelines Regarding blood pressure, we have decided to stick with the targets specified in our recent Malaysian CPG. For most uncomplicated hypertensives <80 years old, that is less than 140/90 mmHg. In terms of dyslipidemia, LDL cholesterol remains the target treatment. There is a lot of robust and consistent positive outcome data on interventions to lower TC and LDL-cholesterol, especially with statins. There is inconsistent (and sometimes harmful) outcome data with interventions to lower triglyceride or raise HDL-C. The target depends whether the patient is risk stratified into very high CV risk, high CV risk, or lesser. For diabetes, we have an excellent table that clearly delineates differing HbA1c targets for diabetics with different clinical characteristics. Several new agents are also now available and these are integrated into a very nice flowchart indicating therapeutic options for glycemic control.

Pulse@NHAM met up with senior cardiologist Dr Jeyamalar Rajadurai, a major driving force of multiple

Clinical Practice Guidelines

An interview with Dr Jeyamalar Rajadurai

Global Risk LDL-C Levels to Initiate Drug Therapy (mmol/L)

Target LDL-C Levels (mmol/L)

Low CV Risk* clinical judgement** <3.0 Intermediate (Moderate) CV Risk* >3.4 ** <3.0 High CV risk !  > 20% 10-year CVD risk !  diabetes without target organ damage !  CKD with GFR 30-<60 Ml / min−1 /1.73

m2

> 2.6 ≤2.6 or a reduction of >50% from

baseline***

Very high CV risk !  established CVD, !  diabetes with proteinuria or with a

major risk factor such as smoking, hypertension or dyslipidaemia

!  CKD with GFR <30 Ml / min−1 /1.73 m2

but not dialysis dependent)

>1.8

<1.8 or a reduction of > 50% from baseline***

*Low%and%Intermediate%(Moderate)%CV%risk%is%assessed%using%the%Framingham%General%CVD%Risk%Score%%!**AAer%a%therapeuCc%trial%of%8F12%weeks%of%TLC%and%following%discussion%of%the%risk:%benefit%raCo%of%drug%therapy%with%the%paCent%!***whichever%results%in%a%lower%level%of%LDLFC!

Target LDL-C levels !

Tight Control (<6.5%)

Intermediate (6.6–7.4%) Less Tight Control (7.5–8.0%)

!  Newly diagnosed !  On medications that do

not cause hypoglycaemia

!  Low risk of hypoglycaemia

!  Proteinuria !  Healthier (long life

expectancy)

!  High CV risk based on Framingham Risk Score

!  High risk of hypoglycaemia

!  Repeated episodes of hypoglycaemia

!  Comorbidities e.g. "  Chronic Renal Failure (GFR < 60 units), "  Decompensated chronic liver disease, "  Chronic dementia, "  Bed-bound due to CVA etc. !  Episode of severe hypoglycaemia !  Limited life expectancy (metastatic

malignancies etc)

A1c Targets for T2DM Without Pre-existing CVD* !

Dr Jeyamalar Rajadurai


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Moments @ NHAM 2017

+ Launching of CPG @ NHAM 2017

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Moments @ NHAM 2017

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+ Walkabout Moments @ NHAM 2017

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saturday, 8 2017 - nham conference · i don’t do rocket-science research. ... social media)...

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