A Review of Discharge Medications in Patients Admitted with Acute Decompesated Heart Failure in a Tertiary Referral Centre

Background: National guidelines for heart failure recommend prescription of certain classes of drugs to improve prognosis in patients admitted with acute decompensated heart failure (ADHF). It has been noted during clinical follow up such patients are discharged with different treatment regimes. Objective: To determine the relationship between drug treatment regimes in patients admitted to a tertiary referral centre with ADHF and their medium term clinical outcomes post-discharge, defined as 90-day mortality and hospital readmissions. Methods: 94 cases with a discharge diagnosis of ADHF were recruited from October 2017 until August 2018. Cases were analyzed retrospectively for their medications at discharge. Patients were followed-up for 90 days via phone. Results: Out of 94 patients, 8 patients died during admission. 86 patients were being analysed for clinical outcomes. 22 (26%) patients were discharged without a single type of guideline recommended medication for heart failure (GRM). 33 (38%) patients were discharged on one type, 22 (26%) patients discharged with two types and 10 (12%) patients were discharged with three or more types of GRM. The main reasons for not being discharged with all GRM were chronic kidney disease, obstructive lung disease, bradycardia and hypotension. The 90 days mortality rate was higher in patients discharged with ≤1 class of GRM drugs compared to patients with discharged on ≥2 classes of GRM drugs. (14.5% vs 6.5%; OR 2.25; 95%CI 0.51, 9.96; p=0.28). The 90 days readmission rate for ADHF was also higher for patients discharged with ≤1 class of GRM drugs (20.0% vs 12.9%; OR 1.55; 95%CI 0.539, 4.457; p=0.416). Overall, patients with discharged with ≤1 class of GRM drugs had also a higher 90-day event rate (27.3% vs 19.4%; OR 1.78; 95%CI 0.797, 3.993; p=0.16). Conclusions: Discharging ADHF patients with ≥2 class of GRM drugs was associated with lower 90 days readmission rates and mortality

Variable Clinical Presentations of Left Atrial Myxoma in Malaysia: A Case Series

Introduction and Purpose: Cardiac myxoma is the most common primary tumour of the heart; often missed due to non-specific symptoms. It may lead to disastrous outcome if it is not treated in a symptomatic patient. Transthoracic echocardiogram (TTE) is the usual imaging modality for establishing the diagnosis. Methods: We reviewed the different types of presentations and outcomes of patients presented to Sarawak General Hospital, Malaysia with myxoma in 2015. Results: Case One: A 67-year-old gentleman, initially treated as bronchial asthma, referred to our centre for worsening shortness of breath despite being treated for one week. Chest X-ray (CXR) was unremarkable. Further work- up with TTE showed left atrial mass suggestive of myxoma measuring 4.3 cm x 3.8 cm. Case Two: A 38-year-old lady, with history of ischemic stroke, presented with sudden unilateral limb weakness and fever. No significant neurological deficit but peripheral vasculitic lesions were noted. She was initially investigated for infective endocarditis with embolic event. However, repeated TTE in our centre showed left atrial mass suggestive of myxoma, measuring 2.1 cm x 2.7 cm. Case Three: A 73-year-old previously healthy woman, presented with worsening reduced effort tolerance over the past one month. Examination was suggestive of left heart failure; consistent with CXR findings. Initial TTE showed atrial mass (1.4 cm x 7.2 cm) causing mitral valve obstruction and pulmonary hypertension. Discussion/Conclusion: The diagnosis of atrial myxoma can be ambiguous and may be easily missed, especially when the different clinical presentations are suggestive of other diagnoses. TTE is investigation of choice for diagnosing myxoma in symptomatic patients. Early surgical intervention is warranted for better outcome. Our review showed all tumour excisions were successful and histopathological examinations confirmed myxoma. Although myxoma is histopathologically benign, they can lead to serious complications e.g. embolism and intracardiac obstruction

Indication, Safety and Clinical Impact of Cardiovascular Magnetic Resonance: A Pilot Run of the First National CMR Registry for Malaysia

Background: Cardiovascular magnetic resonance (CMR) is a rapidly emerging noninvasive imaging technique providing high resolution images without any application of radiation. It has broad range of clinical applications and is increasingly been used in clinical practice in Malaysia. A national CMR Registry is needed to assess its practice in Malaysia. Objective: To evaluate indications, safety and impact on patient management of CMR in Sarawak Heart Centre. Materials Methods: A pilot run of CMR Registry in single centre with consecutive patients who underwent clinical CMR from January-June 2015. Retrospective data collection from CMR database and case notes. Results: A total of 169 patients underwent clinical CMR, with 20 did not complete scan; 25% due to claustrophobia. 94% of patients received gadolinium-based contrast agent. Most important indications were viability assessment (54.4%), cardiomyopathy (28.2%), and risk stratification in suspected coronary artery disease (CAD) (4.7%). 6.7% of patients underwent stress MR (adenosine or dobutamine). Severe complications only occurred in 0.7% of the cases (anaphylactic reaction secondary to contrast agent). No mortality during/due to CMR. There was direct impact of CMR on the clinical management by confirming suspected diagnosis (59.1%), excluding suspected diagnosis (21.5%), providing additional information for suspected diagnosis which is confirmed or excluded (18.1%) and providing unsuspected completely new diagnosis (1.3%). Invasive coronary angiogram was avoided and diagnosis were excluded in all patients referred for risk stratification of suspected coronary artery disease. Invasive therapeutic procedures such as PCI, CABG, valve surgerywere triggered in 49.6 % of patients after CMR was done, regardless of indication. Out of 81 patients who underwent CMR for viability study, 76.5% were planned for revascularisation (CABG or PCI) with the restwere planned for optimalmedical therapy only after the CMR. Conclusions: The top indications of CMR in Sarawak are viability assessment, cardiomyopathy and risk stratification in suspected CAD, which differs from the EuroCMR registry results. This demonstrated the importance of establishing a national multicentre CMR registry in Malaysia, and subsequently substudy on specific conditions. With appropriate medical personnel training and patient selection, CMR is safe and has strong impact on clinical management

Comparison of Resting PD/PA with Fractional Flow Reserve Using a Monorail Pressure Catheter

Background: The RXi™ system (ACIST Medical Systems, MN, USA) is a new Fractional Flow Reserve (FFR) technology utilising an ultrathinmonorail microcatheter (Navvus®; ACIST Medical Systems) with an optical pressure sensor located close to the distal catheter tip. FFR measurement using monorail microcatheter is comparable to the conventional pressure wires. However, the predictive value of resting distal coronary artery pressure/aortic pressure (Pd/Pa) on hyperemic FFR value in the real world practice is unknown. Objective: To explore the diagnostic accuracy of resting Pd/Pa in relation to hyperemic FFR using the monorail pressure catheter. Methods: Resting Pd/Pa and FFR were measured using monorail pressure catheter in 67 consecutive patients with intermediate coronary artery lesions (30% to 80% diameter stenoses) between 01-03-2016 to 17-01-2017. Of 121 studied lesions, 29 (23.97%) were excluded because of no hyperemic FFR due to postive resting Pd/Pa (n=17), severe or non-critical stenosis (n=11) and suboptimal acquisition (n=1), leaving 92 lesions for final analysis. Hyperemic FFR was induced with intracoronary adenosine. The selection of coronary wire and the dose of intracoronary nitroglycerine were at the operators’ discretions. Results: Bland-Altman plots showed a moderate degree of scatter between Pd/Pa and FFR value. On average, Pd/Pa exceeded FFR by 0.066 (-0.09 to +0.22). Receiver-operating characteristic curves of the resting Pd/Pa with FFR≤0.80 as the reference variable showed an area under the curve of 0.78 (95% confidence intervals 0.680 to 0.881, pb0.001), with a diagnostic accuracy of 79.3% when the resting Pd/Pa was ≤0.86. Certain cutoff values of Pd/Pa can reliably predict whether hyperemic FFR was positive or negative (FFR cutoff≤0.80). Resting Pd/Pa value of N0.96 had a negative predictive value (NPV) of 100% and sensitivity of 100%; the resting Pd/Pa value of ≤0.82 had a positive predictive value (PPV) of 100% and specificity of 98.3%. These were consistent regardless of coronary vessel, location of lesion or degree of diameter stenosis. Conclusions: Certain range of resting Pd/Pa measured by monorail pressure catheter had excellent NPV and sensitivity or excellent PPV and specificity to predict hyperemic FFR. Clinical outcome studies are required to determine whether the results might obviate the need for hyperemia in selected patients

Impact of Myocardial Viability Assessed by Delayed Enhancement Cardiovascular Magnetic Resonance on Clinical Outcomes in Real World Practice

Background: Delayed enhancement cardiovascular magnetic resonance imaging (DeCMRI) has become the preferred method for viability assessment. It is well established that viable dysfunctional myocardium has the potential for functional recovery after revascularization. Objective: Our objective is to evaluate whether viability assessment by DeCMRI affects clinical outcome in daily clinical practice. Methodology:We retrospectively studied 132 consecutive patients (114 male, mean age 59 ± 10 years) with ischaemic cardiomyopathy (Mean LVEF: 29.1 ± 14%) who underwent CMRI viability testing from 1st Jan-31st Dec 2015 in our centre. Patientswere divided into 3 groups: Group A: Viable myocardium- optimal medical therapy only (38.6%); B: Viable myocardium- revascularization done (29.5%); and C: Nonviable myocardium (29.5%). Results: Mean age for groups A, B and C were 61.2, 58.3, 56.2 years respectively, p=0.048. The proportion of triple vessel disease in each of the groups were 56.1%, 54.5% and 38.5% (p=0.44); whereas left main involvement was 31.7%, 21.2% and 19.2% respectively (p=0.43). Majority of group C patients did not undergo revascularisation (90%). Group B had statistically significant EF improvement (5.5%, SD 11.9) compared to Group A (-0.6%, SD 6.7) and Group C (-1.2%, SD 9.8), p value 0.014. Mortality at 1 year was significantly higher in Group A compared to Group Band C (31.4%, 7.7% and 12.8% respectively, p=0.009). MACE rates were also increased in Group A compared to the other two groups (41.2%, 20.5% and 27.0%, p=0.09). Odds Ratio for MACE was 3.01 (95% Cl 1.22 - 7.45) for Group A vs B and 2.8 (95% Cl 1.1 - 6.9) for Group A vs C. Conclusion: Patients with viable myocardium who did not undergo revascularization (group A) had the worst prognosis, even when compared to those with non-viable myocardium; with significantly higher 1-year mortality. Although not statistically significant, there was also a trend towards higher MACE in these patients. These findings emphasize that patients with poor LV function but viable myocardium need to undergo revascularisation and that optimal medical therapy alone is not sufficient

Prognostic Value of N-terminal B-type Natriuretic Peptide in Patients with Acute Myocardial Infarction: A Multicenter Study

Background: Several models have been developed to help the clinician in risk stratification for Acute Coronary Syndrome (ACS),such as the TIMI and GRACE risk scores. However, there is conflicting evidence for the prognostic value of NT-ProBNP in acute myocardial infarction (AMI). Objective: (1) To explore the association of NT-proBNP with 30-day clinical outcome in AMI patients. (2) To compare the prognostic value of NT-proBNP with TIMI and GRACE risk scores in AMI patients. Methods: We conducted a multicenter, prospective observational study recruiting patients presented with AMI between 29-October-2015 and 14-January-2017, involving 1 cardiology referral centre and 4 non-cardiology hospitals. NT-proBNP level (Alere Triage®, US)was measured within 24 hours fromthe diagnosis of AMI. Patientswere followed-up for 1 month. Results: A total of 186 patients were recruited, 143 from tertiary cardiology centre and 43 from non-cardiology hospitals. Mean age was 54.7±10.0 years, 87.6% male and 64% were STEMI. The NT-proBNP level ranged from 60 to 16700pg/ml, with a median of 714pg/ml. Using the 75th centile as the cutoff, Kaplan-Meier survival analysis for the 30-day cardiac related mortality was significantly higher for patient with NT-proBNP level of ≥1600pg/ml (6.4% vs. 0.7%, p=0.02). Cox-regression analysis showed that NT-proBNP level of ≥1600pg/ml was an independent predictor of 30-day cardiac related mortality, regardless of TIMI risk score, GRACE score, LV ejection fraction and study hospitals (HR 9.274, p=0.054, 95%CI 0.965, 89.161). Readmission for heart failure at 30-day was also higher for patient with NT-proBNP level of ≥1600pg/ml (HR 9.308, p=0.053, 95%CI 0.969, 89.492). NT-proBNP level was not associated with all-cause mortality, risk of readmission for ACS, arrhythmia and stroke (pN0.05). By adding 50 score to GRACE risk score for NT-proBNP level of ≥1600pg/ml, combination of GraceNT-proBNP scores of more than 200 appeared to be a better independent predictor for 30-day cardiac related mortality (HR:28.28, p=0.004, 95%CI 2.94, 272.1). ROC analysis showed that this new score had 75% sensitivity and 91.2% specificity in predicting 30-day cardiac related mortality (AUC 0.791, p=0.046). Conclusions: NT-proBNP is a useful point-of-care risk stratification biomarker in AMI. It can be combined to the current risk score model for better risk stratification in AMI patients

Reversal of cardiac damage in patients with symptomatic severe aortic stenosis following transcatheter aortic valve implantation: An echocardiographic study

Background: Severe aortic stenosis (AS) results in cardiac damages, such as left ventricular hypertrophy, left atrial enlargement, pulmonary pressure elevation and in advanced stage, right ventricular damage. Généreux and colleagues proposed a staging classification based on these extra-valvular damages in 2017, with increasing stage representing more cardiac damage. While regression of these cardiac damages is expected following aortic valve replacement, the reversal of cardiac damage based on this staging system has not been described. Purpose: This study aimed to describe and stage the changes in cardiac structure and function at 6 months and 1 year after transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe AS. Methods: This was a retrospective, single center, longitudinal observational study. Echocardiographic data of patients who underwent TAVI were retrieved and analysed. Results: From May 2018 to Feb 2021, 31 patients underwent TAVI. 5 patients were excluded due to death <6 months post-procedure (n=2) and incomplete echocardiographic data (n=3). The mean age of the remaining 26 patients was 70.9±9.4 years, 57.7% were male, and 34.6% bicuspid aortic valve. After TAVI, transvalvular aortic mean pressure gradient reduced from 45.2±14.5 mmHg to 8.0±5.4 mmHg (p<0.001), and aortic valve area increased from 0.57±0.21 cm2 to 1.75±0.68 cm2 (p<0.001). At baseline, 6-month and 1-year, the left ventricular mass index (LVMi) were 183.4±60.7g/m2, 150.8±55.3 g/m2 and 126.8±42.1 g/m2 (p<0.001) respectively; left-atrial volume index (LAVI) were 60.4±22.8 ml/m2 , 51.7±23.8ml/m2, and 48.1±23.6ml/m2 (p=0.009) respectively; left ventricular ejection fraction (LVEF) were 52.3±25.4%, 64.2±29.3%, and 62.4±12.1% (p=0.005) respectively. Based on the proposed cardiac damage staging for AS, at baseline 38% of patients were stage 1, 65.4% stage 2, 7.7% stage 3 and 23.1% stage 4. At 1 year, 8.3% were stage 0, 29.2% stage 1, 58.3% stage 2, and 4.2% stage 4. 12 patients (46%) showed improvement in cardiac damage staging, and the other 14 (54%) remained in the same stage. Conclusion: In patients with symptomatic severe AS, there were overall significant regression in LVMi and LAVI, and improvement in LVEF at 1 year after TAVI. However, improvement in cardiac damage staging was observed in only 46% of patients

Prognostic Value of N-Terminal Prohormone of Brain Natriuretic Peptide (NT-ProBNP) and Killip Score in Patients with Acute Decompensated Heart Failure (ADHF): A Sarawak Tertiary Centre Experience

Mortality and readmission due to heart failure is contributing to increase healthcare burden. NT-proBNP is known for its role in diagnosis of heart failure. Higher Killip score was found to be associated with more inpatient death among ADHF patients in Sarawak General Hospital. There are limited data on usage of NT proBNP and Killip score to prognosticate post discharge clinical outcome

ACUTE DECOMPENSATED HEART FAILURE (ADHF) IN A NON CARDIOLOGY TERTIARY REFERRAL CENTRE - RELATIONSHIP BETWEEN NT-PROBNP AND CLINICAL OUTCOMES

Objective We aimed to explore the association of admission NT-ProBNP with length of hospital stay, inpatient mortality or requirement of advanced tertiary care, 30-day and 90-day composite mortality and readmission outcomes. Methods 68 patients with a primary diagnosis of ADHF were recruited between December 2017 to October 2018 at Sarawak General Hospital. NT-proBNP samples were collected within 24hours from diagnosis. Patients were prospectively followed up for 90 days. Other clinical factors assessed include age, gender, hypertension, diabetes mellitus, dyslipidemia, NYHA, ejection fraction, admission BP and admission heart rate. ROC analysis was applied to determine NT-proBNP level with optimal sensitivity and specificity to the outcomes. Clinical factors were investigated for their role in affecting the discriminative value of NT-proBNP. Results The mean age of patients recruited was 58+/-17years old, 57% were male and admitted for approximately 8 days. 16 (28%) patients recorded at least a prespecified outcome within 90 days. The median value of NT-proBNP was 4115 pg/ml. NT-proBNP has no significant correlation or association with length of stay and inpatient outcome. NT-proBNP was significantly associated with the 30 and 90-day outcomes (p=0.050, p=0.024) with fairly good discriminative value (AUC=0.685, 0.694). At the level of 3305 pg/ml, NT-proBNP had a sensitivity and specificity for post-discharge outcome of 88%-92% and 51-54% respectively. The discriminative performance of NT-proBNP improved in the subpopulation of patients who were ≤65 years old, male gender and those with NYHA classfication of 3 to 4, respectively (AUC up to 0.871, p=0.004). Patients with NT-proBNP >3305 pg/ml showed 2 to 16 fold increase in risk of developing 30 and 90-day event (95% CI 1.4-110, p=0.0003-0.005). Conclusion Admission NT-proBNP, at the cut-off of 3305 pg/ml, is useful in predicting short and medium term cardiac events and hospital readmissions. Keywords: Heart Failure, NT-proBNP, Readmission, Mortality, Outcom

Impact of cardiac care variation on ST-elevation myocardial infarction outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention P-PCI). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved