Sunday, May 07, 2006

Cardiac Facilities among best in the country

Perhaps once a month we will allow ourselves a chest thumping post such as this one. The health minister has said that cardiac facilities are among the best planned in the country as compared to other fields of speciality.

Facilities to handle heart problems are among the best in the country as far as speciality fields in Malaysia are concerned, Health Minister Datuk Dr Chua Soi Lek said. He said the country had three cardiac centres – in Penang, Johor and Kuching – with 15 cardiologists, nine cardiac anaesthesiologists and 14 perfusionists (people who operate heart-lung machines). “There are also a number of people in the queue for these training programmes,” he said at the opening of the fourth Biennial Meeting on Cardiopulmonary Bypass here yesterday. His speech was read out by state Assistant Minister of Public Health Dr Soon Choon Teck. Dr Chua said the ministry was setting up a new cardiac centre in Serdang to cater for the central region of Peninsular Malaysia. The centre in Penang handles the northern region, Johor (southern region) and Kuching (Sarawak and Sabah). “I am proud to say that this is one of the most well-planned speciality fields,” he said.

Let me begin by commenting on what the Hon.Min. of Health has announced. It is true that there are good cardiac facilities in Kuching Sarawak and Penang GH. They do open heart surgery regularly. The cardiac team is reasonable by ASEAN standards. We are still far behind Asian or developed country standards. As for the cardiac center in Johore Baru, I think that more work needs to be done. Serdang Heart center, is yet to come on-line.

I was a little surprised that IJN was not mentioned. I must say that IJN is probably the most experienced Malaysian heart center and the one doing most of the cardiac interventions and cardiac surgery. They are quite good at the day to day, bread and butter stuff, but in my opinion, not providing enough leadership in cardiac innovation, research and training. As such, we have lost the opportunity to be the cardiac leader in ASEAN.

As usual in Malaysia, we have facilities as much as our money can buy, but we often forget the personnel. Staff needs to be trained, and I mean world standard staff. That is where the difference is. Anyway, I have said enough.

I was asked whether our facilities can cope with world standard treatment of AMI, namely primary angioplasty for AMI. I must begin by stating that primary angioplasty is the best form of therapy for AMI (acute myocardial infarct) especially anterior infarcts. Small inferior infarcts can still be managed medically with good results. We all know that "time is muscle". The time taken for onset of chest pains to reperfusion is crucial for good prognosis.

But angioplasty results for AMI can only be good if a few criteria are met. :

1. The angioplasty center must be performing angioplasties regularly, if possible > 150 angioplasties a year, with a success rate of >95%, a mortality of <1%,> 120 mins making angioplasty only almost as beneficial as thrombolysis. So there are many centers who will angioplasty if it is during office hours, and thrombolyse, should the time taken to assemble an angioplasty team be too long.

2. Have a team ready to do angioplasty 24/7/365. The door - balloon time should be less than 120 mins. The door to balloon time describes the time taken to put a balloon across the acute occlusion, from the time the patient presents at the ER door.

3. The angioplasty center should also have an active CABG program.

Otherwise IV thrombolysis is a good alternative.

In America and China, some centers only perform coronary angiograms and do not do angioplasties. Should an AMI arrive at these centers, they should be transfered to centers that can perform angioplasties, if possible, within 1-2 hours by road transport.

To the best of my knowledge, in Malaysia, there are about 6 or 7 cardiac centers that are capable and have a program for AMI angioplasties, 24/7/365. Four of these centers are in public hospitals (with highly variable results). They have staff on duty who either live in or are prepared to come in any time of the day to do angioplasties. Their door to balloon time can be 60-90 mins.

Many other centers will do AMI angioplasties should the patient arrive during office hours. Should the patients have chest pains and present themselves after office hours, the time taken to assemble a team may take > 120 mins making angioplasty only almost as beneficial as thrombolysis. So there are many centers who will angioplasty if it is during office hours, and thrombolyse, should the time taken to assemble an angioplasty team be too long.

Whether with 6-7 centers for Malaysia, is the cardiac facilities good enough as the hon.minister claim, well I don't think so. What I also do not know is the results at these centers. I occasionally hear of disasters. But that is not a fair statement since its hearsay. So I really do not know the outcomes data. As an interventionist, I am ashamed. We have money to buy and build the best facilities, but does this mean that we are helping AMI patient get better, I will like to see at least outcome data. Maybe they are all doing very good work, I do not know. Good facilities do not guarantee good results. Well, I m sure that we are better now than 10 years ago, in treating AMI, but we still have along way to go to reach first world standard.


Palmdoc said...

Yeah yeah. But are you guys really

Up To The Mark ?

huajern said...

Are those numbers enough for our 20 million population? Not by a big margin if you work in a peripheral hospital like me, where 8 out of 10 'urgent' referrals are given CLINIC appointments of a month or more.

Lei said...

Dr. Ng,

What an interesting post highlighting the differences and similarities between healthcare in Malaysia and other parts of the world. Your blog is a valuable resource for those interested in cardiovascular disease worldwide.

BTW, you're the featured blog this week at A Hearty Life.

Heart-to-Heart #7: The Heart of the Matter

sleven h said...

Nice to know there are centres trying to achieve the 90 min bar or at least manage 120mins. But are our centres utilised efficiently and cost effectively. I doubt it very much. Basic problem is cath lab staff not always on 24/7 and private doctors have no access to labs. There will always be a learning curve but once this is achieved even cardiac surgical standby can be minimised. Basic principle of time is myocardium if achieved within 90mins should not be sacrificed on the altar of bureacracy.