@ 2017 SELAMAT DATANG. Don t Miss Today! TO NHAM 2017! + NHAM 2017 in numbers. Annual Scientific Meeting 2017 Friday, 7 th April 2017

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1 @ 2017 SELAMAT DATANG TO NHAM 2017! Welcome to the biggest cardiology meeting in Malaysia! This is our 21 st annual conference and we have an exciting 2 ½ day program. The theme of this year s meeting is Essential cardiology from cradle to cane. We aim to provide knowledge and expertise on all aspects of cardiac care for all ages, from the paediatric stage up to our final symposium on Sunday, which deals with cardiogeriatrics. A veritable feast of cardiology is on offer. The usual suspects include didactic symposiums, interactive case presentations, joint symposiums with our colleagues locally, as well as from the American College of Cardiology and the European Society of Cardiology, free paper oral presentations and posters. This year there will be three Clinical Practice Guidelines launched, on infective endocarditis, primary and secondary prevention of cardiovascular disease, and management of dyslipidaemia. Reflecting the importance of clinical cardiology, two dedicated fellow-intraining case competitions will be held, on arrhythmia and heart failure respectively. A two-day paediatric cardiology symposium focuses on the theme of Cardiomyopathy in the young. Lastly, we are proud to present the first ever NHAM-CRM Cardiovascular Research Workshop themed Discover, Collaborate, Translate. This unique offering will focus on basic science research in cardiology and will be graced by the Deputy Director-General of Health of Malaysia. We hope you will have an educational and enjoyable conference! Dr Ng Wai Kiat NHAM President Dr Sazzli Kasim Organising Chairperson Dr Mah Soot Keng Scientific Chairperson Don t Miss Today! Nik Zainal Memorial Lecture: Whither cardiology? American College of Cardiology lecture: Hypertension in European Society of cardiology lecture: Comprehensive imaging in coronary artery disease Symposium 5: All about Guidelines: Case based approach Fellow-in-training Case presentation competition: Heart failure; The many faces of cardiomyopathy th Angio Club Meeting Sentral Exchange, Hilton + NHAM 2017 in numbers 3 Days 48 Symposiums 1795 Attendees 6 Young Investigator Award Presentations 58 Oral Free Paper Presentations 88 Posters 1

2 DISCOVER, COLLABORATE, TRANSLATE The 1 st NHAM-CRM Cardiovascular Research Workshop This Saturday, NHAM is collaborating with Clinical Research Malaysia (CRM) to conduct the first ever-cardiovascular research workshop held at the ASM. This is a completely new, dedicated track, which hopes to build bridges and generate relationships between clinical practitioners and medical scientists. This unique collaboration involves the MSPP and cardiovascular pharmacists. The session has its roots in previous symposiums within the ASM, such as the regular NHAM-Pharmacy symposiums, and the inaugural NHAM-MSPP symposium held last year. NHAM 2017 Organising Chairperson Sazzli Kassim enthuses over the symposium: We wish to galvanise basic scientific innovations in cardiovascular disease. The theme of the meeting is Discover, Collaborate, Translate. We want to discover each other, meaning that for too long, basic scientists and clinicians Dr Akhmal Yusof CEO, CRM Dr Khairul Faizi Khalid Head of Business Development, CRM Dr Sazzli Kasim Organising Chairperson, NHAM have been working in silos, isolated from each other. We want to collaborate and coordinate with each other and then translate our work to the real world. CRM is an NGO dedicated to promoting Malaysia as a preferred destination for industry sponsored research. The Malaysian Ministry of Health established it in Its services include feasibility studies and investigator matching, consultation and management of clinical trial budget, development and placement of study coordinators as well as training related to clinical research. The NHAM-CRM workshop will be attended by the Deputy Director-General of Health, Datuk Dr Shahnaz binti Murad. There will be two major symposiums, three plenary sessions and three free paper presentation sessions encompassing biomedical, Basic Science and clinical fields. A total of 15 oral abstracts and 27 posters will be presented. + Check it out Who can attend? Attendance to the workshop is free for registered delegates of the NHAM 2017 ASM. Where? Gallery Room, Level 8, Le Meridien Hotel When? Saturday, 8 th April 2017,

3 A MESSAGE FROM SOPACE CHAIRPERSON Welcome NHAM Annual Scientific Meeting participants! Dr Mah Soot Keng SoPACE Chairperson It is a pleasure for me to have this opportunity to network, mingle and establish friendship with you all. As said, this year we are bringing in new innovative ways to ensure your participation in this meeting is met with high expectations. The Society of Pacing and Cardiac Electrophysiology (SoPACE) is thrilled to roll out her very first ECG handbook this year! It is the first of many volumes of interesting ECGs which my colleagues and I have collected over the years. The ECGs are presented in the style of multiple choice question, and followed by careful annotation of the main spotlight areas, and adequate but not too verbose explanation with reference to clinical data. Here and there we put in a pinch of humour, where appropriate. I also would like to share my personal 5 principles to clinching any electrocardiographic diagnoses and they are: 1. Always pay attention to zones of changes or transitions in an ECG. They often give away the diagnosis point blank! 2. If you happen to be in-charge of terminating an arrhythmia, be sure to record the ECG from arrhythmia to termination into sinus rhythm. This is where the gems are! But wait, the other 3 are in the handbook, along with case-by-case reviews of many ECGs. Why not pick up a copy while you are at the meeting? And the best part is, they are given as complimentary copies free of charge for any members of SoPACE, be it new or existing members! Limited copies are available, so guys hurry to the NHAM SoPACE BGM* registration counter to pick up one! I shall see you soon! MA Soot Keng SoPACE Chairperson Scientific Chair for NHAM ASM 2017 And the best part is, they are given as complimentary copies free of charge for any members of SoPACE, be it new or existing members! + Check it out NHAM SoPACE BGM will commence on 7 th April 2017 (Friday) Time? at 5:30pm, ~ Dr Ma Soot Keng SoPACE Chairperon Where? Sentral Accord Hilton KL Sentral, 6 th floor 3

4 Three new Clinical Practice Guidelines launched at NHAM 2017! + A lot of work goes into these CPG, and they should be disseminated and used ~ Dr Geetha Kandavello Three brand new Clinical Practice Guidelines (CPG) will be launched at NHAM The long awaited CPG on Primary and Secondary Prevention of Cardiovascular Disease, chaired by Dr Jeyamalar Rajadurai, is prominent amongst the new arrivals. The CPG for the Management of Dyslipidaemia receives its fifth iteration and is chaired by Dr Robaayah Zambahari. Lastly, a less common but very challenging clinical problem is tackled in the CPG for the Prevention, Diagnosis and Management of Infective Endocarditis. Paediatric cardiologist Dr Geetha Kandavello, who chairs these guidelines, said, A lot of work goes into these CPG, and they should be disseminated and used. + Get with the Guidelines at NHAM 2017! Friday, 7 April Symposium 5: All about guidelines-case-based approach CPG on Prevention of Cardiovascular Disease and Infective Endocarditis Saturday, 8 April Symposium 12: Lipidology in 2012 CPG on Hyperlipidaemia 4

5 Infective endocarditis: a challenging clinical problem Pulse@NHAM met up with Dr Geetha Kandavello to discuss the CPG on Infective Endocarditis Infective endocarditis remains a challenging clinical problem to those who manage it, according to Dr Geetha Kandavello, Chairperson of the CPG on the Prevention, Diagnosis and Treatment of Infective Endocarditis. Dr Geetha Kandavello The new guidelines are comprehensive and detailed and are published online and also in pocketbook form in the future. Please outline some of the unique features of the CPG. We have tried our best to place the guidelines in a local context. In the appendix, we have highlighted centers which we refer to as specialist centres(sc),where patients who have complicated endocarditis should be referred to at an early stage. We have clearly defined what is meant by complicated and non-complicated endocarditis. Another unique feature is that we have amalgamated the paediatric and adult guidelines together. There is a growing incidence of endocarditis in patients with adult congenital heart disease, and also neonates with normal structural hearts who have prolonged invasive monitoring and indwelling Prophylaxis has recently been a controversial issue. What do the guidelines say about this? We have clearly defined a group of high-risk patients where antibiotic prophylaxis is mandated. We have also clearly defined the dental and non-dental procedures in which it is necessary. Interestingly, we included in the high-risk group, those with native valve disease including rheumatic valve disease, which is a group not included in the ESC guidelines. This is because our valvular heart disease is more widespread, and sometimes in more advanced Diagnosis of endocarditis can sometimes be challenging. How do the CPG provide direction in this matter? The use of transesophageal echocardiography is highlighted. We feel that this is sometimes underused. In cases of prosthetic valves and indwelling catheters it becomes almost mandatory. There is a higher yield of demonstrating vegetations, perivalvular complications and assessing the need for future valvular intervention. The guidelines contained a series of flowcharts so that one can follow a pathway from diagnosis right up to treatment. In the case of culture negative endocarditis for example, the pathways highlight more sophisticated diagnostic methods that may help. A comprehensive list of the possible organisms to cover in culture negative endocarditis, and even the available facilities in Malaysia to diagnose them, are provided. There has been a move to earlier surgery in the treatment of endocarditis. Yes, absolutely! We outline clear indications for early surgical intervention and a recent randomised trial also showed improved outcomes. Another unique feature of the guidelines is a recommendation of specific timeframes to perform surgery depending on the urgency of the case. Lastly, how has the experience been chairing these guidelines? It has been hard work but it has been a good experience. It has been very instructive and educational to hear and appreciate the views from different specialties. I hope that the guidelines can be disseminated and used and we have plans for roadshows in the future. + Check it out! Friday, 7 April Symposium 5: All about guidelines-case-based approach CPG on Prevention of Cardiovascular Disease and Infective Endocarditis 5

6 Atrial fibrillation and Heart Failure: The double-edged sword Datuk Dr Razali Omar met up with Datuk Dr Razali Omar, senior consultant electrophysiologist at the National Heart Institute he gets more breathless, then it is more likely tachycardia first which was been allowed to go on and on, and now presenting as heart failure. We are not always that lucky of course, as some patients presented for the first time with features of both heart failure and AF. We need to do investigations like angiogram and cardiac MRI etc as TIC becomes a diagnosis of exclusion. If everything is normal, we often label them as non-ischemic cardiomyopathy, so what do we do then? In this case, what I would do is to try and go after the arrhythmia and then monitor the patient carefully. If the patient EF improves, then I know that this is a retrospective diagnosis of TIC. How would you choose between an initial rate- or rhythm-control strategy in the AF and heart patient population? In your clinical practice, what is the proportion of AF patients with impaired LV function? Not many, I would say probably 10%. I believe this is due to referral bias; as all these patient that are referred to me are mainly for AF ablation after they failed at least one or more anti-arrhythmic drugs. It is not representative of the true burden of AF with heart failure out there. How does the interaction of these 2 disorders (AF and heart failure) play out clinically? This is a very important question. In my opinion, I believe that most of the time, AF is a consequence of heart failure. However, we need to make sure, especially in patient with nonischemic cardiomyopathy, that the cause of impaired LV function is not due to tachycardia. Let me give you one example; one of my young patients referred for heart transplant actually has a diagnosis of atrial tachycardia. Over time, the incessant tachycardia has caused negative remodeling of the LV and even fibrosis, which then leads to drop in ejection fraction (EF). This is called tachycardia-induced cardiomyopathy(tic). In this case, it is important to identify whether it is a true TIC or not. After I ablated the atrial tachycardia, the EF improved with time. Same goes with patient with fast atrial fibrillation and this has been demonstrated many years ago by Dr Grogan he showed that by just controlling the rate of AF with medication, the EF improved. This was the first description of TIC. How do you determine that the AF is causing the heart failure and not a consequence of heart failure? This is always something I wrestle about, whenever I see young patient with AF or any form of arrhythmias AND LV dysfunction, is it the chicken or the egg, which came first? Good history taking is important; for example if the patient says that he had palpitations many years ago and was well at that time, and now + AF at NHAM Friday, 7 April Symposium 8: New Paradigm in AF Management Clake Ballrom, Le Meridien Saturday, 8 April Stroke Prevention in AF: Assessing Risk and How to Improve Practical Decision-making in Everyday Clinical Practice In general, I would try to control the rate first and based on RACE-2 trial, an average rate of less than 110bpm is adequate. If I can ensure the patient has adequate rate control and symptoms improve, then I leave it at that. However, if I can prove that the decompensation of heart failure is secondary to AF with fast uncontrolled ventricular rate, despite optimal AV nodal blocker therapy, then I will consider two options: one is catheter ablation, or secondly, AV nodal ablation with implantation of pacemaker. In which patients would you be most likely to recommend curative ablation and which would you recommend AVN ablation with pacemaker? We must balance the possibility of success versus the potential complications of extensive AF ablation. For example if the patient has large atrial size, is elderly with multiple comorbidities and very poor LV function, I would do an AV node ablation and implant a CRT pacemaker with or without a defibrillator. If the patient is a younger patient, parosyxmal AF and left atrial size of less than 5.5cm, I would discuss with the patient the option of cathether ablation of AF. Until further evidence comes to light, what would you recommend to physicians right now as the best way to handle patients with AF and ventricular dysfunction in their hospital? Very good question. Unfortunately in Malaysia, we have very few hospitals that have the capabilities of performing AF ablation. So I think most of the hospital would go for drug therapy. The big question is rate or rhythm management? There have not been many studies since AFFIRM, published in 2002, which basically did not demonstrate any significant outcome in either group. Many apply AFFIRM inappropriately. What I mean is that the trial mainly targeted patients 65 years and older; so we may not be able to extrapolate findings to patient aged In an elderly patient, not very symptomatic, I would go for rate control. If it was a younger patient, very symptomatic, I would be more in favour of rhythm management, based of the fact that AF begets AF, either for drug therapy or catheter ablation therapy. Importantly, remember to anticoagulate this high-risk group of patient, not forgetting optimal anti-heart failure drug therapy and monitor the patient closely to see any improvement in symptoms or LV function. 6

7 3 rd ECHO CLUB MEETING Case Review 3 rd ECHO CLUB MEETING By Dr Effa Abdul Rahman Going for round 3, EchoClub is slowly but surely embedding itself into NHAM ASM!This year, the audience experienced an unexpected twist as the session settled into a more congenital note. UiTM kicked off with a case of a middle-aged man presenting with suspected IHD. TTE showed aneurysmal RCA and absent left main ostium. There was a visible color doppler flow within the pulmonary artery raising suspicion of ALCAPA, which was later confirmed by cardiac CT. Hospital Tengku Ampuan Afzan then presented a case of sinus venosus ASD and showed how TEE can be used to look for anomalous pulmonary venous drainge. Hospital Sultanah Aminah took the audience for a ride with an interesting case of parachute mitral valve and caveats of assessing stenosis severity and subsequent management as compared to the traditional rhuematic and degenerative mitral stenosis. The session continued further with showcases from UMMC and Hospital Pulau Pinang before finishing with an encore from Hospital Queen Elizabeth. The evening drew its curtain closed at 9pm with plenty of intermingling between novices and experts and as well as the Paediatric and adult cardiology disciplines. The Society of Cardiac Imaging will aim to provide similar activities, relatable to all levels of experience, so everyone can experience the doppler effect. 7

8 MySTEMI: Taking Forward STEMI Treatment in Malaysia NHAM embarked on a project named MySTEMI Network for the Klang Valley region. Primary percutaneous coronary intervention (PCI) remains one of the best treatments for myocardial infarction. Clinical evidence suggests that primary PCI provided in a timely manner improves patients clinical outcome. It is hoped by piloting a regional based network, accessibility and improvement in door-in-door out times and door to Balloon times could be achieved among STEMI patients in participating non-pci hospitals and PCI-capable hospitals in Klang Valley. For the very first time, NHAM is coordinating a project with the main stakeholders from the Ministry of Health Hospitals, Universities and Institut Jantung Negara. The current hub hospitals are Institut Jantung Negara, University Malaya Medical Centre (UMMC), Hospital Serdang, Pusat Perubatan UKM (PPUKM) and Hospital University Teknologi MARA (UiTM). A hub hospital may service 2-3 spoke hospitals forming a STEMI cluster. The STEMI clusters are listed below: Hospital Kuala Lumpur Institut Jantung Negara (IJN) Hospital Tengku Ampuan Rahimah Klang UMMC Hospital Shah Alam UMMC Hospital Putrajaya Hospital Serdang Hospital Kajang Hospital Serdang Hospital Banting Hospital Serdang Hospital Ampang PPUKM, Hospital Serdang, IJN Hospital Sungai Buloh UiTM, IJN Hospital Selayang UiTM, IJN Hospital Tuanku Jaafar Seremban Hospital Serdang Based on the data collected between 23 rd February 2016 to 31 st January 2017, the introduction of the MySTEMI network noted 23.4% reduction in median door to balloon (D2B) time from 111 minutes (NCVD ACS Registry Report, 2011 to 2013) to 85 minutes. + MySTEMI at NHAM % of Hub Centres had D2B time of less than 90 minutes, whereas 74.1% of Spoke Centres had D2B time of less than 120 minutes in MySTEMI network. Implementation of MySTEMI network reduced temporal delays and improved the participating hospitals timing of diagnosis, hospital transfer and treatment of patients suffering from acute STEMI Symposium 2: Focus on MySTEMI 8

9 Hot topics and controversies in hypertension: talked about all things hypertension with the Past President of the Malaysian Society of Hypertension, Dr Azani Daud What was the biggest news in hypertension recently? Undoubtedly, the SPRINT trial. This was a trial randomizing patients with systolic BP 130 mmhg and increased CV risk, but without diabetes, to an intensive treatment target (<120 mmhg) or standard target (<140 mmhg). The study showed a benefit in terms of the primary outcome, and even all cause mortality. Of course the intensive arm showed a higher rate of some adverse events. Earlier, studies like ACCORD had put a spanner in the works of the idea that lower is always better. The latest JNC guidelines had also relaxed their targets. It is very important to realize that in SPRINT the methodology of BP measurement is very different to other studies. Usual BP measurements are the traditional clinic-based measurements. In Sprint it was closer to that of home BP monitoring. The patients were taken to a quiet room and rested for five minutes alone, and then an automated machine took three readings. This may affect whether we can extrapolate these readings to what we see in real life. The long and short of it, is that we must individualize BP targets. We must look not only at the chronological age but also the biological age of the patient. We must consider their comorbidities and other drug treatments. So, if we have a young hypertensive diabetic in his 30s we may be aiming for a blood pressure of less than 120/80 mmhg, as we are trying to prevent long-term target organ damage. The situation is different in an elderly diabetic with coronary artery disease and advanced renal impairment. ABPM certainly give you more information; sleep BP and dipping status and earlymorning surge can really only that be diagnosed this way. Which do you find more useful: ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM)? Many of us are using more and more HBPM. But there are certain caveats. Firstly, we must use a validated machine. Secondly we must instruct our patience on the proper method; five minutes quiet rest, back and arms supported, legs uncrossed, no tight clothing, no coffee for 30 minutes prior, and recording three measurements. Thirdly, we must tell them to keep records and bring them to show us, or the whole exercise will be futile. ~ Dr Azani Daud HBPM overcomes therapeutic inertia, in some developed healthcare systems, practice nurses or patients can adjust and vary the dose of treatment based on HBPM, within clear limits and protocols. ABPM certainly give you more information; sleep BP and dipping status and earlymorning surge can really only that be diagnosed this way. What do you think of prescribing antihypertensives at night, instead of the traditional morning prescribing? With once-daily medications with long half-lives this should be less of a problem. However, we know there are patients who are fast and slow metabolizers of drugs. Again ABPM is useful here, to identify non-dippers and those with significant early-morning surge. In these patients one can consider prescribing some of the drugs at night to try and get better control. +Hypertension at NHAM Friday, 7 April, American College of Cardiology lecture: Hypertension in 2017 Ballroom C Dr Azani Daud Past President of the Malaysian Society of Hypertension Friday, 7April Symposium 6: Hypertension: The Practice essentials Clarke Ballroom 9

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12 Annual Scientific Meeting 2017 Friday, 7th April