Exercise stress test showed ECG changes and her doctor proceeded to conduct further examination. That’s when a heart CT scan found Lina had several heart blockages. Lina is among many younger people who have what used to be seen as a disease of the elderly. For cardiologist Dr Al Fazir Omar, the youngest patient he has treated in recent years was in his early 20s.
“Noticeable now is that younger patients are coming in with heart disease,” says the consultant at Cardiac Vascular Sentral Kuala Lumpur. It scares me that patients in their early to late 30s are coming in with 心血管阻塞. “We see a trend of younger people presenting themselves with heart disease,” he says, adding that the average age when a heart attack in Malaysia occurs is 58, so anyone below 40 years is considered young.
需要注意什么
Also known as cardiovascular diseases (CVDs), heart disease is a disorder of the heart and blood vessels leading to coronary artery disease, heart valve disease or an impairment in the heart’s electrical system. Like in Lina’s case, heart disease may present itself in unassuming ways.
Dr Al Fazir says that symptoms may take many forms such as chest discomfort, difficulty in performing physical tasks, breathlessness, swelling of the leg and palpitation. “A classic symptom is chest pain or discomfort in your chest walls. You get this uncomfortable, heavy and pressing feeling in your chest – the centre or to the left of your chest.
“It can also radiate to your arm, back and jaw.” As for breathlessness and difficulty in performing physical tasks, Dr Al Fazir shares: “Patients would say they were able to climb two or three flights of stairs without stopping but now needed to stop after half a flight of stairs. “Another patient once said that he could cycle fast on an incline but started to experience difficulties. When he came in, we found that he had 90% blockage in his artery.
“Some complained of swelling of the leg. “Make sure you go for a check up to find out what is causing this – it could either be the heart or issues with other organs such as the kidney disease that is causing the leg swelling,” he says. Dr Al Fazir says he has also come across a common symptom, especially since the covid pandemic: palpitations. “Patients come in saying there is an extra beat or a missed beat. While this is normally quite benign, it warrants further tests such as checking the patient’s clinical history or conducting an ECG and echocardiogram. “Sometimes, it is recommended to use a Holter ECG to monitor at home for a few days. Some smartwatches are able to pick up irregular heartbeats, too,” he says.
早期筛查很重要
As the saying goes, prevention is better than cure. In this case, Dr Al Fazir extols the importance of early screening. “Malaysians tend to have a lot of risk factors. It is important to know your risk profile and heart screening enables you to be more aware of your health.
“Heart screening is recommended after you are in your 30s. If you have a very strong family history of premature heart disease, you may want to check up even before your 30s. “I treated a patient in her 40s who was a triathlete and her only risk factor was a slightly raised cholesterol level. When we did the stress test and followed by CT cardiac, unfortunately, it showed a high grade of artery narrowing of the main artery,” he says.
Health screening not only screens for persons with coronary artery disease. Many young patients that come for assessment are worried if they are suffering from heart disease or that their friend just suffered from heart disease and it is causing them some distress. So it is nice to inform them that after all the checks that they are well and should continue and resume their daily activities and physical exertions without too much worry. Recently I have been seeing some patients as they are preparing for their Ironman (Ironman is known for their triathlon event).
“It is a good trend that people are exercising regularly but you have to be careful as well because some people have not exercised for a while but they go and sign up for a marathon run. “While exercising is good, you should know what your target heart rate is and know how much to push your body,” says Dr Al Fazir.
腿痛通常被视为短暂的感觉，无需担心，因为我们可能在生活中的某个时刻经历过这些感觉。然而，走路时腿痛可不是我们可以掉以轻心的事情。根据吉隆坡心脏血管中心 (CVSKL) 顾问血管和血管内外科医生 Dr. Tan Kia Lean 的说法，这可能是腿部跛行的迹象，也是外周动脉闭塞病 (PAOD) 的症状，也称为外周动脉疾病。
及早发现心脏病是确保及时诊断和治疗从而获得更好结果的第一步。一项主题为#BreakTheHeartache 的活动旨在通过采取积极的方法确保心脏健康，为患者及其亲人打破心脏病带来的身体和情绪困扰。该活动由社交媒体名人和企业家 Maggy Wang 推动，她与吉隆坡心血管中心 (CVSKL) 和医疗保健公司 Viatris 合作主持了一场小组讨论。
“看起来健康和身体健康不是一回事，因为心脏病会影响任何人。
“这就是为什么我一直倡导定期健康检查和早期发现和筛查的原因，”王在讨论中分享道。
关于与 CVSKL 的合作，Viatris 国家经理 Jeff Bote 表示：“降低心脏病风险的关键是提高认识和寻求早期治疗。
“我们很自豪能与 CVSKL 合作，让马来西亚人无论年龄或风险因素如何，都能过上更健康的生活”。
同时，CVSKL 顾问心脏病专家 Dr Al Fazir Omar 借此机会建议活动参与者进行年度健康检查，作为解决任何健康问题的第一步。参加小组讨论的有 Wang 挑选的 16 位社交媒体粉丝，他们分享了自己的故事。他们与 Dr. Al Fazir 坐下来谈论心血管疾病的症状，以帮助听众更好地了解患者在管理生活习惯方面的历程。
Mah Sing Group Bhd 创办人兼集团董事经理丹斯里梁海锦（右二）在 CVSKL 顾问心脏病专家的见证下，向吉隆坡心脏血管中心（CVSKL）基金会主席丹斯里拉什巴星兰德递交了一张 50,000 令吉的模拟支票，拿督 Rosli Mohd Ali 博士（左）和 CVSKL 首席执行官 Tan Eng Ghee。
It’s no longer surprising when someone says he has a stent placed in his coronary artery, or that she has gone for a bypass surgery.
After all, coronary artery disease (CAD), also known as ischaemic heart disease, is the biggest killer in the world, as well as in Malaysia.
According to the Statistics Department, 15% of medically-certified deaths in 2019 were due to CAD.
Angioplasty involves inserting a tiny balloon catheter into a blocked blood vessel to help widen it and improve blood flow to the heart
The casualties were 11,330 (69.4%) males and 4,995 (30.6%) females, with the states of Selangor, Johor and Perak topping the chart.
Like a number of other non-communicable diseases, the patients being struck down by CAD are getting younger.
In 2019, 18% of CAD deaths occurred in the 41-59 age group and 16% in the above-60 age group.
However, the good news is that medical technology is also advancing to help save patients’ lives.
Since the first coronary angioplasty to unclog blocked arteries was performed in 1977, the field of interventional cardiology has progressed in leaps and bounds, giving CAD patients another shot at life.
Angioplasty uses a tiny balloon catheter that is inserted into a blocked blood vessel to help widen it and improve blood flow to the heart.
It’s often combined with the placement of a small wire mesh tube called a stent, which helps prop the artery open, thus decreasing its chance of narrowing again.
Most stents are also coated with medication to help keep the artery open.
These are known as drug-eluting stents.
Angioplasty is also often performed during a heart attack to quickly open a blocked artery and reduce the amount of damage to the heart.
Angiograms are an essential part of an angioplasty.
An angiogram is a procedure that utilises a contrast agent to look at the blood vessels via X-ray.
It shows a two-dimensional silhouette of the interior of the coronary arteries that allows the cardiologist to see how much the vessel has narrowed.
Now, however, there is an imaging tool that allows the doctor to see a cross-section of not only the interior of the blood vessel, but also the layers of the artery wall itself.
This tool, known as intravascular ultrasound (IVUS), uses sound waves (ultrasound) to generate detailed imaging of the heart’s blood vessels.
This makes it possible to evaluate the amount of disease present, how it is distributed, and in some cases, what it is made of.
Explains consultant cardiologist Datuk Dr Tamil Selvan Muthusamy: “It’s a finer version where a camera-like device is attached to the tip of a catheter so that we can further evaluate the coronary arteries.
“With an angiogram, yes, we can tell that the artery is narrowed, but with IVUS, we can also assess the severity and nature of the blockage as we can see the artery inside out.
“Normally, we will balloon and put in a stent in many situations, but if you have IVUS knowledge, your techniques of angioplasty may differ, particularly if you have a severely calcified (hardened) artery.
“Then a normal balloon or stent may not work, and we have to decide what is the most appropriate device to tackle the blockage.”
IVUS allows doctors to see a cross-section of the blood vessel. Tearing of the blood vessel wall (labelled Dissection) can be seen here, and the diameter of the blood vessel can be measured (blue line), which helps doctors choose the right-sized stent. — Cardiac Vascular Sentral Kuala Lumpur
Improved outlook
In 2018, a three-year study was conducted on 1,448 patients to determine the percentage of patients who had recurring blockages after undergoing a stenting procedure, also known as target vessel failure (TVF).
It was found that only 6.6% of patients who underwent IVUS-guided procedures had TVF.
This was significantly lower than the 10.7% of patients who did not undergo IVUS and had TVF.
Published in the Journal of the American College of Cardiology, the results of the study emphasise IVUS’s ability to help reduce the chances of TVF by almost half.
This is important as a main risk of angioplasty, compared to bypass surgery, is renarrowing of the affected artery.
Thus, the use of IVUS could help improve the long-term results of angioplasty with stent implantation.
Says consultant cardiologist Datuk Dr Rosli Mohd Ali: “With IVUS, doctors can get a clear look at the final stent expansion and reduce the chances of post-procedure complications, thus achieving better long-term outcomes as shown in numerous studies.
“At the same time, we can also see the edges of the stent and if there is any tear in the vessel that may cause a blood clot.
“If this happens, a patient can get a heart attack after the procedure – sometimes within one to two hours.
“In certain areas, it is almost compulsory to use IVUS, e.g. in the left main trunk, which supplies two-thirds of blood to the heart.
“If anything happens there, it can be catastrophic, and sometimes, we can lose a patient there and then.”
Although IVUS technology has been around for more than 20 years, it has only recently made inroads in Malaysia.
Last year, IVUS was used in 8.7% of angioplasties in Malaysia.
In Japan, it was used in 80% of such procedures; in Singapore, 25%; in the United States, 6%; in Europe, 4%; and in India, 3%.
While the long-term outcome is more promising, not all cardiologists are using IVUS.
Cost and experience
It’s probably due to financial issues, Dr Tamil Selvan says, as the overall cost may be 10-15% higher.
In Japan, almost every patient has insurance, so IVUS is widely used.
Dr Rosli opines: “Another reason besides cost is because some cardiologists are not comfortable interpreting what they see.
“When you don’t have the confidence, the chances of picking up the device and using it is probably lower.
“You don’t need special skills, but you need to know how to interpret findings and act on it – this comes with education and experience.
“It does take a bit more time and not all cardiologists have the patience.
“In teaching institutions, the young ones are quick to pick it up, provided they are given the go- ahead by the senior consultants.”
Both consultants have each performed more than 100 IVUS-guided procedures to date.
“Very often, we are faced with patients who return and we see the stents have narrowed – not be- cause of cholesterol plaque, but due to the healing process and scar tissues forming inside.
“In these cases, we prefer to use IVUS.
“We usually find that the stents are underdeployed to start with, so not only are we are treating the scar tissue, but we also have to create enough lumen (space in the artery) so that the renarrowing doesn’t occur,” says Dr Tamil Selvan.
Basically, the concept is: the bigger the lumen, the better.
Dr Rosli elaborates: “Angiographically, you can sort of gauge, but you cannot know what it is like inside the vessel.
“You deploy the stents at a certain point and you think the results will be good, but it may not be because you only see two dimensions, whereas with IVUS, you can see three.
“For me, if the patient comes in with typical symptoms of angina or chest pain due to lack of blood flow to the heart, and he’s got a typical profile – elderly, high cholesterol, diabetic – I will advise an angiogram.
“There are certain patients who say they want other tests instead of an angiogram.
“If the pain is not severe, then it’s okay, but if the symptoms are severe, the blockage is probably significant and they need an angiogram.”
Dr Tamil Selvan adds: “The investigation you do is dependent on the individual.
“If I see an 87-year-old with a typical angina – obviously, the heart is diseased and we try our best to give medications to subside the symptoms.
“We don’t do any procedures (as the patient is elderly) unless the symptoms are really bad, then we take the risk.”
An angiogram provides a two-dimensional silhouette of the blood vessels with the help of a contrast agent. Here you can see narrowing (stenosis) of the right coronary artery in two areas.
Achieve your targets
How long can one live after stenting?
Says Dr Rosli: “One must remember that treatment via stenting or bypass surgery is not a cure.
“I’ve seen bypasses get blocked again within a couple of months; the same thing with angioplasty.
“What is important is to take care of yourself and address all your risk factors, e.g. diabetes, hypertension, smoking, obesity, etc.
“Be on proper medication, but you must achieve the right target.
“There is no point taking cholesterol medications and the level goes down, but it still doesn’t achieve the target.
“That means the disease will still progress on, so you have to do something to halt this progression.”
When a coronary artery gets blocked again, it doesn’t necessarily mean it is from the previously-treated site.
He continues: “Data shows that 50% can be at a different site, so this tells us the progression of disease is what drives lesions at the same or new sites.
“That’s why it is important for people be on proper treatment and achieve targets consistently.”
The other aspect is the procedure itself – the correct technique must be used.
“You have to look at the blood vessels – if the vessel is small, has lesions or is calcified, then whatever the method we use, the results may not be good,” says Dr Rosli.
The blockages are likely to return, although it can vary from being very quick to years.
The upside, as Dr Rosli adds, is that: “Technology is always expanding and devices are only going to get better.”
Not total freedom
A lot of patients feel that once they have a stent, they’re “free” forever.
“That is wrong!
“It is common for patients to ask if they can stop taking cholesterol tablets once their levels are normal and I always tell them no.
“They’ll ask how long more and I tell them they have to take it until they are 90, then we push them off the cliff!” jokes Dr Tamil Selvan.
Another common question patients ask is if they need a bypass surgery if they have more than three blocked vessels.
“It depends on the location of the narrowing,” he says.
“If I put seven or eight stents and I can get very good results, so be it.
“But if I can only put in two stents and get bad results, then a bypass is best.
“Data has shown that the longer the stents and the more we use, the risk of recurrence is higher.
“So we try to use shorter stents instead of longer ones unless there is a valid reason.”
There are also other devices available in the market that can be utilised.
Dr Rosli says: “There are special drug-coated balloons where the drug goes into the tissue and there is a reduction in the risk of renarrowing.
“This drug is similar to the one placed on the drug-eluting stent.
“If the results are good, we don’t have to stent that area.”
Do note that if you’re diabetic – like one in five Malaysian adults – you’re twice as likely to have CAD as high blood glucose levels can damage blood vessels and nerves that control the heart.
Dr Tamil Selvan stresses that CAD will probably strike at an even younger age group in a decade’s time, so the “fight should begin in schools now”.
“Be aware that CAD is a chronic disease and a burden to the country.
“We need to take care of ourselves for ourselves and for our families,” concludes Dr Rosli.
THE World Health Organisation says non-communicable diseases (NCD), including heart disease, stroke, cancer, diabetes and chronic lung disease, are collectively responsible for almost 70% of all deaths worldwide.
NCDs, also known as chronic diseases, are the leading cause of death and morbidity among Malaysian adults.
This has resulted in the formulation of a National Strategic Plan for Non-Communicable Diseases 2016-2025 to address the threats posed by NCDs in Malaysia.
To combat this Covid comorbidity crisis, Switzerland-based pharmaceutical company Novartis hosted a Zoom event entitled “Non-communicable diseases in the new normal”.
“Only 41% of patients have their asthma under control,”said Pantai Hospital Kuala Lumpur consultant pulmonologist Dr Helmy Haja Mydin.
Novartis Corporation patient access and government affairs country head Azwar Kamarudin, in her welcoming remarks, said they had roped in three doctors to share their experience and knowledge of three diseases.
Kicking off the session was Pantai Hospital Kuala Lumpur consultant pulmonologist Dr Helmy Haja Mydin, who discussed asthma as a heterogeneous disease, and explained various conditions of asthma patients.
“What you see in an asthmatic patient is inflamed or swollen airways, ” he said, elaborating that some people would experience difficulty in breathing, chest tightness, wheezing and coughing.
Citing scenarios, he said that there was exercise-induced asthma as well as attacks triggered by changes in temperature. Allergy-induced asthma, he highlighted, was “very specific to an individual”.
Pointing to the situation in Malaysia, he said only 41% of patients had their asthma under control.
“This means they don’t need an excessive amount of reliever inhaler and their asthma does not affect their day-to-day activities, ” said Dr Helmy Haja, who is also head of the private hospital’s lung centre.
While talking on “Asthma in the New Normal”, he said inability to control asthma symptoms with the available treatment options was one of the main risk factors for exacerbated and uncontrolled asthma.
Citing findings on productivity loss, he said 48% of Malaysian patients had missed work or school due to asthma, with an average of 11.2 days away in 2010.
“Malaysians reported an average productivity drop by 21% when their asthma was at its worst, ” he said.
He stressed that correct use of reliever inhaler was important, saying that its overuse could cause death.
“Patients with asthma must take the right inhaler regularly with the right technique. Use a controller inhaler if necessary. Don’t depend on a reliever.”
On the indirect impact of the Covid-19 pandemic on asthma, Dr Helmy Haja said it caused less interaction with doctors.
He said that sometimes the use of masks and sanitiser as well as an unconducive work-from-home environment, increased indoor exposure and stress or anxiety, among others, affected asthmatic patients.
To a question from a participant at the event, he said there was no cure for asthma but it was very controllable.
“Asthma affects many people. Poorly-controlled asthma can lead to poorer health outcomes, impaired quality of life and even death.
“The risk of complications from Covid-19 is less if the asthma is well-controlled, ” he added.
Dr Helmy Haja said it could be difficult to differentiate between an asthma attack and Covid-19 symptoms.
“If you have fever, cough and sore throat, get a swab test done to find out (the cause), ” he advised.
Cardiac Vascular Sentral Kuala Lumpur consultant cardiologist Dr Choo Gim Hooi shared his insights on the topic, “Hypertension in the New Normal.”
Hypertension is the silent killer if untreated, said fellow speaker, Cardiac Vascular Sentral Kuala Lumpur consultant cardiologist Dr Choo Gim Hooi.
Dr Choo said hypertension was a silent killer if untreated, and that it caused various complications.
“Hypertension is the main contributor to cardiovascular (CV) disease burden worldwide.”
He advised patients to measure their blood pressure and said that in general, hypertension was when clinic measurement was consistently above 140/90mmHg.
“Risks associated with blood pressure is a continuum. Controlling hypertension prevents and improves outcomes and saves lives, ” said Dr Choo, who is also board member of the Asian-Pacific Society of Interventional Cardiology and National Heart Association of Malaysia and Interventional Cardiac Society of Malaysia council member.
“During the Covid-19 pandemic, CV disease patients, including hypertensives, continue to be a high risk for adverse events.
“In addition, they are at higher risk of getting a more serious manifestation of Covid-19 and dying from Covid-19 infection.”
Among others, he said that fear of Covid-19 and access barriers to medical care resulted in failure or delayed attention to CV disease and risk factors.
He added that defaulted medical follow-up and prescription refills had resulted in excess deaths.
Dr Choo advised all hypertension patients to wear a face mask, sanitise their hands regularly, maintain physical distancing, boost their immunity and rest well. “Adopt a healthy lifestyle and diet, and ensure your blood pressure is well controlled. See your doctor regularly. Make sure to take your medication, ” he said.
Meanwhile, Gleneagles Hospital Kuala Lumpur consultant dermatologist Dr Peter Ch’ng Wee Beng spoke on “Psoriasis in the New Normal.”
“Talk to your dermatologist if you get psoriasis during this Covid-19 period. Don’t stress too much as it will become worse, ” he pointed out.
He said those with the skin condition should not smoke or drink alcohol excessively.
“Remember to exercise. Take up a new hobby and enjoy time with your family, ” advised Dr Ch’ng, who is also Cosmetic Dermatology and Laser Medicine Board of Malaysia chairperson.
He shared that some of his patients abroad and from other states in Malaysia could not seek treatment during the initial movement control order period.
“Some had financial difficulties and had to cut down their medication and because of this, their psoriasis became more severe.”
Asked if moisturiser could aggravate psoriasis, he said ideally, it should not contain fragrance, preservative and colouring.
“The most important thing is that the patient finds the moisturiser soothing.”
Asked if psoriasis would worsen with age, he said although there was no evidence to back this up, on a personal level his father’s condition improved as he got older.
KUALA LUMPUR, 30 September 2020: Living with heart failure can be terrifying. But people need to know that the condition is preventable, treatable and manageable. People living with heart failure need treatment for the rest of their lives, according to a cardiologist.
“There is effective medication to treat people with heart failure. Treatment improves heart failure symptoms and quality of life, reduces hospitalisation and helps patients to live longer, ” says Datuk Dr David Chew Soon Ping, consultant cardiologist at Cardiac Vascular Sentral Kuala Lumpur.
“Heart failure is a chronic condition whereby the heart can’t pump enough blood to meet the body’s needs. The older you are, the more likely that you may get heart failure. However, this does not mean that heart failure does not affect younger people.”
Up to 10% of those above 65 years of age may develop heart failure. It is also the most common cause of hospitalisation among this group.
Some of the common causes of heart failure include coronary artery disease and heart attack, hypertension, heart muscle disease or valve disease.
Dr Chew points out that medications need to be continued long-term and the challenge with some heart failure patients is medication compliance – they don’t take their medication as directed by their doctors. In some cases, patients stopped their medication without consulting their doctors. This usually results in worsening of their condition and may lead to hospitalisations and death.
Besides medication, other treatment options include implantation of electrical devices or surgery – if patients have severe coronary artery disease or valve conditions, and in extreme cases, heart transplant.
For people in risk groups (high blood pressure, diabetes, high cholesterol and obesity), Dr Chew recommends: “Treat these conditions appropriately to prevent the development of heart disease that can later on lead to heart failure. Watch your salt and sugar consumption. You should exercise too but always discuss with your doctor before you start.”
For healthy people, Dr Chew says: “Maintain a healthy lifestyle that involves watching your diet, maintaining an ideal body weight, exercising regularly and don’t smoke.”
“If you practise healthy habits and lifestyle, the chances of developing high blood pressure, diabetes, and even heart diseases are lower. This helps to prevent heart failure too.”
If heart disease like coronary artery disease develops, Dr Chew advises: “Appropriate treatment and management of your condition can prevent the heart disease from getting worse, reduce heart attacks and prevent the heart from getting damaged and avoid heart failure.”
Some of the signs and symptoms of heart failure include shortness of breath or trouble breathing, fatigue and weakness, swelling (in the ankles, feet, legs, and abdomen), rapid or irregular heartbeat and persistent cough or wheezing.
“Heart failure symptoms are not distinct and some of them are pretty common. That’s why it can be challenging to diagnose heart failure. For some heart failure patients, they think they are short of breath because they are not fit. But if you feel unwell, don’t dismiss it as ageing. Go get it checked, ” he says.
