Early heart screening for peace of mind

‘The average age when a heart attack occurs is 58, so anyone below 40 years is considered young,’ says Dr Al Fazir.

Knowing your risk factors is key to managing heart disease that is increasingly affecting younger people. ONLY in her early 30s, Lina (not her real name) booked an appointment with her doctor after experiencing shortness of breath. She gets tired especially from exertion and climbing up the stairs.

Exercise stress test showed ECG changes and her doctor proceeded to conduct further examination. That’s when a cardiac CT scan found Lina has several blockages in the heart. 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 blockages to the heart. “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.

What to look out for

Also known as cardiovascular diseases (CVDs), heart disease is a disorder of the heart and blood vessels leading to coronary artery disease, 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.

Early screening important

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 screen for person 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).

Know your risk profile

Understanding your risk profile is important to manage your lifestyle and if you have risk factors to manage – which can be divided into modifiable and non-modifiable risks.

“Modifiable risk factors are obesity, blood pressure, sugar, cholesterol levels and lifestyle as well. Lifestyle means the amount of exercise you do if you lead a sedentary life, smoking, and consume excessive amounts of alcohol.”

The non-modifiable risk factors, he says, are those of genetics, sex and age.“Stress is another risk factor that is difficult to measure but can have an indirect effect on your modifiable risk factors. “If the parent has heart disease, the patient may inherit risk factors like diabetes and high cholesterol.”

 
Simple tasks such as climbing a flight of stairs which now makes you breathless can be an indication of heart disease.

Lifestyle for better heart

If you are diagnosed with coronary artery disease, there are actions you can and should embrace. “The first is to adopt a healthier lifestyle. This means exercising for at least 150 minutes a week, reducing dietary cholesterol and salt intake, and cutting out sugar completely if you can.

“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.

He says that your personal physician will advise on these and may advocate important pillar medications if you suffer from diseases such as hypertension, high cholesterol and diabetes. He adds that with the ease of current social media, this can lead to misinformation on side effects and patients sometimes stop taking their medicine.

“Some patients with heart disease just stopped taking their medications because they received a message (from well-meaning friends and family or online). “Please be discerning about the information you received and check with your doctor if you have any concerns about your medication or treatments”

#BreakTheHeartAche

#BreakTheHeartAche is a public education campaign that focuses on driving awareness on heart diseases in Malaysia. Jointly organised by Cardiac Vascular Sentral Kuala Lumpur and Viatris Malaysia, this campaign highlights the importance of early detection of heart problems, and to seek relevant treatment.

For more information, go to www.cvskl.com/breaktheheartache

KKLIU no.: 3133/2022

Expiry: Dec 31, 2024

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Leg pain while walking is not to be taken lightly

A possible sign of artery blockage causing lower blood flow leading to organ or tissue damage

MANY have experienced the pins and needles sensation taking over one or both legs after sitting in a position for too long, while others may have experienced leg pain after completing “leg day” in the gym or even when an old injury creeps up and catches us off guard.

Oftentimes leg pains are seen as fleeting sensations, not a cause for concern since we may have experienced these feelings at some point in our lives. However, leg pain while walking is not something for us to take lightly. According to Cardiac Vascular Sentral Kuala Lumpur (CVSKL) consultant vascular and endovascular surgeon Dr Tan Kia Lean, this can be a sign of claudication in the leg and a symptom of peripheral artery occlusive disease (PAOD), also known as peripheral artery disease.

Severe symptoms of PAOD include leg pain when walking short distances, according to Dr Tan.

Severe symptoms of PAOD include leg pain when walking short distances, according to Dr Tan.

“The shorter your walking distance, the more serious your disease. Intervention or surgical management is recommended when your walking distance (while experiencing pain) is less than 100m. “More severe signs include skin discoloration when it turns grey or purplish. Some may experience pain while resting (also known as rest pain). “When rest pain sets in the medical diagnosis changes. It’s no longer PAOD; instead, it becomes critical limb ischemia (hypoxic injury that causes tissue to die),” he says.

Although symptoms present themselves when the occlusion is severe, he says, early signs can go unnoticed. “Some patients might not show early signs if the blockage is not total. If there are some forms of cholesterol plaque that cause 50%-70% atherosclerosis – the hardening or narrowing of arteries – you might not show any signs especially if you are not active and lead a sedentary lifestyle.

“When the obstruction becomes more severe some of the (early signs) changes include muscle dystrophy, whereby the muscle on the calf and thighs become smaller and is more obvious if it occurs only on one leg. Some skin changes may happen such as shiny skin and hair loss, too,” he says.

Atherosclerosis is the hardening or narrowing of arteries. You may not see early signs of this affecting your body especially if you lead a sedentary lifestyle.

Atherosclerosis is the hardening or narrowing of arteries. You may not see early signs of this affecting your body especially if you lead a sedentary lifestyle.

Younger patients

PAOD is an occlusion in the artery causing diminished or reduced blood flow leading to organ or tissue damage. This typically occurs in the limbs, generally in the lower body – calf, thighs, and even the rear – with more severe occlusion affecting the arms. Moreover, its risk factors are akin to cardiac cardiovascular diseases (CVDs) including family history of PAOD, heart disease or stroke, high blood pressure, high cholesterol, diabetes, physical inactivity, and obesity.

“People who have CVD will develop PAOD and vice versa. Arterial disease is systemic and, on a spectrum, it boils down to which one will manifest first,” he says. “There is a recent trend whereby many young patients are coming in with PAOD. Those in their 40s are considered young while those in their 30s are abnormally young to have PAOD.” Dr. Tan adds that young patients are being treated for PAOD with many of them being diagnosed with diabetes and have shown sensitivity towards cigarette smoking, also known as Buerger’s disease. “Sensitivity towards cigarettes causes the blood vessels to change whereby their small blood vessels become occluded, manifesting in young patients between 20 and 30 years.

“Normally the outcome is quite poor where you can’t even place in a wire or balloon to open up the occluded artery. “This leads to creeping amputation whereby we would remove toes or fingers one by one before resorting to major amputation,” he says, adding that the artery disease progresses more aggressively for younger patients. “With some medication, we can prolong the effects. But usually, patients struggle to control their lifestyle habits. “I had a patient where we had to amputate their fingers, leave the thumb and pinky but they still choose to continue smoking even with the two fingers,” he says.

Young patients are being treated for PAOD with many being diagnosed with diabetes and have shown sensitivity towards smoking cigarettes also known as Buerger’s disease.

Young patients are being treated for PAOD with many being diagnosed with diabetes and have shown sensitivity towards smoking cigarettes also known as Buerger’s disease.

Feel the pulse

Dr. Tan says that diagnosing PAOD is very simple. One way to diagnose PAOD is to feel the pulse. “For the wrist, there are two pulse points to check in the inner and outer parts. If the pulse is present the blood supply should be good. “Similarly in the foot, there are two pulse points including the heel and dorsum of the foot,” he says, adding that while the pulse is present, he cannot say that PAOD is not present as there might be some narrowing.

However, should there be no pulse, he says, the next course of action is to use the Doppler machine to gain the ankle-brachial index (ABI). “If the ABI reading is above 0.9 it is considered normal. If the reading is between 0.6-0.9 there is a cause of arterial disease or PAOD while below 0.6 is considered critical.

“Those who do regular health checks might be able to detect how severe their occlusions are even if they are asymptomatic,” he says. “Those who need to come in for PAOD checks are people above the age of 60, diabetes, and smokers. “Those who are above 65 and do not have symptoms ought to come in for PAOD screening,” he says.

Once diagnosed with either an ultrasound or an angiogram to find out where the blockages are and how severe they are, Dr Tan says, proposed medication to manage PAOD will be prescribed or even surgery where necessary. One of the best ways to avoid leg pain due to PAOD is to lead a healthy lifestyle.

The best way to prevent leg pain due to peripheral artery disease is to maintain a healthy lifestyle, which includes not smoking, controlling, being physically active, maintaining a healthy weight, controlling diabetes, and managing blood pressure and cholesterol.

Source

KKLIU No. 1794/2022

Expiry: Dec 31, 2024

Panel discussion gets to the heart of early detection

Early detection of heart disease is the first step in ensuring prompt diagnosis and treatment, leading to better outcomes. A campaign themed #BreakTheHeartache aims to break the physical and emotional distress that comes with heart disease, for patients and their loved ones, by taking an active approach to ensuring a healthy heart. The campaign is driven by social media personality and entrepreneur Maggy Wang, who hosted a panel discussion in collaboration with Cardio Vascular Sentral Kuala Lumpur (CVSKL) and healthcare company Viatris.

“Looking healthy and being healthy are not the same thing, as heart disease can affect anyone.

“This is the reason why I have been an advocate for regular health check-ups and early detection and screening,” Wang shared during the discussion.

On the collaboration with CVSKL, Viatris country manager Jeff Bote said: “The key to mitigating risks of heart diseases is raising awareness and seeking early treatment.

“We are proud to collaborate with CVSKL to empower people in Malaysia to live healthier no matter their age or risk factors”.

Meanwhile, CVSKL consultant cardiologist Dr Al Fazir Omar took the opportunity to advise participants of the event to go for annual health screenings as the first step to addressing any health issue. Among those who attended the panel discussion were Wang’s 16 selected social media followers who shared their stories. They sat down with Dr Al Fazir to talk about the symptoms of cardiovascular disease to help the audience better understand the patient’s journey in managing lifestyle habits.

For details on CVSKL’s Essential Heart Screening package, call or WhatsApp 03-2276 7002 or email info@cvskl.com

Source

Reference

 

 

Mah Sing donates RM50,000 to CVSKL Foundation

Mah Sing Group Bhd founder and group managing director Tan Sri Leong Hoy Kum (second from right) presenting a mock cheque for RM50,000 to Cardiac Vascular Sentral Kuala Lumpur (CVSKL) Foundation chairman Tan Sri Rashpal Singh Randhay, witnessed by CVSKL consultant cardiologist, Datuk Dr Rosli Mohd Ali (left) and CVSKL chief executive officer Tan Eng Ghee.

 

References:

Heart hospital sets up charity arm

CARDIAC Vascular Sentral Kuala Lumpur (CVSKL) has established the hospital’s first foundation for the benefit of underprivileged Malaysian patients, especially those seeking critical medical care.

CVSKL Foundation, founded by the team of CVSKL doctors, is governed by a board of trustees consisting of industry leaders.

Its objectives are to support medical advancement and research initiatives, increase awareness of cardiac and vascular diseases and provide financial support to the low-income group through management of funds received and raised.

Present to officially launch the foundation was its patron, Yang Dipertuan Besar of Negri Sembilan Tuanku Muhriz Tuanku Munawir, together with Tunku Ali Redhauddin Tuanku Muhriz and the board of trustees.

Dr Rosli (third from right) handing over a mock cheque of RM1mil to Rashpal, witnessed by Tuanku Muhriz (fourth from right), Tunku Ali Redhauddin (fourth from left) and members of the board of trustees.

CVSKL Foundation chairman Tan Sri Rashpal Singh, in his speech, said the launch came at a most opportune time when the government was shifting its priorities from managing the Covid-19 pandemic to restarting the nation’s economy and recovery.

“The high utilisation of public healthcare services has led to overcrowded facilities that result in a longer wait, thus initiatives such as medical research funding and reducing the burden of public hospitals can be looked into.

“We are ready to work with the Health Ministry to complement the government’s hard work in improving the social well-being and health of fellow Malaysians.”

During the event, CVSKL consultant cardiologist Datuk Dr Rosli Mohd Ali handed over a donation of RM1mil to CVSKL Foundation.

Dr Rosli said the establishment of the foundation was an essential piece of the puzzle that would amplify CVSKL as a centre of excellence.

“In 2021 alone, our corporate social responsibility (CSR) efforts totalled RM4.15mil, which benefitted 545 patients.

“With CVSKL Foundation unifying and intensifying this, I am certain we will be able to help more people,” he added.

Source

References

Varicose veins can turn into painful ulcers if not treated early

Pay attention if your veins are enlarged, swollen, lumpy, twisted, blueish or dark purple – they are probably varicosed and need medical attention.

Patients seldom consult a doctor as the initial symptoms may be mild and do not always lead to major health complications.

These unsightly veins can appear anywhere in the body, but most of the time, they show up in the legs because standing and walking increases the pressure in the veins of the lower body.

Our circulatory system is made up of blood vessels that carry blood from and towards the heart.

Arteries are blood vessels responsible for carrying oxygen-rich blood from the heart to the body.

Veins are blood vessels that carry blood low in oxygen from the body back to the heart (and to the lungs) for reoxygenation.

There are tiny one-way valves inside our veins that open to let the blood through, and then close to prevent it from flowing backwards.

If the walls of our veins become stretched and lose their elasticity, it causes the valves to weaken.

When the valves malfunction, the blood then leaks and flows backwards in a condition called venous reflux or chronic venous insufficiency (CVI).

This results in blood pooling in the veins.

For blood to return from the legs to the heart, the veins in the leg must work against gravity and as they are unable to do so, they become swollen or enlarged.

Other CVI symptoms include restless or heavy legs, fatigue, leg or ankle swelling, pain, aching, cramping, burning or itching skin, and ulcers.

CVI is two times more common than coronary artery disease and five times more common than peripheral arterial disease, yet there is poor awareness among Malaysians of the possible complications resulting from untreated varicose veins.

From cosmetic to pain

There are six stages of varicose veins:

  • Stage 0: No visible or palpable (detectable by touch) sign of venous disease.
  • Stage 1: Telangiectasis (also known as spider veins) or reticular veins, which are both visible, but not palpable signs of venous disease.
  • Stage 2: Varicose vein.
  • Stage 3: Oedema (swelling due to fluid accumulation).
  • Stage 4a: Pigmentation of the skin or eczema.
  • Stage 4b: Lipodermatosclerosis (inflammation of the layer of fat under the skin).
  • Stage 5: Healed venous ulcer.
  • Stage 6: Active venous ulcer.
Most people tend to ignore their spider or reticular veins, which is the first stage of varicose veins, but getting treatment early can stop it from getting worse. — Photos: Dr TAN KIA LEAN

As the disease progresses, the skin above the affected vein becomes pigmented, hardened and itchy, and eventually develops non-healing ulcers.

Occasionally, veins close to the skin’s surface can also burst and cause bleeding.

Varicose veins may start off as light spider veins (telangiectasis).

For many, this presents a simple cosmetic concern until pain and discomfort sets in.

Consultant vascular and endovascular surgeon Dr Tan Kia Lean says: “A lot of people live with varicose veins and think it is nothing because it doesn’t cause much pain in the early stages.

“I won’t say this is the wrong attitude as people are scared of operations and being cut up, but modern treatment is different.

“When it gets to the last stage (ulcer), varicose veins become very difficult to treat and may take months or years to heal.

“One of my patients had a non-healing ulcer for 20 years!

“Even with treatment, he was only able to go back to stage 5 and that’s why early treatment is vital.”

While in stage 3, the symptoms can still be reversed, but at stage 4 when there is skin damage, the symptoms cannot be completely reversed.

Dr Tan explains: “The pigmentation around the ankle area is like rusted iron.

“Our red blood cells carry iron and this iron has oxygen-binding capacity.

“But in varicose veins, when the vein is dilated and turns tortuous (i.e. twisted), the red blood cells cannot pass through and remain outside the veins.

“The iron within those cells will be oxidised and this oxidisation gradually leads to stage 4b, changing the colour of the skin and damaging it.

“The drying and hardening of the skin results in it stretching, and causes micro-oxidisation that cannot be seen with our eyes.

“But we can feel it because when it is exposed to air, it turns itchy; when we scratch, it gets infected and inflamed.”

Women more prone

While genetics can play a role, women below the age of 60 are more commonly afflicted with varicose veins.

This is due to the presence of oestrogen and progesterone in their bodies.

Dr Tan says: “These hormones make the vein walls more relaxed, especially during pregnancy, so the neck area of the vein gets dilated easily.

“In addition, the enlarging uterus in the pelvic cavity compresses the venous system and speeds up the formation of varicose veins.”

Being overweight and having jobs that require one to be on their feet for long hours also contribute to the problem, e.g. barbers or hairstylists; hawkers, cooks or chefs; teachers, etc.

“Sometimes, when you wear your shoe in the morning, it will fit well, but as the day passes on, it becomes tight as the blood is gushing down to the leg.

“With sitting, you can also get CVI, but it may not lead to varicose veins,” he adds.

Most people tend to take more note of their varicose veins when they become bulging or painful.

Lifestyle management, leg rest and skin care are important interventions to delay disease progression.

Often, patients only consult a medical practitioner when there is pain, and when the doctor asks them when they started seeing their varicose veins, they will say since childhood!

“Varicose veins can be there for two or three decades without causing symptoms.

“When a patient turns up with symptoms, we have to find out where the problem is.

“Usually, it’s through diagnostic tests via an ultrasound as it provides real-time information on whether blood flow is one direction or bi-directional.

“Varicose veins can also reflect something in the heart – it can be quite difficult to tell what is causing the leg swelling.

“If we suspect something else, then we do a CT (computed tomography) scan,” says Dr Tan.

Evolving treatment

The earliest record of varicose veins is in the papyrus of Ebers, written 1550 BCE, where the author described them as “tortuous and solid, with many knots, as if blown up by air”, and recommended people leave their veins in place.

Later, the ancient Greek physician Hippocrates, widely touted as the father of modern medicine, suggested that people do something about their varicose veins as he noticed a correlation between veins and leg ulcers.

This marked the introduction of vein punctures, cautery (using a hot or caustic agent) and compression bandages as a treatment for varicose veins.

“Now we have compression stockings that prevent the reflux – you might have to use it for a lifetime, but it provides very good control.

“When doctors started understanding the disease better, they used the stripping method where they cut the skin near the top and bottom of the damaged vein, put a thin wire through the top (usually the groin), tie the vein over with wire and then pull it out through the cut in the lower leg,” Dr Tan explains.

Since 1990, endovenous treatment such as thermal ablation, i.e. radiofrequency ablation and laser therapy; sclerotherapy; and mechanochemical ablation; have been available.

Of late, these treatment modalities have become less invasive and less painful, without the need for general anaesthesia to carry them out.

Most people tend to take more note of their varicose veins when they become bulging or painful.

Gluing it shut

In the last five years, cyanoacrylate glue – a special type of “super glue” – has become a popular form of treatment for varicose veins.

In this treatment, medical grade glue is placed in a catheter and inserted into the affected vein at the thigh to close it off.

Once the affected vein is glued shut, blood will immediately be rerouted through other healthy veins in the leg.

The closed vein will undergo a process of hardening (sclerosis) and will gradually be absorbed by the body.

“The therapy is quick and effective, takes around 30 minutes and is done as a daycare procedure – the patients don’t feel anything and there is no need for compression stocking afterwards either,” says Dr Tan.

There are also no pre-procedure drugs involved and patients can return to their normal activities right after the treatment.

There is no risk of skin burns or nerve damage, and immediate post-treatment pain medication is not necessary.

There are no guaranteed methods of preventing varicose veins, but the condition can be managed by getting diagnosed early, making lifestyle adjustments via diet and light to moderate physical activity, and symptom control.

The latter can consist of putting on compression stockings, taking intermittent breaks to sit if you have a job that requires long periods of standing, and resting the legs by elevating them above heart level before sleeping.

On the use of compression stockings, the surgeon says to use them only while standing, walking or exercising.

“When you lie down, there is no venous reflux, so why do you need compression stockings at night?” he notes.

“If you’re travelling, then the worry is not so much about varicose veins, but deep vein thrombosis (DVT, blood clots that form in the deep veins of the leg and travel to the lungs).

“The stockings that you wear for DVT are different from the ones used for varicose veins.

“If you’re on a long haul flight, it is good to put on a DVT stocking, but be sure to maintain hydration throughout so that your blood does not become concentrated.

“Also, walk around to get the blood circulation going,” he advises.

A common myth is that massage is good for varicose veins.

Dr Tan points out: “A massage does not prevent varicose veins from returning; in fact, it will rupture the veins.

“You can massage the legs, but not the affected vein.”

Source

References 

Using ultrasound to see inside the heart’s arteries

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.

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Reference

Tips on managing chronic diseases during pandemic

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.

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Beware Of Heart Failure

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, exercise 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, 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.

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