38

FP 1.1CATHETER ABLATION FOR ATRIAL FIBRILLATION (AF) -PULMONARY VEIN ISOLATION (PVI) VERSUS LEFT ATRIALCATHETER ABLATION (LACA)Al Fazir O, Abdul Ahad K, Surinder K, Zunida A, Tay GS, Azlan H, Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Objective: To assess the relative efficacy of LACA versus PVI and predictor for recurrence of atrial fibrillation

Methods: Retrospective study of patients underwent catheter ablation from 2001–2007 at IJN. Catheter ablation for AF wasperformed on those who have failed a trial of medical treatment. There are several ways to perform catheter ablation of AFbut at our institute, we started in 2001 with PVI till 2005 then we moved to LACA. Fifty-seven underwent catheter ablation,51 patients had paroxysmal AF and 6 patients had persistent atrial fibrillation. Thirty-two patients had LACA and 25 had PVI.Mean age was 51 years (range 25–75), co-relation between different variables like, age, sex, co-morbid conditions,technique for recurrence of atrial fibrillation. The patients were followed for recurrence of symptoms, ECG, Holter at 1 month,3 months and then 6 monthly for 2 years, event recorder were used in patients who had infrequent symptoms. The outcomewas assessed at 6 months and 24 months for recurrence of AF.

Results: At 6 months 74% of LACA and 54% of PVI were free of symptoms. At 2 years 70% of LACA and 46% of PVI werefree of symptoms, 54% of LACA and 28% of PVI were off medication. We also look for the recurrence of atrial fibrillationamong the different variables, age sex, duration, frequency, ejection fraction, hypertension, diabetes, CHD, structural heartdisease LA size and technique of ablation. Only the technique PVI was independent predictor of recurrence of AF. At theend of 2 years 48% of LACA and 26% of PVI were off medication and free of symptom of atrial tachycardia and flutter.

Conclusion: Patient undergoing catheter ablation (LACA) to encircle PV is better than PVI with reduction in recurrence of AF.

37

FP 1.0A STUDY OF ASSOCIATION BETWEEN SEVERITY OFCORONARY ARTERY DISEASE (CAD) IN PATIENTS WITH ORWITHOUT PERIPHERAL ARTERY DISEASE (PAD) ATUNIVERSITY MALAYA MEDICAL CENTREAbdul Wahab bin Undok, A/P Haizal Haron KamarDivision of Cardiology, University Malaya Medical Center, Kuala Lumpur.

Background: There is a high incidence of peripheral artery disease (PAD) in patients with coronary artery disease (CAD)but little is known about the relationship between CAD severity and that of PAD. Both conditions are associated withincreased morbidity and mortality.

Objectives: The main objective was to study the relationship between the degree of severity of CAD and that of PAD.

Study Methods: The Ankle-Brachial Index (ABI) was measured by using handheld doppler ultrasound in 139 patients whowas proven to have CAD by coronary angiogram. Beside that, symptomatic PAD patients were assessed by history andEdinburgh Claudication Questionnaire (ECQ) . The risk factors for atherosclerosis and treatment given were also analysed.The association between the severity of CAD and ABI were analysed using SPSS programmed.

Results: The median age of the patients was 61±15 years with predominantly male population (79.1%). All major ethnicgroups were represented almost equally. Most of the patients had underlying CAD (82.8% had recent history of acutecoronary syndrome), hypertension (77.7%), diabetes mellitus (57.6%), hypercholesterolaemia (69.1%), cerebrovasculardisease (7.9%), chronic kidney disease (9.4%) and current smoking status (40.3%). Only a few patients were symptomatic(3.6%) for PAD by using Edinburgh Claudication Questionnaire (ECQ). However, there was a high prevalence of PAD inCAD patients (42.1%) after measuring of ABI .There was a significant association between severity of CAD and severity ofPAD (p=0.006) and age-related PAD (p=0.018 , r=0.25)..

Conclusions: This study showed significant association between severity of CAD and that of PAD.

40

FP 1.3FEASIBILITY OF THE PROCAM RISK CALCULATOR INPREDICTING SIGNIFICANT CORONARY STENOSISDIAGNOSED ON 64-MULTIDETECTOR ROW COMPUTEDTOMOGRAPHY IN AN ASIAN POPULATIONFong AYY1, Ong TK1, Ang CK1, Liew HB1, Liew CK1, Chan WL1, Chin WM1, Yew KL1, Nor Hanim1, Chua SK1,Annuar R2, Sim KH1.Department of Cardiology, Sarawak General Hospital1 and Faculty of Medicine and Health Sciences, UniversityMalaysia Sarawak (UNIMAS)2.

Background: The PROCAM risk calculator (PRC) has an established algorithm, universally accessible, to predict a 10-yearcardiovascular event (CVE) risk. However, its application to Asian patients undergoing 64-multidetector row computedtomography of the coronary arteries (MDCT-CA), in the diagnostic workup for atypical cardiac chest pain and Type 2diabetes mellitus with at least one other cardiovascular risk factor (T2DM), has not been done. We sought to establish if thePRC can predict the result of a MDCT-CA examination, when patients were grouped to low and high risk (≤10 and >10% 10year CVE risk, respectively), and to assess the same factor in the atypical chest pain and T2DM subgroups.

Methods: Records of MDCT-CA examinations performed in 2005 of 160 consecutive patients, with no previous documentedCVE, experiencing atypical chest pain and or with T2DM were examined. MDCT-CAs were performed by trainedCardiologists who were blinded to PRC scores. An abnormal MDCT-CA was defined as any stenosis ≥50% found in acoronary segment ≥2mm diameter or significant calcification. Chi-square analysis was performed to ascertain if low and highPRC scores can predict the result of the MDCT-CA.

Results:At two predefined 10-year risk CVE risk levels, the PROCAM risk calculator was able to predict the result of MDCT-CA (p=0.032). At a low PRC score, there was a 2.9 likelihood ratio that the MDCT-CA was normal (74.4% vs 25.6%). At ahigh PRC score, there was a 0.82 likelihood ratio that the MDCT-CA was abnormal (45.2% vs 54.8%). In atypical chest painand T2DM subgroup analysis, the PRC scores were not able to predict result of the MDCT-CA (p=0.974 and p=0.138respectively; likelihood ratio of normal MDCT-CA at low vs high risk scores of 3.6 vs 3.5; and 2.0 vs 1.0 respectively).

Conclusion: In an Asian cohort, the PROCAM risk calculator could predict the result of the 64-multidetector row computedtomography of the coronary arteries examination, in particular if the patient was adjudged to be in the low risk group.

39

FP 1.2LONG TERM OUTCOME OF CARDIAC RESYNCHRONIZATIONTHERAPY AND AV-NODAL ABLATION IN PATIENTS WITHADVANCED HEART FAILURE AND PERMANENT ATRIALFIBRILLATION.Al Fazir O, Surinder K, Tay GS, Zunida A, Azlan H, Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Background: AF aggravates heart failure due to loss of AV synchrony and rate controlling agents may not be able toadequately control the ventricular response ultimately, requiring AVN ablation. The role of CRT and AVN ablation inpermanent AF and advanced heart failure has yet to be better defined. The PAVE study showed patients with permanentAF subjected to CRT and AVN ablation experienced a significant improvement in the 6 min walk test and ejection fraction(EF) compared to right ventricular pacing and this effects were greater in patients with impaired systolic function or withsymptomatic heart failure.

Objective: The aim of this retrospective study was to report the benefits of Cardiac Resynchronization Therapy (CRT) andAV-nodal (AVN) ablation in patients with permanent Atrial Fibrillation (AF) and advanced heart failure.

Methods: Based on this, we implanted 20 patients with permanent AF and poorly controlled ventricular rates in advancedheart failure and EF less than 35% with a CRT device and performed AVN ablation from 2004 to 2007 and evaluated thebenefits retrospectively.

Results: Mean follow up was for 13.7 ± 11.2 months. Mean duration of AF was 6 months. Eight (40%) of patients wereischemic and 12 (60%) were non ischemic. Clinical (NYHA) and echocardiographic LVEF, LV end diastolic diameter, leftatrial diameter and mitral regurgitation was performed at baseline, 6 and 12 month follow up. There was a significantimprovement in symptoms NYHA functional class P<0.0001 and increase in EF from 30 ± 5.5% to 33 ± 8.2% P<0.039. Therewas also a significant decrease in the number of hospitalization from heart failure

Conclusion: Patients with permanent AF and poor LV function implanted with CRT device and had AV-nodal ablationshowed significant improvement in functional class, LV systolic function and reduced number of hospitalization from heartfailure.

41

FP 1.4TYPE 2 DIABETES MELLITUS CONTROL ANDCOMPLICATIONS IN PRIMARY CARE DEPARTMENT OFUNIVERSITY MALAYA MEDICAL CENTREDr Chew Boon How, Prof Chia Took ChinPoliklinik Komuniti Tapah, Department of Primary Care Medicine, University of Malaya

Background: There are national and international guidelines to treat diabetes mellitus to the recommended targets so asto reduce complications. In spite of this a large proportion of diabetic patients are still not controlled to these targets.

Objective: The objective of this study was to determine the proportion of patients with Type 2 Diabetes in an urbanacademic institution who meet these treatment goals and who suffer from complications.

Materials & Methods: The three most recent FPS (Fasting Plasma Sugar), HbA1c and FLP (Fasting Lipid Profiles) withinthe past three years were taken as measures of diabetic control. The most recent pharmacological treatment, height andweight, year of onset of T2D, systolic blood pressures (SBP), diastolic blood pressures (DBP), earliest single proteinuria andother complications were captured from records.

Results: 212 patients were included into the study. Two thirds were females. The mean age was 62.7 (SD± 10.8) years andduration of T2D was 11.74 (SD± 6.7) years. A quarter achieved HbA1c ≤ 7.0% ( 23.6%) and LDL-C ≤ 2.6 mmol/L (26.2%);less than half reached target HDL-C > 1.0 mmol/L for male (42.5%) and HDL-C > 1.2 mmol/L for female (43.5%). Only 8.0%achieved FPS < 6.0 mmol/l. The most prevalent comorbid condition was hypertension (77.3%). 24.5% had blood pressure< 130/ 80 mmHg. 86.5% had only one complication. CAD and proteinuria < 1gm/L were the two most commoncomplications.14.6% had diabetic proteinuria; out of which 32.3% had more than 1 gm/L. 2.8% developed proliferativediabetic retinopathy (PDR). 5.2% had a stroke; 9.9% suffered a coronary artery disease (CAD). Metformin was used in 84%of the patients. Only 16% of the patients were on subcutaneous insulin. Insulin usage was significantly correlated with higherFPS (r = 0.352, p < 0.0001) and higher HbA1c (r = 0.287, p < 0.0001).

Conclusion: Poor control of T2D, SBP and LDL-C was found to be highly prevalent in this study, and only a very smallnumber of diabetic patients had most cardiovascular risk factors controlled to target. Urgent audit is needed to look intocontributing factors for this poor level of control.

42

FP 1.5COMPARISON OF THE EFFICACY OF AMLODIPINE ANDCAPTOPRIL IN THE TREATMENT FOR HYPERTENSIVEURGENCY IN EMERGENCY DEPARTMENT AND KLINIKRAWATAN KELUARGA, HUSMDr Chia Boon Yang, Dr Mohd Idzwan B Zakaria, Dr Suhairi B IbrahimHospital Universiti Sains Malaysia

Background: Hypertensive urgency was defined as elevated BP>180/110 mmHg without target organ damaged. It shouldbe treated with oral antihypertensive agent to achieved BP reduction in 24-48 hours.

Objective: To compare the efficacy of amlodipine and captopril in the treatment for hypertensive urgency.

Methodology: This is an open labelled randomized prospective control study with blinded end point conducted from Oct2006-Sept 2007. Patient aged >18-year-old with persistent elevated BP>180/110 mmHg after 30 min bed rest was includedin the study. Patient who allergic to study drugs, with target organ damage (acute coronary syndrome, CVA, CRF), elevatedblood sugar >20mmol/l, pregnancy or breast feeding was excluded. They were randomized using block randomization intoamlodipine group (T. amlodipine 5 mg) and captopril group (T. captopril 25 mg). Single NIBP machine was used to monitorBP and PR hourly for 4 hours, then 4 hourly until 16th hour of medication. If target BP not achieved at 4th hour of medication,T. Chlorothiazide 250mg was added.

Result: 28 patients enrolled in the study, 18 patients in amlodipine group and 10 patients in captopril group. Median agewas 60-year-old (iqr 17) for amlodipine group and 45-year-old (iqr 23) for captopril group, p=0.046. The other patientsʼcharacteristics were not significantly difference. Median SBP on admission was 202.5 mmHg (iqr 29) for amlodipine groupcompared to 202.0 mmHg (iqr 25) for captopril group, p=0.487. SBP at 1st hour was significantly difference with p=0.004.The SBP reduced gradually from 2nd to 16th hour, with no significant difference. DBP on admission was significantlydifference (p=0.009) with median at 113.5 mmHg (iqr 11) in amodipine group and 124.5 mmHg (iqr 19) in captopril group.The differences in DBP were not significant after bed rest and throughout the study. The differences in MAP between studygroups were not significant. The median MAP on admission was 142.5 mmHg (iqr 19.2) in amlodipine group compared to151.2 mmHg (iqr 11.4) in captopril group, p=0.137. Repeated measure analysis for SBP, DBP, MAP and PR showed nosignificant difference between study groups.

Conclusion: Amlodipine is comparable to captopril in the treatment of hypertension urgency

44

FP 1.7PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PCI)MODIFIED CONVENTIONAL POOR PROGNOSTIC RISKFACTORS IN ST-ELEVATION MYOCARDIAL INFARCTION(STEMI) PATIENTS.Dr Chiew Kean ShyongInstitut Jantung Negara

Background: TIMI risk score for STEMI identified risk factors which carried poor prognosis for a group of fibrinolytic-eligiblepatients with STEMI. It is unknown whether some of these factors carry the same prognosis in patients who underwentprimary PCI. Primary PCI may improve prognosis despite presence of these factors.

Objective: To determine whether primary PCI modified poor prognostic risk factors and improved mortality.

Methods: All consecutive STEMI patients in 2006 who underwent primary PCI in Institut Jantung Negara, Malaysia werestudied. Known poor prognostic risk factors ie age > 65, presence of diabetes or hypertension, anterior myocardial infarctionand door to balloon time were analyzed for their significance in terms of mortality. Statistical analysis was done with chisquare test.

Results: A total of 46 patients were included. Age > 65 carried a poor prognosis (p: 0.04). Mean door to balloon time was120 minutes. Door to balloon time > 90 minutes was also a risk factor associated with higher mortality (p: 0.05). Other riskfactors ie presence of diabetes (p: 0.82) or hypertension (p: 0.86) and anterior myocardial infarction (p: 0.39) wererendered insignificant and did not affect mortality after patient underwent primary PCI . Mean mortality at 30 days was 15.2%. Patients with at least one of these significant risk factors constituted 86% of overall mortality.

Conclusion: In STEMI patients who underwent primary PCI, age > 65 and a prolonged door to balloon time wereindependent poor prognostic risk factors associated with a higher mortality. However, presence of conventional risk factorsie diabetes or hypertension and anterior myocardial infarction did not affect mortality in patients who underwent primary PCI.Primary PCI modified these risk factors and resulted in mortality benefit.

43

FP 1.6COMPARISON OF NUMBER OF MODIFIABLECARDIOVASCULAR DISEASE RISK FACTORS INHYPERTENSIVE VERSUS NORMOTENSIVE INDIVIDUALSFong AYY1, Ong TK1, Ang CK1, Liew HB1, Liew CK1, Chan WL1, Chin WM1, Yew KL1, Nor Hanim1, Chua SK1,Annuar R2, Sim KH1.Department of Cardiology, Sarawak General Hospital1 and Faculty of Medicine and Health Sciences, UniversityMalaysia Sarawak (UNIMAS)2.

Background and AimIt is well recognized that hypertensive patients usually have other cardiovascular disease (CVD) risk factors besides theirelevated blood pressure. This paper compares the number of modifiable CVD risk factors in hypertensive versusnormotensive individuals.

Methods:An epidemiological survey of was conducted in Banting, a semi-rural community. Subjects age 55 years and above wereselected by attendance at a free health screening service in the community.A standardized questionnaire was applied by interview. History of current smoking was captured. Blood pressure (BP) wasmeasured using a standardised mercury sphygmomanometer. Waist circumference (WC) was measured according tostandardised procedure Fasting serum lipids and glucose were also measured. Hypertension was defined as BP ≥ 140/90mmHg. Modifiable CVD risk factors was defined as men age >55 or women >55 years; total serum cholesterol ≥5.2 mmol/l;hdl-cholesterol < 1.03 and <1.3 mmol/l for men and women respectively and fasting plasma glucose of ≥7 mmol/l. The Asia-Pacific criteria of WC ≥ 90cm for men and ≥ 80cm for women was used as definition of overweight/obesity

Results:1417 subjects participated in this survey. The response rate was 56%. A follow-up survey of the non-responders did notshow any differences from the initial responders in any systematic way.The mean age was 65.4 ± SD 8 (range 55-95 yrs, 53% men and 47% women)Amongst the hypertensive subjects, 65% had total cholesterol of ≥ 5.2 mmol/l, 25.8% had fasting glucose ≥7mmol/l and28.3% were smokers. 42% hypertensive men and 77.4% hypertensive women were overweight or obese. 44.7%hypertensive men and 66.4% hypertensive women had hdl-cholesterol below the desired levels.The total number of modifiable CVD risk factors in hypertensive subjects was significantly greater than in the normotensiveindividuals (p<0.001) 77% of hypertensive and 73.9% of normotensive individuals have, besides their elevated BP, at least2 or more other modifiable CVD risk factors (p=0.003)

Conclusion: The majority of hypertensive individuals have many other modifiable CVD risk factors besides their elevatedBP. Management of hypertension should include treating other CVD risk factors.

46

FP 1.9BENEFIT OF CARDIAC RESYNCHRONIZATION THERAPYFOR HEART FAILURE PATIENTS WITH MECHANICALASYNCHRONYChong YS*, Lam KH, Ng KH, Tay SG, Zakaria M, Azlan H, Azhari R and Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Background: Cardiac Resynchronization Therapy (CRT) is new treatment option for heart failure patients. Despitecompliance to the current CRT guideline, there are 30% non-responders. This study was designed to evaluate the role ofcardiac resynchronization therapy in heart failure (HF) patients with echocardiography evidence of mechanical asynchrony.

Methodology: This is a prospective study involving 42 subjects with New York Heart Association (NYHA) functional classIII to IV were enrolled. All subjects fulfill the current guideline for CRT implantation. Tissue Doppler imaging (TDI) determinethe present of systolic asynchrony prior to implantation, all heart failure patients with demonstrated mechanical asynchronywas implanted with CRT device. Clinical and echocardiography assessments were performed at baseline, 6 months and 24months after CRT implantation.

Results: At 6 months, there was a significant left ventricular modeling after CRT implantation as demonstrated by 17.1%improved in the left ventricular ejection fraction, 20.1% reduction in the end systolic volume and 12.7% reduction in the enddiastolic volume. The left ventricular remodeling was maintained and remained stable from 6-month till 24 months of followup. Clinical parameter demonstrate improvement in 6 minutes walk test from 401 ± 120 meters to 455 ± 87 meter with p =0.046, the functional class using the NYHA improved from 3.1± 0.4 to 1.3± 0.8 with p< 0.001.

Conclusion: Cardiac Resynchronization Therapy (CRT) demonstrates significant benefit in heart failure patients withdemonstrate mechanical asynchrony. There were significant remodeling of the left ventricular function and dimension duringthe first 6 months after implantation and these improvements were maintained in the next 24 months in patients with systolicasynchrony. There are also significant clinical improvement in 6 minute walk, functional class and QRS complexes after CRTimplantation.

45

FP 1.8WEEKEND VERSUS WEEKDAY ADMISSION AND MORTALITYFOR MYOCARDIAL INFARCTIONDr Chiew Kean ShyongInstitut Jantung Negara

Background: Urgent diagnostic and therapeutic measures are needed for acute myocardial infarction. However, thestandard of care may vary over the week. During the weekends when the hospital is less staffed, urgent therapeutics maybe delayed and hence, affect patientsʼ outcome. This may pose a major concern for patients admitted during the weekends.

Objective: To determine whether there is a difference in standard of care in patients admitted with myocardial infarctionduring the weekdays or weekends.

Methods:We examined differences in door to balloon time for primary percutaneous coronary intervention, duration to rescueangioplasty for patients who failed thrombolysis, duration of stay and 30 day mortality for patients presenting with a firstacute myocardial infarction to National Heart Institute in 2006.

Results: There were no significant differences in demographic characteristics and infarction site between patients admittedon weekends and those admitted on weekdays. However, there were more patients during the weekends with hypertension(P<0.05). There were no significant differences in other co-existing conditions. In the 2 group of patients admitted during theweekday and the weekend, there were no significant differences in door to balloon time (mean=121 min versus 113 min,P=0.754), duration to rescue angioplasty (P=0.177), duration of stay (P= 0.732) and 30 day mortality (P=1.000).

Conclusions: For patients with acute myocardial infarction, admission on weekends or weekdays to National Heart Instituteis not associated with a difference in use of invasive cardiac procedures or short term mortality. Our findings suggest thatregardless of the time of the day, urgent diagnostic and therapeutic measures are still being carried out with the sameefficiency. However, further measures need to be undertaken to improve the door to balloon time to less than 90 minutes.

48

FP 2.1A STUDY OF CUSTOMER SERVICE GAP IN DELIVERINGEXECUTIVE SCREENING PROGRAM IN INSTITUT JANTUNGNEGARAChong Yoon SinDepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Background: This study aims to examine customersʼ service quality gap in the delivering of executive screening programin National Heart Institute. Service quality was measured through a survey instrument termed SERVQUAL. Five servicedimensions were used to measure the service quality; these are intangible, reliability, responsiveness, assurance andempathy. The focus of this study is to determine factors and dimensions that influence expectations and perceptions ofcustomers. Determination of the gap score and identification of influencing factors that narrow the gap score would beinstrumental to improvement of service quality. This is important when medical institution is moving towards providingexcellent service quality to meet customerʼs expectations apart from the physiciansʼ skills and reputation of the hospital.

Methodology: Preliminary study consisting of 100 respondents receiving executive screening program at out-patient clinic,Institute Jantung Negara were surveyed. The survey was performed based on one-to-one interviews measuringrespondentsʼ expectation and perception on the service quality and process in this institution. SERVQUAL questionnairewas used during this study. Gap score was calculated and the difference between expectation and perception wasmeasured. Positive gap score reflects service quality exceeds customerʼs expectation while negative gap score reflectsfailure to meet customerʼs expectation.

Results: The overall gap score of –0.632 showed that customersʼ expectations were not met. The widest gap score is intangible dimension. Customersʼ overall satisfaction was good, although service quality performance was lesser than theirexpectations.

Conclusion: Service providers should concentrate in dimensions which fall short in customerʼs expectation and strive toimprove on it. Service quality improvement is a continuous process which requires multi-disciplinary approach as discussedin detail.

47

FP 2.0BIO-ENGINEERED R STENT WITH ENDOTHELIALPROGENITOR CELLS (EPCS): 6 MONTHS CLINICAL FOLLOWUP IN REAL WORLD PCI REGISTRYChong Yoon Sin, Lam Kai Huat, Rosli Mohd Ali and Robayaah ZambahariDepartment of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia

Bio-engineered R stent with Endothelial Progenitor Cells (EPCs): 6 months Clinical Follow up in Real World PCIRegistry

Background: The Genous bio-engineered R stent, unlike drug eluting stent (DES) which inhibit tissue growth, Genouscapture patientʼs own endothelial progenitor cells (EPCs) to accelerate the natural healing process. Once attached, EPCsrapidly form a protective endothelial layer over the stent which minimized risk of thrombosis and restonosis.

Aim of the study: the purpose of these study is to assess the clinical performance, safety and efficacy of Genous bio-engineered R stent in the treatment of denovo lesion in unselected “real world” patients in our institution.

Method: 80 patients underwent percutaneous coronary intervention and received Genous stents from January 2006 tillDecember 2006. Clinical performance, safety and efficay of the Genous stents were assessed and these patients werefollow up and reviewed for MACE (Major Adverse Cardiac Events) at thirty days and six months. The incidence of stentthrombosis was also been assessed.

Results: Baseline clinical characteristics were mean age of 58.9±8.9 years, 77.5% were male gender. 70% presented withstable angina, 7.5% presented wtih unstable angina and 88.8% are elective coronary intervention. The majority of thelesions were located in the left anterior descending coronary artery (60.5%) followed by the right coronary artery (22.1%).The majority of the lesion were type B1 lesion (53.5%) followed by type C lesion (29.1%) and type B2 lesion (16.3%). Themean stenosis was 76.3 ± 12.7 %. The mean stent diameter was 3.04 ± 0.31 mm and the mean stent length was 26.06 ±12.65 mm. The procedure success was 97.5%. At 1-month follow-up, TLR rate was 1.3%, MACE rates was 3.8% and therewere no cases of subacute or late thrombosis. At 6-month clinical follow-up, TLR rate was 1.3%, MACE rate was 10.0%with no cases or late stent thrombosis.

Conclusion: Genous bio-engineered R stent Janus demostrated good safety profile with high procedural success rate.Genous stent also showed absent of stent thrombosis with low rate of MACE at 1 month follow up and 6 months follow up.

50

FP 2.3AN AUDIT ON HYPERTENSION CARE AT GOVERNMENTPHYSICIANS CLINICDr Fazirah Abdullah, Dr Rosemi SallehMedical Department, Hospital Raja Perempuan Zainab II

Background: Adequate blood pressure control will reduce long term complications related to hypertension. Several factorsmay influence blood pressure control however it was inadequately documented.

Objectives: To determine the effectiveness of blood pressure control in hypertensive patients managed or supervised byphysicians at Government Hospital.

Methodology: Records of hypertensive patients referred to Physician Clinic Hospital Raja Perempuan Zainab II between1st January 2004 till 31st December 2006 were randomly selected. Parameters for analysis were recorded and analysed.

Results: 100 hypertensive patients consists of 47 males and 53 females aged 58.4 ± 11.9 (range 29-88) were selected.Duration of follow up was between 6 months to 3 years. Co morbidities noted among these patients were 51% had IschemicHeart Disease, 49% with hyperlipidemia, 25% were diabetics, 6% with CVA and 3% with chronic kidney disease.Blood pressure (SBP, DBP) changed between first visit and last visit as follows : SBP 145.0 ± 26.3 mmHg ; 142.4 ± 20.2mmHg ; DBP 87.6 ± 15.4 mmHg ; 84.2 ± 9.9 mmHg. Only 33% had blood pressure < 140/90mmHg at the last clinic visit. Interms of antihypertension treatment, 38% on monotherapy, 43% on dual therapy, 17% on triple therapy and 2% on quadripletherapy. For types of antihypertension prescribed ; 64% on beta blocker, 47% on ACE inhibitor, 40% on calcium channelblocker, 22% on diuretics, 8% on ARBs and 5% on alpha blocker.

Conclusion: Only one third of hypertensive patients managed at our Physician Clinic had controlled blood pressure. Mostcommon antihypertension prescribed were beta blocker, ACE inhibitor and calcium channel blocker. Nearly half of them ondual anti hypertension.

49

FP 2.2SHORT AND LONG TERM CLINICAL OUTCOME OF FEMALEPATIENTS IN STEMIDr Chong Wei Peng, Yap Wee Fang, Dr Sanjay Rampal, Prof Wan AzmanUniversity Malaya Medical Centre, Kuala Lumpur

Background: There were conflicting data regarding the exact role of gender on short and long term mortality in STEMIpatients. While most studies showed a poorer outcome for female patients, adjustment for age, co-morbidities and treatmentdifference often resulted in similar outcome between male and female patients.

Objective: To determine the relationship between gender and the clinical outcome in STEMI, and the effect of otherconfounding factors on this relationship.

Materials & Methods: A retrospective cohort study of all STEMI patients admitted to UMMC between 1-1-2004 and 31-12-2006 was performed. The first co-primary end point was in-hospital mortality, and the second co-primary end point wasmortality at 1 year after index STEMI. The secondary end points were hospitalization at 1 year for acute coronarysyndromes, heart failure or urgent revascularization. Cox regression model was used to examine the relationship betweengender, co-morbidities, clinical presentation, treatment and the primary end points.

Results: A total of 589 patients were included in the study: 483 (82%) male and 106 (18%) female. Female patients wereolder, had a higher prevalence of diabetes mellitus, hypertension and higher Killip class (II or higher) on presentation andhad longer time delay from symptom onset to fibrinolytic treatment. There was also lower usage of ADP antagonist, βblocker, ACE inhibitor and statin among them. The in-hospital and 1 year mortality were significantly higher among femalepatients, 29.2% vs 13.5%; p<0.001 and 35.8% vs 17.8%; p<0.001 respectively. After adjustment, age, diabetes mellitus,Killip class on presentation, the use of ADP antagonist, β blocker and ACE inhibitor were found to be independent predictorsof death at 1 year.

Conclusions: Female patients had poorer short and long term clinical outcome after STEMI. This difference was dependenton other confounding factors.

5251

FP 2.4MYOCARDIAL INFARCTION AND ETHNIC DIFFERENCES INMALAYSIA – A SINGLE CENTRE STUDYDr Haizal Haron Kamar, Siti Noor Baizura, Prof Wan Azman Wan AhmadDepartment of Medicine, Faculty of Medicine, University of Malaya

Background: It is well known that ethnic differences play an important role in coronary artery disease (CAD). To date, therehas not been a published study looking at the pattern of myocardial infarction (MI) among the major ethnic groups inMalaysia.

Objectives: The aim of this study was to determine the association of risk factors, clinical presentation and clinical outcomeof myocardial infarction (MI) in all three main ethnic groups (Malay, Chinese and Indian) who presented to the UniversityMalaya Medical Centre (UMMC).

Methods: It was a retrospective study looking at all patients admitted with MI to UMMC from 1st of November, 2006 to 31stof October, 2007. The data were collected from the National Cardiovascular Disease Database (NCVD) notification forms inthe Cardiology Unit, UMMC.

Results: 144 (40.0%) of the total 370 patients identified were Malays, 78 (21.7%) patients were Chinese and 138 (38.3%)patients were Indians. There were differences in peak age for MI in each ethnic group. 68.0% of Chinese patients presentedat the age of 60 and above, whereas 59.7% of Malays presented earlier at the age between 50-70 years old. However,Indians presented much earlier with 60.2% of the cases were between 40-60 years of age. About 90% of patients in all threeethnic groups were discharged alive from hospital, but 4% of these died of acute complications within 30 days following theMI. For the Malays, dyslipidaemia, hypertension and diabetes affected the patients in almost equal proportions (54.2-55.6%). Hypertension (67.9%) was the predominant risk factor for the Chinese, whereas diabetes (63.0%) and hypertension(62.3%) affected the Indians the most. Per ethnic group, the Malays had the highest number of smokers (48.6%) followedby the Indians (41.3%) and the Chinese (30.8%).

Conclusion: We found that there were strong differences in the incidence, age of presentation, risk factors and outcome ofacute myocardial infarction in the three main ethnic groups in an urban population in Malaysia. Understanding thesedifferences will help us to better manage CAD in Malaysia.

FP 2.5MYOCARDIAL INFARCTION SYMPTOM RECOGNITION BYTHE LAY PUBLIC IN MALAYSIA: THE ROLE OF GENDER,AGE GROUP, ETHNICITY, SOCIOECONOMIC STATUS ANDLEVEL OF EDUCATION.Dr Haizal Haron Kamar, Mariam Taha,, Nik Halmey Nik ZainalDepartment of Medicine, Faculty of Medicine, University of Malaya

Background: Limited knowledge of heart attack symptoms may prevent patients from seeking time-dependent and life-saving thrombolysis and revascularisation therapy. Previous studies carried out in developed countries demonstrated adeficit of knowledge about a wide range of heart attack symptoms.

Objective: The aim of this study was to describe the knowledge of heart attack, heart attack symptoms and risk factors, andanticipated first response to symptoms among the lay public in Malaysia.

Materials & Methods: A total of 502 participants were interviewed using a standard questionnaire in a cross-sectionalmanner. Those below 18 years of age, all health professionals, and individuals with a history of heart attack were excluded.

Results: Both men and women recognised chest pain (men;54.3%, women;59.6%) and shortness of breath (men;42.8%,women;41.7%) as important symptoms of heart attack. Symptom recognition was lower among Malays and Indians thanChinese, younger and older persons than middle-aged persons, persons with less education and persons with no previoushistory of heart attack. Younger and older aged groups were more likely than middle-aged group to choose an incorrect riskfactor (stress and alcohol). Many of the participants (44%) didnʼt know about heart attack. 80% of the participants, whorecognised chest pain as a symptom for heart attack, suggested that chest pain for heart attack is left sided. About 38% ofthe participants couldnʼt identify the immediate actions for heart attack. Out of the 87 participants who chose to callambulance, 94% of them identified the correct telephone number to call.

Conclusions: The level of knowledge on myocardial infarction is low in Malaysia. Much work is needed to increase therecognition of the major heart attack symptoms in both the general public and groups at high risk for an acute coronaryevent.

54

FP 2.7DOES THE OCCURRENCE OF VENTRICULARTACHYARRHYTHMIAS IN CRT-D PATIENTS AFFECTOUTCOME?Kevin LJ, Surinder K, Azhari R, Tay GS, Zunida A, Azlan H, Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Objective: The objective of this study was to assess the impact of biventricular implantable cardioverter defibrillator (CRT-D)implantation on mortality and the occurrence of ventricular tachyarrhythmias in patients with moderate to severe heartfailure.

Methods: This retrospective study enrolled all patients implanted with a CRT-D between January 2001 and December 2006.Patients were divided into 2 groups based on whether the CRT-D was implanted for primary (Group 1) or secondary (Group2) prevention. Patients were reviewed at 3 month intervals or when the patient experienced a shock from the device. Onlyappropriate shocks were evaluated.

Results: Eighty-four patients were recruited (61 in Group 1 and 23 in Group 2). The mean duration of follow-up was 420days. The average time to the first appropriate shock being delivered was 227 days. Seventy percent of the patients weremale. There were more diabetics in Group 1 and more patients in Group 2 were on Amiodarone (P<0.05). Five patients(5.95%) experienced an appropriate shock [1 patient (1.6%) in Group 1 and 4 patients (17.4%) in Group 2]. Of those patientswith an appropriate shock in Group 2, 75% subsequently developed an electrical storm and died.

Conclusion: The number of patients experiencing an appropriate shock is small. This may be due to the reduction inventricular tachyarrhythmias following positive ventricular remodelling with CRT-D. Mortality rates in the primary preventiongroup are low, consistent with findings from the SCD-HeFT and MADIT II trials which show a relative mortality reduction ofabout 30%. Patients with a CRT-D for secondary prevention have a high mortality following the first appropriate shock.These patients are known to have a higher risk for ventricular tachyarrhythmias and as such have a higher incidence ofappropriate shocks. Progression to electrical storm may be a marker of end-stage heart failure.

53

FP 2.6IMMEDIATE OUTCOME OF PERCUTANEOUS TRANSVENOUSMITRAL COMMISSUROTOMY FOR PATIENTS OF MITRALSTENOSIS WITH ATRIAL FIBRILLATIONDR MD Toufiqur Rahman, Prof Syed Azizul HaqueNational Institute of Cardiovascular Diseases(NICVD),Dhaka

Objectives: The purpose of this study was to address the effect of atrial fibrillation (AF) on the immediate outcome ofpatients undergoing Percutaneous Transvenous Mitral Commissurotomy (PTMC).

Background: There is controversy as to whether the presence of AF has a direct negative effect on the outcome afterPTMC.

Methods: The immediate procedural and in- hospital clinical outcome after PTMC of 88 patients with AF were prospectivelycollected and compared with those of 96 patients in normal sinus rhythm (NSR).

Results: Patients with AF were older (51 ± 12 vs. 38 ± 13 years; p < 0.0001) and presented more frequently with New YorkHeart Association (NYHA) class III-IV (79.8% vs. 59.9%; p < 0.0001), echocardiographic score >8 (39.8% vs. 24.9%; p <0.0001), calcified valves under fluoroscopy (25.2% vs.20.1%, p < 0.0001) and with history of previous surgicalcommissurotomy (22.2% vs. 10.5%; p = 0.0002). In patients with AF, PTMC resulted in inferior outcomes, as reflected in asmaller post-PTMC mitral valve area (1.7 ± 0.6 vs. 2 ± 0.4 cm2; p < 0.0001).

Conclusion: Patients with AF have a worse immediate outcome after PTMC. However, the presence of AF by itself doesnot unfavorably influence the outcome, but is a marker for clinical and morphologic features associated with inferior resultsafter PTMC.

56

FP 2.9CHANGING TRENDS IN THE PRACTICE AND MODES OFPERMANENT PACEMAKER IMPLANTATION AT THE NATIONALHEART INSTITUTE: A RETROSPECTIVE ANALYSIS OF THELAST 23 YEARSMahmood SZ, Zunida A, Tay GS, Azhari R, Hasri S, Surinder K, Lam KH, Mohd Nasir M, Amin Ariff N, DavidChew SP, Rosli MA, Robaayah Z, Azlan H, Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Objective: To analyze if the cause of bradyarrhythmia requiring pacemaker have changed over the last 23 years, toevaluate the changing type and modes of pacing and to assess our complication rate

Methods: This registry involved 2555 patients from 1983 to November 2006 and they are divided into 3 era. Group I arethose implanted from 1984 to 1994, Group II from 1995 to 2000 and Group III from 2001 to 2006. They are analyzed in termsof indication, mode, venous access, types and fixation of lead; and complications of pacemaker implantation.

Results: Adult (88.7%), paediatric (11.3%) of the total implant. Commonest indication for pacemaker was Complete HeartBlock, Sinus node dysfunction and 2nd degree AV block. Mode of choice in Group I was Single chamber pacemaker (SCPPM) (93%), however Group III was Dual chamber (DC PPM) (55.6%). Access from left cephalic vein cut down side waspreferred with cephalic vein cut down initially popular in Group I (68.5%) but in Group III, subclavian puncture (3.9%) wasthe commonest. The lead has also change from unipolar to bipolar in Group II and III. In Group I all the leads was passivefixation but by Group II and III most of leads were active fixation. Minor complications remain stable between 10% to 13%.Commonest complications are mild hematoma followed by pneumothorax and lead dislodgement.

Conclusion: The trend of pacemaker implantation in IJN has shown a steady change over the years with respect toincrease number of devices implanted. There is preference for DC PPM over SC PPM with increase use of rate responsedevices. The trend also shows an increasing the non bradycardia cardiac pacing and multisided pacing. The overallcomplication is quite low.

55

FP 2.8ABERRANT CIRCADIAN PATTERNS OF HYPERTENSIONCORRELATE WITH LEFT VENTRICULAR HYPERTROPHYLiew Houng Bang, Seng-Keong Chua1, Nor Hanim1, Kuan-Leong Yew1, Alan Fong1, Rowland Chin1, Choon-Kiat Ang1, Tiong-Kiam Ong1, Annuar Rapaee2, Kui-Hian Sim1

1. Department of Cardiology, Sarawak General Hospital, Kuching, Sarawak, Malaysia.2. Universiti Malaysia Sarawak, Kuching, Sarawak, Malaysia.

Background: Ambulatory blood pressure monitoring (ABPM) can predict cardiovascular (CV) risk better than officereadings. The thresholds of normalcy for ABPM have been lowered, following the recent large longitudinal study by theInternational Database for ABPM in relation to Cardiovascular Outcomes (IDACO). The implication of new cutoffs needsprospective evaluation in terms of target organ damage.

Objective: To evaluate the adequacy of BP control using the new ABPM thresholds; to examine the correlation of variousABPM measurements to left ventricular hypertrophy (LVH).

Methodology: Subjects are hypertensive patients, with uncontrolled clinic BP (SBP>140, DBP>90mmHg) who underwentABPM and echocardiography. Definition of hypertension is based on IDACO thresholds: for 24-hour SBP>130 and/orBP>80mmHg; for daytime SBP>140 and/or DBP>85mmHg; for nighttime SBP>120 and/or DBP>70mmHg.

Results: Amongst 222 subjects, the mean age is 58.4yo, 54.5% male. 23.4% has optimal control by ABPM thresholds.

SBP (± SD ) DBP (± SD)

Mean 24-hour, mmHg 140.7 ± 14.4 81.1 ± 9.8

Mean daytime, mmHg 141.9 ± 14.7 82.3 ± 10.5

Mean nighttime, mmHg 137.3 ± 16.9 78.1 ± 10.9

Mean BP load (SBP>135, DBP>85), % 56.9% 34.1%

Among those with suboptimal control, 33.5% has isolated systolic hypertension (ISH), 2.4% has isolated diastolichypertension (IDH). Among subjects with normal daytime BP, 60% has isolated nocturnal hypertension (INH). The meanpercentage difference of day/night average SBP is -3.2%, with 49.5% “non-dipper” status, and 33.3% “inverted” dipper. LVHis prevalent at 89.2% of this cohort, with mean IVS of 1.43cm ± 0.31. There is also significant correlation with the presenceof LVH with CKD, IHD and CVD.

Correlation analysis of ABPM measurements to IVS thickness:

Correlation coefficient (r) P value

24-hour mean SBP 0.182 <0.01

24-hour mean DBP 0.113 NS

Daytime mean SBP 0.148 <0.05

Daytime mean DBP 0.078 NS

Night-time mean SBP 0.241 <0.01

Night-time mean DBP 0.194 <0.01

Conclusion: Approximately ¾ of treated hypertensives has suboptimal BP control, of which 1/3 has ISH. Majority hasaberrant dipping status. Nocturnal BP has significant stronger correlation to LVH than daytime BP. LVH is significantlycorrelated with target organ damage.

58

FP 3.1A STUDY OF METABOLIC SYNDROME AMONG CORONARYARTERY DISEASE PATIENTS UNDERGOING CORONARYANGIOGRAM IN HOSPITAL UNIVERSITI SAINS MALAYSIANani Draman1, Azidah Abdul Kadir1, Suhairi Ibrahim2, Mohd. Sapawi Mohamed2, Tee Meng Hun2,Kamarul Imran Ariffin3, Prof Madya Zurkurnai Yusof21Department of Family Medicine; 2Department of Internal Medicine, 3Department of Community Medicine,Universiti Sains Malaysia.

Introduction: The metabolic syndrome (MS) is a cluster of risk factors that is associated with an increased overall risk ofcardiovascular events. Study objectives were to determine a) the prevalence of MS using IDF criteria, as well as b) todescribe the severity of coronary artery disease (CAD) among patients with MS who undergo coronary angiograms inHUSM.

Methods: A cross-sectional study was designed where all adult patients undergoing coronary angiograms from September2006 until Jan 2008 were screened for MS. Data on MS criteria using IDF definition, waist circumference, body mass indexand fasting lipid profile were collected. Patientʼs marital status, occupation, smoking history, past medical history and familyhistory as well as angiogram results were also obtained.

Results: One hundred and eighty-nine patients were recruited. Of these, 160 (84.7%) were male and 29 (15.3%) femalewith a mean age of 56 ± 9.4 years old. The prevalence of MS using IDF definition was 47.1% (89 patients), of which 72 weremale and 17 female.146 (77.2%) had positive coronary artery disease, of whom 65 (44.5%) patients had MS and 81(55.4%)had no MS. 43 (22.8%) patients had a normal coronary artery disease on coronary angiogram, of whom 24 (55.8%) patientshad MS and 19 (44.1%) had no MS. Among the MS group (89 patients) using the IDF criteria, 18 (20.2%) had normalangiograms, 30 (33.7%) had 1 vessel disease, 27 (30.3%) had 2 vessel disease and 14 (15.7%) had 3 vessel disease.Among the non-MS group (100 patients), 14 (14%) had a normal angiogram, 24 (24%) had 1 vessel disease, 25 (25%) had2 vessel disease and 37 (37%) had 3 vessel disease.

Conclusion: The prevalence of MS amongst patients in this study was 47.1%. Majority of angiogram positive patients inthis study did not have metabolic syndrome. Patients with MS mostly had single vessel disease.

57

FP 3.0ANEMIA IN ACUTE CORONARY SYNDROME IS ANINDEPENDENT PREDICTOR OF MAJOR ADVERSE CARDIACEVENTSMiza Hiryanti Zakaria, Tee Meng Hun,Zurkurnai Yusof, Sapawi Mohamed, Suhairi IbrahimHospital Universiti Sains Malaysia, Kubang Kerian, Kelantan

Background: Anemia has a worse prognostic effect in patients with coronary artery disease. Its presence will worsenischemia in an already injured myocardium namely in acute coronary syndrome (ACS).

Methodology: The primary objective of this study was to determine association between hemoglobin and MACEs inpatients presented with ACS in Hospital USM. The secondary objectives were to determine prevalence of anemia in patientwith ACS and to compare mean hemoglobin between patients with and without MACEs 6 months post ACS. A total of 219patients were included in this retrospective cohort study. Baseline characteristics, admission hemoglobin and outcomes after6 months post discharge were recorded.

Results: The prevalence of anemia among ACS patients was 32% and incidence of MACEs was 14.6%. Only age(p=0.004;adjusted OR 1.05 95% CI 1.02-1.08) and creatinine (p=0.002; adjusted OR 1.01 95% 1.00-1.02) were significantafter multivariate analysis. Hemoglobin was found to be an independent predictor of MACEs. There was significantdifference between mean hemoglobin in those patients who developed MACEs and those who did not (p=0.005).This wasmaintained in multivariate analysis (p=0.001; adjusted OR 0.22 95% CI 0.31-1.68). Other variables that were significant inthis study after multivariate analysis were smoking (p=0.019 adjusted OR 3.69, 95% CI 1.64-10.98), dyslipidemia (p=0.011;adjusted OR 3.84 95% CI 1.36-10.85) and PTCA (p=0.001; adjusted OR 0.63 95% CI 0.49 - 0.83).

Conclusion: Anemia was an independent predictor of MACEs in 6 months post ACS. Other independent predictors foundin this study were diabetes, smoking, dyslipidemia and PTCA.

60

FP 3.3PREVALENCE OF MAJOR ADVERSE CARDIOVASCULAREVENTS IN PATIENTS POST CORONARY ANGIOPLASTY -AN HUSM EXPERIENCENg Seng Loong, Tee Meng Hun, A. Prof. Zurkurnai Yusof, Sapawi Mohamad Mohamad Sapawi, Suhairi IbrahimHospital Universiti Sains Malaysia, Kubang Kerian, Kelantan

Background: Percutaneous coronary intervention (PCI) has been done in most cardiology centres worldwide for relief ofangina. However,the procedure is also associated with intra and post procedural complications.

Objectives: The primary objective of this study was to determine the prevalence of major adverse cardiovascular events(MACEs) in patients undergoing PCI in our cardiology unit in HUSM. The second objective was to have a baselinedemographic and angiographic data of the patients.

Methods: A total of 240 patients who underwent coronary angioplasty electively were recruited into this prospective cohortstudy.

Results: 21 patients (8.9 %) had MACEs post PCI. 5 patients had drop out from the study during follow-up. 2 variables weresignificantly associated with MACEs post PCI using univariate and analysis including two vessel residual disease (p<0.001)and right coronary artery disease(RCA)involvement (p=0.004). Multivariate analysis maintained the association. HbA1C alsohad significant association with MACEs (p=0.011, adjusted OR 1.93,95% Cl 1.16-3.20).Patients who were current smokers,had prior myocardial infarction (MI), dyslipidaemic and multivessel disease had increased risk for development of MACEspost PCI,but this did not achieve statistical significance.

Conclusion: Prevalence of MACEs in patients undergoing PCI was not high in HUSM. Residual two vessel disease, RCAinvolvement and higher HbA1C were highly predictive of increase risk for MACEs post PCI. This group of patients maybenefit from earlier reangiographic studies, staged revascularization therapies and more aggressive control of metabolic riskfactors

59

FP 3.2THE USEFULNESS OF TISSUE DOPPLER IMAGING INIDENTIFYING DYSSYNCHRONY IN MODERATE TO SEVEREHEART FAILURE PATIENTSNg KH, Tay GS, Lam KH, Surinder K, Azhari R, Zunida A, Zakaria M, Rosila R, Azlan H, Razali ODepartment of Cardiology, Institut Jantung Negara, Kuala Lumpur

Objective: To assess the prevalence of LV dyssynchrony using Tissue Doppler Imaging (TDI) in narrow and broad complexQRS heart failure patients.

Methods: Heart failure patients, refractory to optimal medical therapy, with an ejection fraction �35%, LVIDd �5.5cm, insinus rhythm, were referred for echocardiography to look for mechanical dyssynchrony, regardless of their QRS duration.Myocardial velocity curves were reconstituted using the 6-basal and 6-mid segmental region in the LV. Time to peak systole(Ts) were measured with reference to the onset of QRS complex. LV dyssynchrony is defined as a standard deviation (SD)of �32.6msec (Ts-SD) of the time difference.

Results: In 199 patients (168 males and 31 females), age 53.9 �12.8 years were studied. Mean QRS duration was 118.8�28.9 msec. Patients were divided into three groups, 107 patients with QRS <120msec, 47 patients with QRS 120-140msecand 45 patients with QRS >140msec. A total of 107 patients (53.8%) had LV dyssynchrony by echocardiography TDI.Prevalence of dyssynchrony was present in 49 (45.8%), 20 (42.6%) and 38 (84.4%) patients with QRS <120msec, QRS120-140msec and QRS >140msec, respectively.

Conclusion: This study demonstrates that a large group of heart failure patients with narrow QRS duration do showsignificant mechanical dyssynchrony. Nevertheless, in patients with broad QRS duration, 84% do show mechanicaldyssynchrony, in keeping with clinical responders in major clinical trials. This study suggests that echocardiography TDI isa better technique to identify mechanical dyssynchrony for suitable CRT candidates..

62

FP 3.5PRIMARY PERCUTANEOUS CORONARY INTERVENTION(PCI) MODIFIED CONVENTIONAL POOR PROGNOSTIC RISKFACTORS IN ST-ELEVATION MYOCARDIAL INFARCTION(STEMI) PATIENTSDr. Chiew Kean Shyong, Dr. David Chew Soon Ping , Dr. Rosli Mohd AliInstitut Jantung Negara

Background: TIMI risk score for STEMI identified risk factors which carried poor prognosis for a group of fibrinolytic-eligiblepatients with STEMI. It is unknown whether some of these factors carry the same prognosis in patients who underwentprimary PCI. Primary PCI may improve prognosis despite presence of these factors.

Objective: To determine whether primary PCI modified poor prognostic risk factors and improved mortality.

Methods: All consecutive STEMI patients in 2006 who underwent primary PCI in Institut Jantung Negara, Malaysia werestudied. Known poor prognostic risk factors ie age > 65, presence of diabetes or hypertension, anterior myocardial infarctionand door to balloon time were analyzed for their significance in terms of mortality. Statistical analysis was done with chisquare test.

Results: A total of 46 patients were included. Age > 65 carried a poor prognosis (p: 0.04). Mean door to balloon time was120 minutes. Door to balloon time > 90 minutes was also a risk factor associated with higher mortality (p: 0.05). Other riskfactors ie presence of diabetes (p: 0.82) or hypertension (p: 0.86) and anterior myocardial infarction (p: 0.39) wererendered insignificant and did not affect mortality after patient underwent primary PCI . Mean mortality at 30 days was 15.2%. Patients with at least one of these significant risk factors constituted 86% of overall mortality.

Conclusion: In STEMI patients who underwent primary PCI, age > 65 and a prolonged door to balloon time wereindependent poor prognostic risk factors associated with a higher mortality. However, presence of conventional risk factorsie diabetes or hypertension and anterior myocardial infarction did not affect mortality in patients who underwent primary PCI.Primary PCI modified these risk factors and resulted in mortality benefit.

61

FP 3.4ACUTE ISCHAEMIC MITRAL REGURGITATION AND EARLYMAJOR CARDIOVASCULAR EVENTS IN PATIENTSPRESENTING WITH ACUTE CORONARY SYNDROMENor Hanim MA1, Rowland WM Chin1, KL Yew1, HB Liew1, AYY Fong1, SK Chua1, Annuar R2, CK Ang1, TKOng1, KH Sim1

1Department of Cardiology, Sarawak General Hospital. 2Universiti Malaysia Sarawak

Background: Acute ischaemic mitral valve regurgitation (IMR) has been shown to be an independent predictor of long-termcardiovascular mortality. Associated factors for IMR include advanced age, prior myocardial infarction, large infarct andrecurrent ischemia.

Objectives: The aim of our study was to determine if acute IMR predicts early events in patients admitted to our hospitalwith ACS over a one year period.

Methods: Using the National Cardiovascular Database (NCVD) as our source, we identified 283 patients admitted to ourinstitution with ACS between January and December, 2006 who also had an echocardiogram during the index admission.They were divided into 2 groups, those with IMR (n = 126, mean age 60�10 years) and those without IMR (n = 157, meanage 56�13 years). Echocardiography was performed within 48 hours of admission in every case. We analyzed their 30–dayoutcomes looking at all cause mortality, coronary revascularization, recurrent ACS, heart failure and stroke.

Results:Advanced age (p < 0.05), hypertension (p<0.05) and low ejection fraction (p< 0.05) have significant correlation withdevelopment of acute IMR. There were no significant correlations between acute IMR and other co-morbidities, gender,diabetes mellitus, dyslipidaemia, renal disease and recurrent ACS. The site of infarction did not influence development ofIMR. The presence of acute IMR did not predict a worse 30 day outcome. Outcome was also similar regardless of the modeof therapy (medical, angioplasty or surgery).

Conclusion: Incidence of acute IMR was high in our ACS patients but has no prognostic significance for 30 day outcome.Advanced age, hypertension and low ejection fraction have significant correlation with incidence of IMR.

64

FP 3.7CENTRAL AORTIC PULSE WAVE AND THE QUANTITY OFCORONARY ARTERY CALCIUM ASSESSED USING 64-MDCTIN ASYMPTOMATIC PATIENTSR Annuar1, Ong TK2, Ang CK2, Liew HB2, Fong AYY2, RWM Chin2, Nor Hanim MA2,SK Chua2, KL Yew2, KH Sim2

1Universiti Malaysia Sarawak, 2Cardiology Department, Sarawak General Hospital

Introduction: Coronary artery calcium (CAC) score determined by computed tomography and central aortic pulse wave(CAPW) is associated with higher risk of cardiovascular event independent of traditional risk factors. However CAC has animpact on the diagnostic accuracy of 64-slice multi detector computed tomography coronary angiography (CTA).

Objectives: The objective of the study is to determine the correlations of CAPW and CAC score. We also sought todetermine whether CAPW is superior to CAC in differentiating patients where the CTA is not diagnostic hence can be usedas an initial test for patients plan for CTA.

Methodology and Results: We studied 213 asymptomatic patients screen for coronary artery disease using 64-sliceMDCT. Central aortic wave indices were quantified non-invasively using a commercially available Sphygmocor Systeminclude augmentation index (AIx), augmentation pressure (AP) and augmentation index corrected at heart rate of 75 perminute (AIx@75). Mean age 57.4�9.4 years with 59.2% males. Correlation coefficient between CAC score and AIx, AIx@75and AP were 0.78, 0.69, 0.78 and p < 0.0001 respectively. At cutoff CAC score of 210 showed a sensitivity of 98% andspecificity of 97.1% able to interpret CTA. Logistic regression showed CAC score is the only significant factor that can predictwhether CTA can be interpreted conclusively (p < 0.0001) as compared to AIx (p = 0.6), AIx@75 (p = 0..5) and AP (p = 0.7).Receiver operating characteristic (ROC) curve showed the CAC score has the highest area under the curve of 0.98 compareto AIx (0.94), AIx@75 (0.89) and AP (0.91).

Conclusions: CAPW is strongly correlated with the CAC score determined using 64-slice MDCT. However, compared toCAC score, CAPW is less significant predictor on the diagnostic accuracy of 64-slice MDCT. Therefore CAC score is still auseful parameter to determine the diagnostic accuracy of CTA.

63

FP 3.6CENTRAL AORTIC PULSE WAVE ANALYSIS AND SEVERITYOF CORONARY ARTERY DISEASE IN PATIENT PRESENTINGWITH ACUTE CORONARY SYNDROMER Annuar1, Ong TK2, Ang CK2, Liew HB2, Fong AYY2, RWM Chin2, Nor Hanim MA2,SK Chua2, KL Yew2, KH Sim2

1Universiti Malaysia Sarawak, 2Cardiology Department, Sarawak General Hospital

Introduction: Arterial stiffness determined by central aortic pressure indices such as augmentation pressure, augmentationindex and central pulse pressure has been shown to be associated with the risk of atherosclerosis. It also has been shownto predict clinical outcome in patients with coronary artery disease (CAD).

Objective: The objective of this study was to determine whether a non-invasive assessment of central aortic pulse wavecould be used to predict the severity of CAD in patients presenting with acute coronary syndrome (ACS).

Methodology and Results: We prospectively studied 203 consecutive patients admitted with ACS who subsequentlyunderwent coronary angiography. Central aortic wave analysis was quantified non-invasively using a commercially availableSphygmocor System. A modified coronary stenosis scoring system was used for classification of mild, moderate and severeCAD. Patients were also classified based on the number of vessels with significant disease. Mean age was 58.2�9.4 yearswith 80% males. Mean augmentation indices (AIx) for patients with mild, moderate and severe disease were 8.7�6.3,22.1�9.8 and 34.2�4.8 respectively (p <0.0001). After normalization to a heart rate of 75 bpm (AIx@75) the resultsremained significant (p<0.0001). The mean augmentation pressures (AP) in patients with mild, moderate and severe CADwere 3.7�4.6mmHg, 7.7�5.5mmHg and 12.3�3.9mmHg respectively (p<0.0001). Univariate analysis showed that the AIx,AIx@75 and AP independently predicted severity of CAD (p<0.0001). However, linear regression analysis identified the AIxas the most significant predictor of CAD severity (p <0.0001) compared to either AIx@75 (p=0.8) or AP (p=0.07).

Conclusions: Arterial stiffness assessed non-invasively correlated well with the severity of CAD. Of the various centralaortic pressure indices, the one which most significantly predicted severity of CAD was the AIx. He

66

FP 3.9INCIDENCE AND SURVIVAL OF PATIENTS WITHCEREBROVASCULAR EVENTS SECONDARY TO INFECTIVEENDOCARDITIS IN UNIVERSITY MALAYA.Lim Yin Cheng1, Syahidah Syed Tamin2, Najmi Anuar1, Imran Zainal Abidin2, Wan Azman21Faculty of Medicine, University Malaya, Kuala Lumpur.2Division of Cardiology, University Malaya Medical Center, Kuala Lumpur.

Background: Cerebrovascular events (CVE) remain a major cause of morbidity and mortality in patients with infectiveendocarditis†. Despite the frequency of stroke only a few studies have focused specifically on stroke in patients with IE*.

Objective: The intention of this study was to document the demographics, clinical presentation and outcome of endocarditispatients who suffered cerebrovascular events in University Malaya. In addition, the one-year survival rate from the indexadmission and differences in patients with and without CVE were examined.

Materials & Methods: This was a retrospective study of 86 cases of IE in University Malaya Medical Centre, (UMMC) fromJanuary 2000 to December 2007. Patients were identified from hospital medical records and the modified Duke criteria wereused to select confirmed cases of IE. Data on the patientsʼ demographic characteristics, predisposing factors, clinicalfindings, incidence of CVE, result of investigations, method of treatment and clinical outcome were extracted from the casenotes. Data on 1-year survival was obtained from either phone interview with the patient or from the patientʼs medical casenotes.

Results: From January 2000 to December 2007 there were a total of 86 confirmed cases of IE. Out of these, 63% weremale and 37% female. At the index IE episode, the majority of patients had native valves except for 7% who had surgicallyrepaired valves and 8% with valve replacements. The most common complications recorded were systemic embolization(24%) followed by cerebrovascular events (21%). A total of 20 patients (23%) suffered a CVE in this study. All patients whosuffered CVE had positive blood cultures. Haemorrhagic stroke contributed to 70% of CVE (14 patients) whilst 30% of cases(6 patients) had embolic stroke. Out of 49 patients who had vegetations on their mitral valve, 12 patients (12%) suffered aCVE and from 14 patients with vegetations on the aortic valve 6 patients (43%) suffered a CVE. From the index admission71 (83%) patients were discharged alive whilst 15 (17%) had died. 12 patients who had died at the index admission suffereda CVE which is 80% of the total number of deaths. Out of the total number of patients who suffered CVE, 60% died at theindex admission.

Conclusions: These results show that cerebrovascular event is one of the most important risk factors for a fatal outcomeduring IE. In-hospital mortality was much higher in patients with a CVE than those without a CVE. In conclusion, CVE is acommon and severe complication occurring in every fifth patient with IE. The occurrence of CVE significantly contributes tothe patientsʼ poor outcome.

†Salgado AV. Central nervous system complications of infective endocarditis. Stroke. 1991;22(11):1461-1463.

*Hart RG, Foster JW, Luther MF, et al. Stroke in infective endocarditis. Stroke. 1990;21(5):695-700.

65

FP 3.8ATTITUDES AND COMPLIANCE TO ORALANTICOAGULATION THERAPY AMONG PATIENTS WITHMECHANICAL PROSTHETIC HEART VALVESLee Kok Soon1, Alwi Mohamed Yunus2, Syahidah Syed Tamin3, Wan Azman3.1Faculty of Medicine, University Malaya, Kuala Lumpur.2Department of Cardiothoracic Surgery, Institut Jantung Negara, Kuala Lumpur.3Division of Cardiology, University Malaya Medical Center, Kuala Lumpur.

Background: Patients with mechanical prosthetic heart valves are at high risk of developing thrombosis if not anti-coagulated adequately†. Compliance of patients to warfarin has been shown to be affected by various factors, mostimportantly knowledge‡. Other factors may contribute to compliance such as social background, financial constraints andpatientsʼ personal perceptions towards anticoagulant therapy.

Objective: The intention of this study was to examine the various factors which affect compliance towards anticoagulationtherapy as well as the common side effects of anticoagulation experienced by patients with mechanical prosthetic heartvalves.

Materials & Methods: This was a prospective qualitative questionnaire study of adults above the age of 18 years withmechanical prosthetic heart valves who routinely visited the INR clinic in the National Heart Institute, Kuala Lumpur. Thepatients enrolled had undergone mitral valve replacement, aortic valve replacement or both.Four components were studied. The first component assessed patientsʼ knowledge regarding anti-coagulation therapy. Thesecond examined social and financial factors affecting compliance. The third component assessed patientsʼ personalperception and the final component the looked at side effects of therapy. All four components are associated with complianceas these factors determine the behavior of the patient in taking the therapy. The questions were designed in a “yes/no”format. Questions that elicited positive responses stemmed into further multiple choice questions.

Results: A total of 50 patients were interviewed, 42% male and 58% female. They were of mixed ethnicity, 50% Malay, 28%Indian and 22% Chinese. In the knowledge component more than 60% of patients responded positively to questions aboutwarfarin except when they were asked what INR was. In the social and financial component 38% of patients reported thatthey tended to forget to take medication and 48% relied on family members to help them in taking medication. 26% ofpatients had difficulty attending follow up in INR clinic. 32% had financial difficulty in obtaining warfarin. As for personalperception 98% thought it was important to take their medication. Persons who influenced the patients most in adhering tomedication were their own selves (44%) followed by their doctor (24%). 92% were satisfied with the information given bytheir health care providers. In assessing the side effects of warfarin, bruising was reported to be the most common sideeffect which was experienced in 40% of patients followed by gum bleeding (24%) and rectal bleeding (12%).

Conclusions: Considering the importance of optimal anti-coagulation therapy to prevent thrombosis in patients withmechanical prosthetic heart valves, it is vital that all patients have adequate understanding of their therapy. This studyreveals the areas in which improvements could be made to ensure that this objective is achieved and maximal complianceto therapy is attained.

†Cannegieter SC, Rosendaal FR, Wintzen AR et al. Optimal oral anticoagulation therapy in patients with mechanical heart valves. N EnglJ Med 333:11, 1995.

‡Begum N, Gregory Y H Lip, Kaur B , Nadar S and Sandhu S. Patients’ Understanding of Anticoagulant Therapy In A Multiethnic Population.JORSOM 2003;96:175-179

68

FP 4.1ORAL N-ACETYLCYSTEINE IN PREVENTION OF CONTRASTINDUCED NEPHROPATHY FOLLOWING CORONARYANGIOGRAPHYDr Wan Mohd Izani Bin Wan Mohamed, Ass Prof Zainal Bin Darus / Ass Prof Zurkurnai Bin YusofHospital Universiti Sains Malaysia, Kubang Kerian, Kelantan

Introduction: Contrast induced nephropathy (CIN) is defined as acute renal failure within 48 hours of contrast exposurewithout other aetiology. N-acetylcysteine have been used to prevent CIN due to its anti-oxidant properties, but previousstudies produced conflicting results. This is mainly due to heterogenicity in the study designs. This study standardized thetype of contrast agent,hydration and NAC dosage to reduce possible confounders.

Materials and Methods: We studied 100 patients with renal impairment (mean serum creatinine 124.1�19.68µmol/l) whounderwent elective coronary angiography. They were randomly assigned to receive either N-acetylcysteine (600mg orallyBD for 4 doses) and intravenous saline (NAC group) or intravenous saline only (control group).The main objective was tocompare the proportion of patients with CIN between NAC and control groups. The secondary objectives were to assessthe changes of serum creatinine and the risk factors for CIN.

Results: The baseline serum creatinine concentrations in both groups were similar. CIN occurred in 4.1% patients in NACgroup and 11.8% patients in control group (p= 0.269).Changes of serum creatinine after coronary angiography between thetwo groups also were not significant (p=0.821).The only significant predictor of CIN was the contrast volume (mean diff -112.44, 95% CI -184.22,-40.66, p=0.002).

Conclusion: NAC is not effective in preventing CIN in patients with mild to moderate renal impairment post coronaryangiogram. The amount of contrast agent is a significant predictor of renal function deterioration and the incidence of CINafter coronary angiography.

67

FP 4.0COST EFFECTIVENESS OF USING NT- PRO B-TYPENATRIURETIC PEPTIDE IN THE MANAGEMENT OF ACUTEHEART FAILURE IN A PUBLIC HOSPITALTan Sian Kong, Leong Weng San, Alan Fong Yean Yip, Rosleena, Phan Hui Sieng, Ong Tiong Kiam,Sim Kui HianCardiology Department, Sarawak General Hospital

Background: Heart failure accounts for about 10% of all medical admissions in this country. NT-ProBNP levels have beenshown to be higher in patient with congestive heart failure than in patients with dyspnoea from other causes.

Objective: The aim of this study was to evaluate the cost effectiveness of using NT-ProBNP in the management of heartfailure as recommended by the Malaysian 2007 Heart Failure Clinical Practice Guidelines.

Methology: We conducted a prospective controlled study of 160 patients who were admitted for acute dyspnoea. 80patients in the historical control group had been subjected to a conventional diagnostic strategy which included chestradiography (CXR) and electrocardiography (ECG). Another 80 patients had NT-ProBNP assays in addition to the standarddiagnostic strategy. The CXR and ECG were reported independently by the ward medical teams. Primary outcomes werelength of hospitalization and direct cost of treatment.

Results: Baseline demographic and clinical characteristics were matched between the two groups. The mean length ofhospital stay was 5.34 days in the NT-ProBNP group and 6.67 days in the historical control group (P<0.001). The meandirect cost of treatment was RM183.89 (95% CI, RM143.07-224.71) in the NT-ProBNP group compared to RM240.50(95%CI, RM165.13-315.86) in the historical control group (P =0.007). The mean total cost (Direct cost of treatment + Directcost of investigations) was RM287.81 (95% CI, RM220.29-355.32) in the NT-ProBNP group compared to RM360.31 (95%CI, RM274.59-446.03) in the historical control group (P=0.036).

Conclusion: The addition of NT-ProBNP improved the clinical evaluation and treatment of patients presenting with acutedyspnoea, leading to reduced length of hospitalization, direct cost of treatment as well as total cost of management.

70

FP 4.3GENDER DIFFERENCES IN NON ST-ELEVATIONMYOCARDIAL INFARCTION (NSTEMI) PATIENTS IN UMMCHilmi Z, Ham MC, Chan CBT, Halmey N, Imran ZA, Haizal HK, Wan Azman WUniversity Malaya Medical Center, Kuala Lumpur

Background: Gender differences have been identified in nearly every aspect of cardiovascular disease including acutecoronary syndrome. Studies have shown that there are differences between male and female in term of their age, presentingsymptoms, risk factors, presence of other related comorbidities, duration of hospital stay, tendency of urgent interventionand overall outcome.

Objectives: To analyse the gender differences in NSTEMI patient population among our local population.

Method and Materials: This is a retrospective study where 126 patients (63 males and 63 females) with NSTEMIhospitalized between June 2006 and June 2007 in University Malaya Medical Center were included. Their demographic andclinical data, duration of hospital stay and in-hospital mortality were recorded from National Cardiovascular Database(NCVD) forms. All data were statistically analysed using SPSS version 12.0.

Results: We found that women tend to be older than men (mean age 59.95 vs 66.25, p 0.002), have higher prevalence ofdyslipidaemia (47.6% vs 30.2%, p 0.047), hypertension (87.3% vs 63.5%, p <0.001), Diabetes Mellitus (76.2% vs 47.6%, p0.004) but significantly lower prevalence in the smoking status (p < 0.001). In term of cormobidities, more women were foundto have previous myocardial infarction (25.4% vs 22.2%, p 0.003), pre-existing renal disease (23.8% vs 7.9%, p 0.03),previous cerebrovascular disease (14.3% vs 4.8%, p 0.047) and peripheral vascular disease (11.1% vs 3.2%, p 0.009).Women was also found to stay in the hospital longer than men (mean days 6.85 vs 5.19, p 0.001). There was no significantdifference between the gender in the in-hospital mortality

Conclusion: Our study highlights the significant differences in demographic and clinical characteristics among male andfemale patients with NSTEMI, as well as the differences in their co-morbidities. Some of the differences could be accountedfor by the older age of female patient population

69

FP 4.2ONE YEAR OUTCOME IN PATIENTS WHO UNDERWENTCORONARY CT ANGIOGRAPHY FOR ATYPICAL CHEST PAINKuan Leong YEW1, Rowland CHIN1, Alan Yean Yip FONG1, Choon Kiat ANG1, Houng Bang LIEW1,Tiong Kiam ONG1, Kui Hian SIM1, Nor Hanim1, Seng Keong CHUA1, Rapaee ANNUAR2

1.Department of Cardiology, Sarawak General Hospital, Sarawak, Malaysia.2.University Malaysia Sarawak, Sarawak, Malaysia.

Background: Atypical chest pain (ACP) is a cluster of symptoms which may have either a cardiac or non-cardiac cause.About one-fifth of ACP may be due to myocardial ischemia. Coronary CT angiography (CTA) has been increasingly used toscreen ACP patients for coronary artery disease. However, the impact of this strategy on clinical outcome in this group ofpatients is unknown.

Objective: The aim of our study was to evaluate the one year outcome following CTA for ACP. The primary outcomes wereacute coronary syndrome (ACS) events, need for further cardiac investigation, coronary revascularization and all causemortality 12 months after CTA.

Methods and Materials: Ninety eight patients with ACP underwent CTA using a 64-slice multi-detector computertomography (64-MDCT) scanner. The patients were briefed on proper breath-holding techniques and given beta blockers toachieve relative bradycardia (HR <65 bpm). Significant coronary artery disease was defined as the presence of either (a)coronary artery stenosis >50% and/or (b) total calcium score >400 Agatston and/or (c) dense localised calcium deposits.One year outcomes were obtained through review of medical records and phone contacts with patients. Statistical analysiswas done using the SPSS software.

Results: Forty four (44.9%) patients had a normal CTA, twenty (20.4%) had minor lesions, fourteen (14.3%) had significantcoronary stenosis, fifteen (15.3%) had significant coronaries calcification and two (2%) had intramuscular bridging. Calciumscore predicts the need for further investigations {conventional coronary angiography (CCA), MRI, stress test} (p<0.05).Thirty one (31.6%) patients with preliminary significant coronary lesions underwent further cardiac tests with seven (7.2%)eventually requiring CABG or PCI. There was no ACS event or mortality at one year post CTA.

Conclusion: CTA using a 64-MDCT can accurately identify significant coronary lesions and coronary calcification. Itrepresents a valuable screening tool to ʻrule outʼ myocardial ischaemia as a cause of ACP. It helps the clinician to plan furtherinvestigations and management strategy. Using this approach, the majority of patients with ACP avoided an invasivecoronary angiogram with no increased risk of ACS or death at one year.