Strengthening Cardiac Care in Malaysia: Expanding access and expertise to combat heart disease

THE heart, like most organs in the body, requires oxygen and nutrients for metabolism. These reach the heart through blood vessels called coronary arteries.

However, atherosclerotic plaques (fatty deposits) obstruct the blood flow in coronary arteries with age, limiting blood flow to the heart. This causes Ischaemic Heart Disease (IHD) which is the leading cause of death both in Malaysia and worldwide, accounting for 15-17 per cent of all deaths.

High blood pressure (hypertension), high blood sugar (diabetes mellitus), high cholesterol level (hypercholesterolemia), smoking, sedentary lifestyle, and obesity accelerate the process of atherosclerosis and are considered risk factors for IHD.

The National Health & Morbidity Survey (NHMS) 2023 found that among adults in Malaysia, 15.6 per cent have diabetes mellitus, 29.2 per cent have hypertension, 33.3 per cent have hypercholesterolemia and 54.4 per cent are overweight and obese. Meanwhile, the prevalence of tobacco smoking in Malaysia currently is 19 per cent.

Metabolic syndrome, which is a combination of three or more of the following - abdominal obesity, high blood pressure, high blood sugar, high blood triglycerides (a type of fat in blood) and low HDL-cholesterol ('good' cholesterol) - can lead to high risk of IHD, which occurs in 35.9 per cent or 8.5 million adults in Malaysia.

Metabolic dysfunction associated fatty liver disease (MAFLD), found in 28.2 per cent of adults in Malaysia, can lead to serious liver damage and is also associated with diabetes, high blood pressure, heart disease, chronic kidney disease, cancer, and other health problems.

The progression of atherosclerotic plaques can be hindered by lifestyle changes like healthy plant-based diets with minimal processed food, smoking cessation, regular exercise, stress-free life-style, adequate sleep and weight loss.

Medications can help to manage diabetes mellitus, hypertension, and hypercholesterolemia while also assisting with weight loss and smoking cessation. When significant blocking occurs from blood clots forming on atheromatous plaques in coronary arteries, critical reduction in blood flow to the heart muscle develops suddenly (also called acute coronary syndrome, ACS or “heart attack”). This often necessitates anti-thrombotic drugs or catheter-based intervention to re-establish adequate blood flow.

The most common cause of death following an ACS is an abnormal heart rhythm originating from its blood deprived ventricles. Such rhythms are fatal unless reverted within minutes to normal rhythm by electric shock using a defibrillator.

About 50 per cent of such deaths occur prior to arrival at the hospital. Thus, it is laudable that in March 2022 the Malaysian government has made automated external defibrillators compulsory in government and public buildings from 2025.

Medical therapy, including anti-thrombotic, anti-coagulant, anti-platelet therapy, angiotensin receptor-neprilysin inhibitor, cardioselective or β1-selective beta blockers and more, are cornerstones of managing IHD and are widely available.

Interventional cardiology is a specialty that diagnoses and treats heart and blood vessel conditions using tubes called catheters and contrast medium enhanced imaging of blood vessels, called angiography. This procedure is often done in Interventional Cardiac Laboratories (ICL) or simply “cath labs”.

An interventional cardiologist accesses the coronary arteries using catheters introduced through arteries in the forearm or thigh and uses balloons and stents to reopen blocked coronary arteries (a procedure called percutaneous transluminal coronary angioplasty [PTCA or percutaneous coronary intervention (PCI)] or simply “angioplasty”).

Cardiac surgeons perform coronary artery bypass graft (CABG), a surgery to create a new path for blood to divert around a blocked coronary artery. Interventional cardiologists work with cardiac surgeons to determine which mode of treatment would be best suited for a given patient. Guidelines (including the Malaysian Clinical Practice Guidelines) based on evidence from numerous studies guide the use of such interventions.

However, the Annual Reports of the Acute Coronary Syndrome Registry (ARACSR) over the last decade (2011-21) has highlighted the low number and density of registered cardiologists in Malaysia compared to developed countries. It has also highlighted the uneven distribution of cardiologists and cath labs across the country. The density of cardiologists in Malaysia is 10.3 per million population (pmp).

In most European countries, this is 70-110 cardiologists pmp. Furthermore, most cardiologists in Malaysia (80.2 per cent) were employed by the private sector while only 19.8 per cent were attached to the public sector according to the ARACSR (Malaysia, 2020-21).

The average cost of hospitalisation in 2017 for IHD in a private hospital was around three times that of a public hospital. Add to that the fact that less than half of Malaysians are covered by health insurance.

To improve access to life-saving cardiac care in Malaysia, it is crucial to make more public sector hospitals (particularly those in under-served areas) PCI capable. Increasing the recruitment and training of more cardiologists, along with enhancing health insurance coverage, can further ensure more equitable treatment.

Malaysian hospitals have already developed protocols, standard operating procedures and networks linking non-PCI-capable centres to those with PCI capabilities. Interventional cardiology, alongside other related specialities like cardiac surgery and cardiac electrophysiology, remain essential in reducing the impact of cardiac disease and improving patient outcomes.

Associate Professor Dr Benjamin Samraj Prakash Earnest and Dr Sulaimann Tint Soe Lwin are academics at the School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University. The views expressed in this article are the author's own and do not necessarily reflect those of Sinar Daily.