Critical Factors in Quality of Life: A Qualitative Explorations into the Experiences of Malaysian with Heart Failure

@#Introduction: Heart failure (HF) prevalence is increasing in Malaysia and brings about significant poor outcomes especially on the patients’ wellbeing. Despite the devastating physical symptoms of HF experienced by patients, other social consequences on patients are often not discussed by their health care professionals. Hence, this qualitative study aims to explore and understand the quality of life (QOL) for patients in Malaysia of various ethnicity who have been diagnosed with heart failure. Methods: Nineteen (n = 19) patients with recurrent HF were recruited via purposive sampling. One-to-one semi-structured interviews were conducted after patients’ informed consent was obtained. The aforementioned sessions were audio-recorded and transcribed verbatim. Finally, the transcribed data was analysed through Braun and Clarke’s framework for thematic analysis. Results: The findings revealed that Malaysians with HF reported either positive or negative experiences related with QOL which had an effect on their well-being. Four main themes emerged included physical, psychological, social, and spirituality. Interestingly, cultural and beliefs consideration were important to understand these QOL themes of HF patients as a whole, especially in Malaysia’s multi-ethnic communities. Conclusion: Informants were able to give vivid descriptions of living with HF experiences and the way it affected their QOL due to the disruptive and uncertain nature of HF in four major themes. However, the individual themes of QOL in HF patients need to be comprehended in detail including the local cultural perspectives, particularly by health professionals who deal with HF patients of minority ethnicities, in order to improve treatment and health outcomes.

Image Quality of Coronary CT Angiography (CCTA) using 640-slice Scanner: Qualitative and Quantitative Assessments of Coronary Arteries Visibility (Kualiti Imej Tomografi Berkomputer Angiografi Koronari Menggunakan Mesin Pengimbas 640 Hirisan: Penilaian Kualitatif dan Kuantitatif ke atas Keterlihatan Arteri Koronari) / Jurnal Sains Kesihatan Malaysia

@#The purpose of this study was to evaluate the image quality and diagnostic accuracy of coronary computed tomography angiography (CCTA) using 640-slice scanner. Advancement of multidetector computed tomography (MDCT) technology with higher spatial, temporal resolution, and increasing detector array have improved the image quality and diagnostic accuracy of CCTA. A total of 25 patients (12 men and 13 women) underwent CCTA examination was chosen and data was acquired by 640-slice scanner. All 16 segments of coronary arteries were evaluated by two reviewers using a 4-likert scale for qualitative assessment. In quantitative assessment, the evaluation of 4 main coronary arteries were analysed in terms of signal intensity (SI), image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). All 25 patients with a mean age of 52.88 ± 14.75 years old and body mass index (BMI) of 24.24 ± 3.28 kg/m2 were analysed. In qualitative assessment, from the total of 400 segments, 379 segments (95%) had diagnostic value while 21 segments did not have diagnostic value, which means 5% artefact was detected. In quantitative assessment, there was no statistical differences in gender, race, and BMI (p>0.05). Overall evaluation showed that higher SI at the left main artery (LM) at 393.7 ± 47.19. Image noise was higher at right coronary artery (RCA) at 39.01 ± 13.97. SNR and CNR showed higher at left anterior descending (LAD) with 12.73 ± 5.17 and LM 9.14 ± 4.2, respectively. In conclusion, this study indicates that 640-slice MDCT has higher diagnostic value in CCTA examination with 95% vessel visibility with 5% artefact detection.

Exploration of the Factors in Treatment Adherence to Coronary Heart Diseases Diagnosis Among the Multi-Ethnic Patients: A Qualitative Study

Abstract@#Introduction: Introduction: Coronary heart disease (CHD) is the leading cause of death in Malaysia. This study aims to explore the treatment experiences of patients with recurrent coronary heart disease during hospital admission and after discharge. This research also attempts to understand patients’ adherence to the prescribed treatment. Method: The main sample for this study includes inpatients and outpatients with recurrent CHD who have undergone secondary prevention treatment at certain tertiary hospitals which were purposively sampled. The transcripts of one-to-one semi-structured interviews (N=22) were analyzed using the Interpretative Phenomenological Analysis (IPA). Results: Three themes emerged in the analysis of treatment adherence among multi-ethnic patients with CHD: (i) doctor-patient relationships; (ii) information-seeking behaviour; and (iii) psychosocial beliefs. Other factors that influence treatment adherence include patients’ cultural, religious, or spiritual beliefs-based complementary alternative medicines (CAM), if these factors were inadequately addressed by their respective heath professional. Conclusion: The results demonstrate that for future cardiac rehabilitation program development, health professionals must not only focus on the patient’s care improvement but must also be knowledgeable on the patient’s preferred alternative treatment.

Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction

mortality and an important cause of morbidity in Malaysiafor several years. To reduce global cardiovascular (CV) riskin the population, primary preventive strategies need to beimplemented. Hypercholesterolaemia is one of the majorrisk factors for CVD. This paper is an expert review on themanagement of hypercholesterolemia focusing on high andvery high risk individuals. In low and Intermediate riskindividuals, therapeutic lifestyle changes (TLC) and ahealthy lifestyle alone may suffice. In high and very high riskindividuals, drug therapy in conjunction with TLC arenecessary to achieve the target LDL-C levels which havebeen shown to slow down progression and sometimes evenresult in regression of atherosclerotic plaques. Statins arefirst-line drugs because they have been shown in numerousrandomized controlled trials to be effective in reducing CVevents and to be safe. In some high risk individuals, despitemaximally tolerated statin therapy, target Low DensityLipoprotein Cholesterol (LDL-C) levels are not achieved.These include those with familial hypercholesterolaemia andstatin intolerance. This paper discusses non-statintherapies, such as ezetimibe and the newer Proproteinconvertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Augmentation index is a better marker for cardiovascular risk in young Malaysian males. A comparison of involvement of pulse wave velocity, augmentation index, and C-reactive protein

To determine the association between carotid femoral pulse wave velocity PWV[CF] and augmentation index [AI] with future cardiovascular disease [CVD] risk, and to assess whether high sensitivity C-reactive protein [hs-CRP] is an important mediator towards these vascular changes, among young men. This cross-sectional study was conducted at Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia from July 2011 to December 2012. Two hundred and eleven young men were recruited. The PWV[CF] and AI were measured using Vicorder. High sensitivity C-reactive protein was measured by using immunological methods. The future CVD risk was assessed by Framingham risk score [FRS] and age adjusted FRS [A-FRS]. Data for analysis was conducted using the Statistical Package for Social Sciences Version 15 [SPSS Inc., Chicago, IL, USA]. The mean age of the subjects was 27.09 [95% confidence intervals [CI] 26.39-27.79] years old. Those with >/-2 risk factors had significantly higher AI [10.09 [95% CI: 9.06-11.12] versus 6.56 [95% CI: 5.54-7.57] [p=0.001], but not PWV[CF] 7.45 [95% CI: 7.29-7.61] m/s versus 7.29 [95% CI: 7.06-7.51] m/s, [p=0.90] when compared to the healthy subjects. High sensitivity C-reactive protein was not an independent determinant for PWVCF and AI. Only AI was significantly associated with FRS and A-FRS [p=0.0001]. To assess the impact of risk factors on vascular damage and for future assessment of CVD risk among the young men, AI may be a better marker than PWVCF. The increase in AI among these subjects was not related to hs-CRP

Systolic function and intraventricular mechanical dyssynchrony assessed by advanced speckle tracking imaging with n-terminal prohormone of brain natriuretic peptide for outcome prediction in chronic heart failure patients

The aim of this study was to assess longitudinal systolic function and mechanical synchrony parameters derived from advanced speckle tracking echocardiography [STE] and to determine their correlation with N-terminal prohormone of brain natriuretic peptide [NT-proBNP]. Their influence on heart failure [HF] outcomes at a one-year follow-up, not clarified in previous studies, was also examined. Advanced STE was performed from August 2009 to January 2012 in 103 chronic HF patients at the University Kebangsaan Malaysia Medical Center to assess their longitudinal systolic function and synchrony parameters; NT-proBNP blood measurement was taken at the same time. Longitudinal cardiac velocity; strain; strain rate; displacement; intraventricular mechanical dyssynchrony based on the standard deviation [SD] of time to peak systolic strain rate [Tsr-SD]; displacement, and antero-septal to posterior [AS-P] delay were associated with cardiac events. In multivariate analysis, NT-proBNP and AS-P delay were identified as independent predictors for cardiac events. Significant correlations were found between NT-proBNP and longitudinal velocity; displacement; strain; strain rate, and ejection fraction. Log NT-proBNP levels correlated moderately with the SD of time to peak displacement and to peak strain, and there was a small correlation with maximal differences and SD of time to peak velocity. A multiple linear analysis revealed that NT-proBNP levels significantly correlated to age, ejection fraction and velocity. Advanced STE is a promising technique which accelerates the clinical application of the quantification of myocardial function and synchrony. STE parameters and NT-proBNP have the ability to identify patients at higher risk of death and hospitalisation

Clinical Pathways: Development and Implementation at a Tertiary Hospital in Malaysia

Clinical pathways have been implemented in many healthcare systems with mix results in improving the quality of care and controlling the cost. CP is a methodology used for mutual decision making and organization of care for a well-defined group of patients within a well-defined period. In developing the CPs for a medical centre, several meetings had been carried out involving expert teams which consist of physicians, nurses, pharmacists and physiotherapists. The steps used to develop the pathway were divided into 5 phases. Phase 1: the introduction and team development, Phase II: determining the cases and information gathering, Phase III: establishing the draft of CP, Phase IV: is implementing and monitoring the effectiveness of CP while Phase V: evaluating, improving and redesigning of the CP. Four CPs had been developed: Total Knee Replacement (TKR), ST Elevation Myocardial Infarction (AMI), Chronic Obstructive Airways Diseases (COAD) and elective Lower Segment Caesarean Section (LSCS). The implementation of these CPs had supported the evidence-based medicine, improved the multidisciplinary communication, teamwork and care planning. However, the rotation of posts had resulted in lack of document ownership, lack of direction and guidance from senior clinical staff, and problem of providing CPs prior to admission. The development and implementation of CPs in the medical centre improved the intra and inter departmental communication, improved patient outcomes, promote patient safety and increased patient satisfaction. However, accountability and understanding of the CPs must be given more attention.

Two months aerobic exercise improves endothelial function and reduces oxidative DNA damage in women with elevated blood pressure

Regular aerobic exercise has been shown to improve endothelial function and reduce oxidative stress in hypertensive patients. However, the information regarding the amount of exercise that is needed to produce this adaptation is scarce. Thirteen women [35 to 60 years of age] with elevated systolic blood pressure [SBP] were recruited. Six women underwent four weeks aerobic exercise [EG] three times per week at 50% heart rate reserve [HRR] for 30 minutes per session, which was then increased to 70% HRR for 45 minutes per session for another four weeks. Seven women served as control group [CG]. Flow mediated dilation [FMD] and plasma von Willebrand Factor [vWF] were measured of oxidative DNA damage. Baseline measurements were repeated at four and eight weeks. ANOVA repeated measures via SPSS version 15 was used for data analysis and the level of P<0.05 was considered as statistically significant. At baseline, there were insignificant differences in all parameters between the groups: age [EG=48.17 +/- 6.21 vs. CG= 50.00 +/- 8.29 years, P=0.84], resting SBP [EG=136.00 +/- 7.69 vs. GC=133.57 +/- 9.81 mmHg, P=0.73], FMD [EG=2.10 +/- 3.11 vs. CG-2.01 +/- 5.50%, P=0.73], plasma vWF [EG=51.72 +/- 28.60 vs. CG= 49.68 +/- 30.48%, P=0.84] and urine 8- OHdG [EG=6.58 +/- 2.26 vs. CG= 7.85 +/- 2.50 ng/mg creatinine, P=0.34]. After intervention, significant reduction was found for plasma vWF [EG=41.12 +/- 22.65 vs. CG=56.70 +/- 22.35%, P<0.05] and urine 8-OHdG [EG=4.33 +/- 0.79 vs. CG=7.02 +/- 1.73 ng/mg creatinine, P< 0.05]. Two months aerobic training using the prescribed exercise regime increased endothelial function and reduced oxidative DNA damage in women with elevated SBP