Setiap kamu adalah pemimpin…

Pengajaran dari peristiwa hari ini mengenai kepimpinan masyarakat
1. Sebagai Muslim, asas memimmpin bermula dalam solat. Seorang Muslim akan sentiasa berusaha untuk solat jamaah, baik di rumah, di masjid, di musolla shopping dsb, Istiqamah seseroang dalam solat berjemaah itu akan jadi nilai pandangan umum. ‘Kebolehan’ untuk memimpin atau mengajak orang lain (termasuk orang yang tak dikenali) untuk bersolat jamaah adalah ukuran minima seseorang Muslim itu boleh memimpin masyarakat.
hmmm teringat beberapa insiden terjumpa hamba Allah yang tak nak diajak solat jamaah, jom solat sekali – geleng kepala. Eh takpe, saudara jadi Imam, saya ikut – geleng kepala…takpelah katanya. Kejadian spt ini jarang-jarang, paling kurang kita dah cuba, inilah usaha ‘dakwah’ dan taaruf paling minima.
2. Orang melihat dan menilai peribadi kita, betul sebagaimana pesanan Mufti Menk. Buat seorang Muslim, dengan menunjukkan akhlak yang baik (dalam setiap urusan, ibadah, muamalah dengan orang, percakapan dll) ini adalah langkah pertama untuk menarik kepercayaan orang. Tetapi ia satu yang fitrah bukan dibuat-buat, dan orang dapat menilai hanya dengan melihat, mereka mungkin juga menilai ahli keluarga, isteri, anak2 sebab fitrahnya tentulah individu ini memberi pengaruh pada keluarga, kalau diri nampak baik, keluarga tunggang langgang, mungkin ada yang tak kena di situ…
3. Anda mungkin mahu merubah kepimpinan atas, masyarakat pun sudah mahu dan sedia berubah. Tetapi kepimpinan atas tak bersedia melepaskan jawatan….malah manipulasi proses pemilihan kepimpinan….dalam hal ini sifat tawaduk dan menunggu takdir saja tak cukup. Strategi untuk merealisasikan agenda perubahan perlu melibatkan berbagai peringkat, pada masa yang sama usaha mendidik dan berdakwah perlu berterusan, jangan setakat tunggu pemimpin berubah, sedangkan masyarakat pula masih tak bersedia…
4. Sejauh manakah penyokong-penyokong anda bersedia menyokong malah berdepan risiko demi merealisasikan perubahan? Di belakang mungkin boleh berkata begitu begini, tetapi bersediakah mereka menyatakan sokongan di depan khalayak ramai, berdebat mempertahankan calon mereka….ini semua bergantung sejauh mana anda menyediakan/memimpin penyokong-penyokong tersebut, jangan buat anggapan mereka akan sedia mempertahankan anda tanpa membuat sebarang persediaan, situasi yang tak dijangka…

A woman leads the way in education…who is behind her?

One of the cliches that had been circulating around is the following sentence, in which the reader is required to put appropriate punctuations
A WOMAN WITHOUT HER MAN IS NOTHING
Many man would have put a coma after the woman, but a clever woman has put the most appropriate punctuation and it became like this
A WOMAN, WITHOUT HER, MAN IS NOTHING!

When a woman complains and a man listens…

I think I want to quit….she whispered.
May be not yet….my simple reply. I sat closer and put my arm around her shoulder, fingers gently stroking her hair…
That must be her tenth or eleventh time of ‘tempting’ me to say yes. But even the last time when I did, she still carried on. One day she came back really look exhausted, eyes swollen with tears. I can’t cope anymore….too many complaints…everything I did was wrong….she murmured. After a long conversation (well, most of the time I just listened, my only strength being a patient listener) she cooled down. We spoke and spoke about it again. I did not want to interfere in the school affair. She is the Headmistress, she practically runs every bit of the school, inevitably there are always problems, and any unpleasant things happened at school will bother her. Often time, after the school board meeting she will share certain issues (I kept it to myself, its confidential afterall), have I registered everything she said, I would have become sleepless and exhausted as much or even more….woman, you know is good in telling you everything, while man is generally more reluctant. When stressed, women talk, but men under stress will withdraw into their inner ‘caves’ and keep quiet.

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Long ago, a man met a woman, history began
She has been a resounding success.
What began more than 20 years ago, had materialised into a colourful history. And I always would like to claim the credit, even if I don’t deserve it. It was her quality.
One day, 21 years ago, during a meeting at an Islamic school in Dublin Ireland there were voices of desperation, as there were shortage of women activitsts to help build the school in the community. I told one of the committee members, that there is going to be a very good muslimah from Malaysia coming to Ireland, she will actively participate and possibly take a leading role…and that news really pleased them. It was a promise came true. Only later they knew the ‘woman’ I meant was my future wife, who joined me to live in Dublin following our marriage.
She began in a small way, involved in the study circle among the young Muslim girls, organising their camps and other indoor and outdoor activities. Then she gradually got involved in the community school, many people liked her and she quickly gained their trust, more so because the husband is someone they knew for long. She started to get involved in the teaching and later recruited as a board member of the school. Meanwhile she continued her activism in the community, making herself known as a representative of the Malaysian Muslim community there.
With such a unique background, when we finally returned home to Malaysia for good, it wasn’t long before she was offered a post as a teacher in the preschool of Adni Islamic School. Yes it was not a very prestigious position. But I was happy enough, knowing that such a position will help her to continue her interest in education, while giving her ample time to manage the children, as we just began new life back home.
It wasn’t long before she climbed in rank to be one of the assistants to the Principal, maintaining the same commitment in the preschool education and later the primary school teaching. But she was never satisfied remaining in the same position all the time, she wanted to move further. Finally she quit Adni and told me she just wanted a rest so she could follow me everytime I go abroad! That’s not a problem with me of course a pleasure to have her company, but at the same time I wanted her to progress further. There was not a long gap, when, in 2011 Pertubuhan Ikram Malaysia WP initiated the community education project, which aimed at building more Musleh schools at each state. This was the start of the Sekolah Islam Al-Amin WP Wangsa Maju, when they invited her to be part of the project committee. As the committee began planning seriously, they needed someone with a sound background in teaching plus experience in the preschool to add uniqueness to their brand new school. And Wan fit their requirement perfectly.

A new beginning…the making of a diamond
I took a deep breath, it was great, great news. It also meant she is holding a very important and busy position in the community, and as I am becoming busier in my practice, it only meant our life will ever become more hectic. But I did not see that as a hindrance, we had to keep going in our ‘dakwah’ life. And this one time opportunity should not be wasted. At first she herself was a bit reluctant, but once she started off, everything went off smoothly. It wasn’t long before her school began making name in the community, many of the achievements were partly attributed to her innovative approaches in many things. She told me, she wanted to be unique and do things beyond ‘ordinary’, some of the traits that she inherited from that long years of experience in Ireland. Just think of ordinary events at school – sports day, award presentation, teachers day – all were organised and tuned into something thrilling and memorable. Even the school teachers were not spared a rest, and having their creativity drilled into the deepest, they have come up with this excellent musical band and a ‘nashid’ group teamed up with another celeberity, producing a commercial album.
The school that began in a humble corner lot buiding grew up from mere 2 classrooms of 87 children to a current state of over 400 children and 40 staff. They introduced the preschool and daycare school which was a great attraction to parents – so they can leave their toddlers for all day while they are at work, while their school going children will stay at the daycare when the formal school hours ended while awaiting collection.
Then they introduced the tahfiz (Quran memorisation) which is a highly popular program in Islamic School. Interestingly the children are able to join the tahfiz program without having to miss a year or two of their regular school, this calls for special adjusted syllabus or modules. This excellent Quranic program have produced many excellent Quranic readers and chlldren who memorise up to 4 juzu’(chapter) of the Quran beginning from Year 4. Later they intoduced intensive tahfiz that began in Year 1 aimed at training the children to memorise as many as 15 juzu’ (half of the Quran) by the end of their primary school.
The revised curriculum which was slightly different from the mainstream Al Amin school is a powerful tool that some other schools including external ones developed interest and request permission to adapt it for their own curriculum.
Even at its infancy the children have had the greatest exposure and it is not too much to claim that the school began its international outreach, when a delegation from Korea paid a visit to the school to study their unique curriculum and teaching method. The children have had the opportunity to learn other cultures in South East Asian when the school organised educational (and charity) trip to Acheh last year, and Pnom Penh this year.
As a recognition of her achievement, Wan was nominated most potential Headmistress among the new Al Amin School of Malaysia. The school received recognition from the Ministry of Education (Co-Curriculum) and won financial awards from several authorities including the JAWI and Selangor government.

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Managing crisis?
Managing a school is a very demanding job. Dealing with children from a variety of background, parents with divergent views, teaching staff and the school board, and not to forget the authorities. And the food often bothered her. Frequent complaints from children and parents alike, and staff who testified to quality of the food services had her ‘stretched’ her authority a bit further by enforcing rules to improve the food provision by the school caterer. This led to the state Ikram excos drawn into the ‘conflict’ which caused uneasiness among some people. Then there were issues with the Parents-Teachers body, with their unnerving views on the school. Though I was one of the state Ikram excos then, I restrained from interfering, any issues about the school that were raised in the meeting, usually came from the dedicated education committee. If there were arguments or disagreement, I stayed in the neutral.
But, at home I gave her full moral support. Everyday there is always a new thing she updated me on the school. Often she asked for advice or help such as writing draft of her speech. Since I left Ireland, I had completely left behind interest in education and young children. Mounting responsibilites at work prohibited me from committing seriously in any community affair, I admitted this as my weakness. Therefore, having the previliged to support my wife and occasionally give hand in things like medical opinion or services when required, or even donating money and promoting the school to friends and other people were among the little things I could do to help.

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As time goes by, she became busier, two days in a week she will have meetings – one for school, another for the Ikram activities, and another night each of us have our own group usrah. Means, in a week sometimes only a day or two when both of us are free and available at home, this certainly somehow compromise quality time for our children as well as both of us as a couple. Sometimes, I will come over to her during lunchtime, evening or even morning when she is free for a cup of coffee or meal. Yes, I do it, now you know as time goes by, who is the busier one between us! Nevertheless, I thank God for this, and both of us tried to use that little free time together as a family.
She is good in involving everyone into her working career, and at the same time this create opportunities or even new jobs. There were friends and relatives looking for jobs, with appropriate qualifications she recruited them to various temporary and later permanent position as teachers or administrators. Even our children and their school friends were involved, helping as part time teaching staff during holidays, or helping the school children performances. One day she told me the school aimed to create usrah group for all teachers, and there were vacancy of ‘naqib’ or group leader for one of the usrah, I happily agreed to lead.
At some point there was uneasiness among the staff when the issues of appointment of one’s own relatives were brought up. That may have involved our own children, cousin or even her own sister (and brother in law). That was quite a challenge that must be handled delicately. I suggested to her that all decisions on appointments of her own relatives should be handled by the selection committee and agreed, independent of her, well documented and minutes recorded in the board meeting. Everything should be documented, and the appointees should not at any time take advantage of them being a relative to the Headmistress to gain special previliges like prolonged leave etc.

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Quitting for a better position?
Five years of success in building the school. No doubt it is heading in the right direction. Despite lack of funding and inadequate resources, frequently changing staff and teachers, slow approval from the authorities, the school is making great progress and received several local and national recognition awards.
Now she wants to quit, she thought she has done enough and want to rest or perhaps do something else? Yeah this one woman is not happy doing one thing for too long and I have to think of what is her next line…
As the Al Amin primary school is soon producing its graduate (year six students, including my daugher), they now have to plan where therse children should go the following year. This was the impetus for yet another project, building the secondary school. At the same time they are still looking for alternative new school buidling complex that could possibly accommodate both the primary and secondary schools.
They had an offer from one of the closed factory building, not very far from the current school, big enough to accommodate the need for the above. However, in the final moment the bid fail due to some administrative issue and they had to look for other options.
While the process was going on, now there is a new opportunity coming up, the post as Secondary School Principal. I told her to go for it. She was not very keen. ‘I just want to quit’. She said it firmly. She wanted to concentrate on the children. She wanted to care for the little boy Hazim, and our younger daughter who is entering secondary school. She thought her job had been busy enough that she yearned to be back as a fulltime housewife.
She always joked, arguing that the reason I don’t want her to quit because I would not like her to be a full time housemaker, as this will give her a lot more time to ‘bother’ me. But my point, looking at her accomplishment, she is capable of achieving more, give more to the society – this is something I myself could not do. So let me make money and support the family, while she goes out to the community, that was my point.
The ‘brothers’ out there were good at persuasion. They firmly said she is currently the best candidate to lead this new school based on a unique acclaim of ‘usahawan’ (enterprenaurship), in the end she agreed.
At any stage of her social involvement, it was never about money. When she started at Adni, she was paid a meager salary, she used to tell friends that she received her monthly from the husband, much more thant what the school gave her (involving in teaching was more from her passion than money). Even now, when she is earning quite a handsome amount monthly, she never worried about not having money if she stopped working. At the management level, she had fought hard to ensure the teachers and staff were renumerated appropriately, given their yearly allowance etc at par or even better than other schools. But she never fought for her own self! Now as she was offered this new position, she quietly told me, she may be paid less due to some ‘mistakes’ by the administration. She had given them words, that unless this matter is rectified, she will not take the offer. I think it is a fair demand, it’s not about the amount, but it was about how people acknowledge and recognise your achievement. I am sure the issue will be resolved, and will soon see a smiling face on the headline, a new school with a unique brand of enterpreneurship (Sekolah Menengah Usahawan).

Anecdote
They always say, behind a successful man, there is a woman. And behind a successful woman, there is certainly a man, at least in our case. One day, I stood beside a friend, whose wife is also a teacher holding the post of assistant Principal. He said ‘hard life for them, harder for us having to listen tot their moaning daily…’ Then we both smile and proudly said, we have made ‘great’ contribution to the community, by giving our women to them, and this is our sacrifice as men…

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Some background of the Sekolah Menengah Usahawan Al Amin Ulu Klang (SMUAAUK)
Rapidly expanding world technology, global culture and communication poses new challenges in imparting education to the young people. Developing resilient Muslim personalities that possess integrity and intelligence to adapt to changes is essential elementl in modern education. The Akademi Al-Amin Sdn Bhd had come up with this idea of opening an Enterpreneurship school adopting the idea of developing credible personalities that will be able to face future such as the ability to self-manufacture employment and adapting to more diverse culture of the outside world.
Among the co-curricular activities planned are clubs and societies, sports and games, ‘wafdul Amin’, Co-Curriculum Carnival, Robotic. ‘Tarbiyyah’ or Islamic education such as Usrah/study circle, Daurah/iftar/itikaf and mukhayyam dagili (personal development camp). They emphasised on discipline and personality development, leadership, cleanliness and happiness, counseling, charity, safety and merit and demerit system. Subjects covered (for a start Form 1 and 2) include Bahasa Melayu, Bahasa Inggeris, Matematik, Bahasa Arab Komunikasi, Science, Sejarah, Geografi, Kemahiran Hidup and Pendidikan Islam along with ‘Diniyyah’ Al-Amin curriculum’such as Tasawwur Islami, AlQuran and ICT.
Registration (Form 1 and 2) are open now at http://www.al-amin.edu.my/

Views expressed in this writing is entirely of my own, not related to any organisation or other individuals. I am a senior member of Pertubuhan Ikram Malaysia and hold the post of Chairman of Ikramhealth.

A monthful of lectures and meetings….chasing the time or being chased by time??

 

Within these coming few weeks I have committed myself to a series of lectures. In fact one of them had just been delivered today (20 September).

On 20 September, I delivered a lecture entitled Facts and Myth on Statin: Deal or No Deal? It is about evidence based outcome studies on statin, a block buster drug that has been hailed as a life saver to millions of people the world over. Wave a goodbye to those statin skeptics ‘statinnation’ people

On 24 September I will be speaking at the Cardiovascular Metabolic (CVM) Masterclass conducted at the UKM Medical Centre, the title which is on Lipid – The role of non-statin in Dyslipidaemia Management: What the Recent Guideline Recommend? Again the focus is on management of dyslipidaemia (disorder in lipid) which the emphasis this time is on secondary prevention, while touching on primary prevention as well. Besides statin, there is now another (in fact not one but two…the other coming soon) that has been proven to improve cardiovascular endpoints.

On 25 September, I will be speaking, this time to public, at Karnival Khidmat Kesihatan ’16 Titiwangsa – the venue is at Dewan Komuniti PPR Jelatek. I have not finalised the title but likely it will be on something like ‘Silent heart disease’, hmmm well I need to figure out what is the Malay translation of this title, since I will be speaking entirely in Malay medium during the presentation.

The following weekend is kind of a little break, I won’t be speaking, though will be involved among the country’s cardiologists at an expert forum in Hong Kong (1st Asia Atherosclerotic Forum), on yet, yes, another ‘non-statin’ advances which is the PCSK9 agent due to be released soon, Alirocumab. We are also part of the research network conducting a landmark clinical trial on this agent, the trial is expected to close by early next year (ODYSSEY).

 

On 8 October, I will be spending the weekend in Jakarta, speaking at a Breakfast Symposium on NOAC (new oral anticoagulants) How can clinical data and real world evidence support my daily practice? This will be deliberation on the latest clinical data of NOAC – real world, means how the new drug perform in daily clinical practice as has been proven from the clinical registry data.

15 October will be another busy weekend, as I am scheduled to deliver two lectures in one day, plus other commitments as moderater/chair at a local workshop at UKMMC. My first lecture will be on ‘the new landscape in management of atrial fibrillation in Asia Pacific’. At the end of the question/answer session I will be rushing to another workshop organised by Roche lab to deliver a lecture on ‘ntProBNP in monitoring cardiotoxicity among oncology patient’.

The following weekend will be yet another full academic weekend which I will be stationed in Malacca from the Friday evening of 21 October. Besides lecture on ‘Latest, Asian Pacific real world data on NOAC’ (full title yet to be finalised), I will be acting as Chairperson/panel/moderator of a number of session.

Hoping to end the strings of traveling commitment, and yet, eh more are coming as I will be involved in one advisory meeting followed by a research investigator meeting in the following two weeks (both in Singapore). So, 7 lectures and 3 major meetings to face within a period of 6 weeks and roundtrip to Hong Kong – Jakarta – Singapore…that could see me with a number of sleepless night!

I pray to God to be able to manage my time well and may He give me the strength and eloquence to deliver the lectures in an unbiased, academic and evidence based way.

Class Reunion: Menyilam sejarah hampir 33 tahun lalu…tak terkata!

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Rakan-rakan yang hadir majlis reunion di rumah Majid

Jam menunjukkan 3.30 petang. Sudah lewat, tapi aku tetap dengan niat singgah di pekan Parit Sulong. MPV di berhentikan berhampiran jambatan kecil lalu aku bergegas keluar bersama isteri. Anak-anak sedang tidur nyenyak, takpalah biar enjin on sebentar. Terus kami melangkah ke kedai pertama.

“Ada jersi JDT tak” direct to the point….”Maaf, sudah habis”ringkas jawab budak penjaga kedai. Kami melangkah ke deretan gerai di seberang pasar. Satu demi satu kedai di lawati sampai ke kedai aneka baju ada ternampak iras biru merah terus kami singgah. Ada beberapa, saiz tak menepati selera, aku ambil sebiji T-shirt yang biru…entah edisi tahun berapa tak tau lah, selama ni memang jarang menonton JDT bermain pun al maklum…sebiji jersi dan satu lagi Tshirt biru saiz S, ditambah baju tidur JDT saiz kecil 7 tahun (sebab takde dah jersi atau Tshirt untuk anak bongsu). Kira oklah tu…asalkan memenuhi tema JDT merah biru…

“Pakai saja ye…” Arah kami pada anak-anak, masa pun dah suntuk. Kusarung Tshirt JDT biru tu, agak berkedut, detik isteri….takpelah, janji JDT.

Sedang sibuk berjalan tadi dapat panggilan dari Majid, sepupu. Hah, mesti dia cari aku ni dah la lewat….aku tekan dail semula dapat bercakap tapi tak jelas…mesti signal tak bagus di Pt Laman Tegak tu detik hati…rupanya Majid dah menghantar Whatsapp bertanya aku di mana. “Kat PS”jawabku ringkas. PS = Parit Sulong orang Johor semua tahulah.

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Sempat kujeling group whatsapp, ada yang dah menghantar gambar. Memang stress rasanya. Aku mula melayan ingatan…kira-kira 3 minggu lepas…selepas mengikut rancak rancangan untuk mengadakan Majlis Reunion Ex5A1 SMDS, tiba-tiba ada saja yang tak kena buatku.

Dapat fone baru, terputus whatsapp, hilanglah mesej-mesej yang lama. Entah macamana terpadam pula Google Drive akibat storan yang dah penuh…lalu borang pendaftaran Reunion yang aku cipta hilang di awang-awangan. Patutlah, Rashid dan Fadhilah asyik dok tanya, berapa orang dah final datang, berapa orang anak-anak…aku cuma mampu terkebil-kebil dah lah masa nak menjawap pun sungguh terhad almaklum terburu-buru pergi dan balik dari Rom, dan urusan-urusan lain korang maklumlah aku ni memang tak pandai mengatur masa kan hehe.

Lepas tu datang pula berita mengejut. Mun, anak angkat kami datang ke rumah, hantar surat jemputan, beliau akan mengadakan majlis perkahwinan. Tarikhnya? 17hb. September…adoi, memang aku termangu sebentar…nak jawab: Tak boleh nak, kami dah ada plan…tak kan sampai hati. Akhirnya majlis Reunion jadi korban. Nasib baik kawan-kawan semua baik, faham pula dia orang.

Yang aku tabik habis, sepupu aku sorang ni. Dia ni, sebenarnya baru je masuk group whatsapp ni. Memang aku contact dia sentiasa, dan tau dia aktif dan ramai follower dalam Facebook. Satu hari aku tanya, kau nak masuk group whatsapp 5A1 tak…ok jawab Majid. Semenjak haritu bertambah rancaklah group kami, dan kadang-kadang hangat dan hangit adalah tu. Yang keluar masuk pun ada. Tapi si Majid ni memang istiqamah, dan ada saja topiknya. Tak lekang pula dengan tazkirah, salam setiap hari, kejut Subuh dan macam-macam. Alhamdulillah bila ada yang cadang buat majlis reunion ni, setelah bincang-bincang buntu dengan venu, beliau terus offer buat di rumah beliau. Ini aku memang tak jangka. Tapi itulah kehebatan sepupu aku, alhamdulillah syukur aku ada sepupu dan kawan macam beliau.

Bukan itu saja, sudahlah beliau yang susah payah ke hulu hilir buat persediaan, sibuk melayan bermacam idea dalam group whatsapp, semuanya beliau buat dengan cukup licik, ‘excited ni…’ jawap beliau bersahaja.

Tiba beberapa seminggu betul-betul sebelum majlis. Aku terima berita sedih, ditakdirkan ibu beliau yang tercinta telah menghembuskan nafas terakhir, tiba-tiba. Terkejut dan hiba, apa lagi waktu tu aku di Dungun Trengganu, tak terkata apa. Aku telefon beliau dan bercakap ringkas, beliau cukup tenang. Rasa amat bersalah, tapi apa aku nak buat, baru tiba di Dungun tu, anak pula kurang sihat, memang tak ada kelapangan untuk menziarah arwah. Urusan keluarga beliau yang handle semua berjalan baik.

Hanya sehari dua, beliau kembali aktif, di samping sibuk mengurus kenduri dan tahlil arwah beliau tak putus-putus berhubung dan meng’update’ komiti tentang persediaan rancak. Memang Allah beri kekuatan beliau yang luar biasa. Aku dapat berdoa saja untuk arwah, solat jenazah ghaib. Dan aku doa sahabat dan sepupu aku ni terus kuat dan tabah, dapat ganjaran setingginya.

Buat diri aku yang sentiasa konon tersibuk ni, hanya dapat menyumbang makanan kampung – tu pun, aku keluar duit je, adikku Esa yang siapkan semuanya. Aku juga setuju sponsor durian kampung.

Kawan-kawan dalam group whatsapp, yang ada tak pernah berjumpa semenjak meninggalkan sekolah, dapat ber’chat’ dalam bahasa yang ‘casual’ macam bersaudara. Inilah keistimewaan classmate. Walau apapun tahap yang dicapai setiap orang, kawan sekelas tetap tak dilupa, dan apapun levelnya tetap dipandang hormat dan mesra. Sebab itu bila rancangan reunion ini timbul, aku cuba mencetus idea sedikit sebanyak dan merancakkan planning. Rupanya bila dah lantik komiti memang kesemuanya osem, komited, terutamanya Rashid sebagai pengerusi, Dila koodinator group, dan Majid sebagai tuan rumah. Masing-masing tak putus bersuara dan merancang sampai setiap perkara kecil pun masuk dibincang, almaklum ini pertama kali class reunion akan berlangsung. Biarpun kosnya agak besar, ramai komiti dan ahli lain sponsor, ini tak termasuk yuran, memang ramai yang murah hati mudah jadinya mengurus majlis seperti ini. Syukur segalanya berjalan lancar, dan kesemua yang dah komit nak hadir, sampai awal, kecuali aku lah. Itu yang rasa terkilan huhu, apa nak buat atas sebab-sebab di atas.

Panjang aku mengelamun, dah sampai ke Parit Laman, tersergam masjid jamek di depan mata. ‘Tak jauh bang, ikut je map ni…’ telah si isteri. Aku hentikan MPV, pakai stokin dan kasut, eh gaya sikit nak jumpa kawan-kawan sekolah lama ni bisikku dalam hati. Tiang letrik 26, itu arahan dari Jam. Selang beberapa minit ternampaklah khemah berderetan disulami warna merah dan biru sedikit. Hah, tak salah lagi inilah tempatnya. Memang aku pernah pergi ke rumah Majid sekali, dan ingat rumah beliau di seberang jalan. Tapi bila nampak khemah ala JDT tu, terus tak ingat apa lagi, kebetulan ada halaman rumah luas, aku parking MPV di situ dan melangkah bersama keluarga. ‘Ayah, kenapa tak nampak orang pakai baju JDT pun…’ bisik anakku. Hmmm ya jugak….eh ini orang kahwin ni….salah….aku berpatah balik. Nasib baik belum bersalam tuan rumah lagi! Memang kebetulan betul, kemudiannya aku diberitau nama tuan rumah tu pun Majid….adoii boleh pulak jadi macam tu…

Setelah hampir malu besar sebab tersilap rumah tu, teruslah memandu dan baru nampak confirm kali ini rumah majid dengan khemah bersulam warna JDT. Tak sabar-sabar terus aku menderu bersama isteri dan anak-anak, menyeberang jalan. Hah, barulah cam, muka-muka yang dikenal. Ida, Aisyah dan Dila tiga orang saja Ex5A1 perempuan yang hadir. Di sebelah dalam aku mula bersalam dan mengenalkan isteri pada kawan-kawan. Rashid, Nizam, Majid, Yazi, Ashari, Jam, Khalid Shah, Harun, Azhar, Tahir dan aku lah semuanya 14 orang. Jemadi tak datang, dan yang lain tak dapat dihubungi atau ada urusan tak dapat hadir. Ok lah tu. Yang perempuan, memang inilah kali pertama bersua selepas tinggalkan sekolah dulu, Ida, ada aku jumpa semasa bercuti dari Ireland tahun pertama. Yang lelaki, kecuali Khalid, aku dah pernah berjumpa seorang-seorang atau berkumpulan.

Bermacam juadah ada, aku cuma sempat mengimbas saja aneka lauk, kuih dan buahan. Sempat menjamah beberapa, dan selebihnya berseronok mengopek durian untuk diri sendiri, keluarga dan kawan-kawan sambil beramah mesra.

Oleh kerana aku lewat, memang masa yang ada agak singkat, tak sempat nak aku ‘engage’ dengan setiap seorang. Rasa terkilan juga. Dapatlah bergambar, bertegur secara rambang saja, dan dapat bersembang agak mendalam dengan beberapa orang. Apa yang penting, ini satu detik bersejarah menemukan semula kami yang pada satu masa dulu duduk sekelas yang sama di SMDS. Dan sebagai pelajar 5A1 yang merupakan ‘cream’ tingkatan 5 pada masa itu, memanglah ada imej dan harapan yang tinggi. Alhamdulillah, apapun, semuanya telah membuktikan kejayaan hidup, dan pencapaian tersendiri. Biarpun ada yang berbeza pandangan (err politik kut), tapi kami dapat bersama, dan yang kurang atau jarang bersuara di group whatsapp, tetap merasa riang dan teruja dengan pertemuan ini. Ya, kegembiraan waktu rehat sekolah, atau waktu yang terluang semasa di kelas, kini dikembalikan 33 tahun kemudian…dalam suasana yang amat berbeza. Syukur Allah mempertemukan kami, dan memberikan kami laluan hidup di bawah petunjukNya, dan menyatukan hati-hati kami untuk hadir, memberikan penghormatan sesama kawan serta kerjasama dan saling membantu.

Harus dimaklumkan, tentang sahabat kami arwah Mohd. Kamal Adnan, yang telah meninggalkan kami lebih awal, tahun lepas. Dalam group kami sentiasa melakukan perbincangan dan perancangan sedikit sebanyak membantu keluarga beliau. Di kesempatan ini kami sedekahkan pahla tahlil buat beliau (dan juga arwah ibu Majid), serta kami peruntukkan sebahagian wang yang dikumpul dari peserta untuk dihadiahkan pada keluarga beliau.

Ramai yang tak hadir atas sebab-sebab tertentu. Mereka tetap kawan ex5A1 dan tetap aktif dalam group whatsapp. Ramai juga yang aku sempat bertemu sebelum ini Hisham, Muhammad, Harison, Sulaiman dan yang lain; walaupun tak hadir ruh tetap bersama insyallah di kesempatan akan datang mereka join. Doa kami juga untuk mereka semua dan ahli keluarga.

Akhirnya….aku sharekan sajak karangan Ida Manan ini untuk dikongsikan bersama rakan-rakan. Bahasa Inggerislah, sebab beliau dan seorang lagi Ex5A1, Harison memang champion BI masa di sekolah dulu…

 

A reunion was planned

For class 5a1 of 1983

Only 14 could attend

3 ladies including me

It was lovely.

The mood was informal

Feeling special and jovial

We donned red and blue

As true JDT would do.

Food was abundant

From gearbox to durian

Often we just stared longingly

For we are 50

And want to stay healthy.

We gathered swift and nice

Re-knotting old ties

33 years have passed

All the times we have been blessed.

Many chapters we have turned

Many roads we have travelled

Dear old friends

Let’s meet again while we are still able!

Terima kasih kepada sahabat-sahabat yang hadir, yang menjayakan majlis dan menyerikan hari pertemuan tersebut. Kepada tuan rumah Majid, isteri dan keluarga, yang sentiasa senyum dan ceria dalam keletihan, semoga Allah membalas kebaikan-kebaikanmu. Tidak lupa kepada pasangan-pasangan dan keluarga kami yang membantu dan memberi sokongan berterusan sehingga majlis yang dirancang berjaya. Semoga Allah swt memberkati pertemuan kami dan memberikan kami semua kekuatan menjadi hamba-hambaNya yang sentiasa bertaqwa dan bermujahadah

(ps: Video link untuk majlis tersebut di sini)

ESC CONGRESS 2016 HIGHLIGHT

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ESC congress is perhaps the world largest (or at least one of the largest) gathering of cardiologists, over 30,000 delegates from all over the continent thronged the convention centre in Rome (Fiera di Roma)

MANY ‘NEGATIVE’ TRIALS, LOTS OF POSITIVISM FROM THE CONGRESS

Apology to those who were waiting for my synopsis on the recent European Society of Cardiology Congress Highlight. Due to overwhelming family and academic demand I had to delay writing up, indeed for long my blog has not been updated for similar reason, or rather excuses (at times!)

First of all I must declare that this was going to be one of the most memorable ESC congress, to me personally. One, because of the special venue, Rome. This was my first time in Rome. It is a city that is filled with history and reminiscent of thousands of years of civilisation, one of the very few places that was mentioned in the holy Quran (during the battle of Rome /Byzantine vs Persian), and the downfall of Constantinople that was once a capital of Roman/Byzantine by the famous Muhammad AlFateh army.

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Beautiful historical landmark of ancient Roman civilization at the Coloseum. Beside this structure lie the Forum and Palatino, another two important marks of Roman history

The second reason, this was the longest ever time I have spent attending ESC congress, 9 days, yes, coz I left 3 days before the congress, flew to Kota Bharu to be an external examiner for Lincoln Universtiy 4th. Year Exam, flew back to KLIA 2 days later and immediately took the flight to Rome via Doha (Qatar Airways).

The third, an important reason, this was the first time our academic contribution in the form of abstract was accepted as a poster at the congress. Yes, nothing big about it, but it does give us hope as well as better idea how to make your presence felt in a European conference.

 

Highlight of our abstract – a study of high dose loading of statin drug in patients with acute coronary syndrome

The full title of the abstract: Efficacy and safety of high-dose rosuvastatin loading at emergency room before percutaneous coronary intervention among patients admitted with acute coronary syndrome, a pilot study authored by O. Maskon, KL. Koo, HH. Che Hassan, AZMI. Tamil, CHOOR. Chee Ken, RAFIZI. M Rus, SF. Mohamed, ISMAIL. M Saibon, D. Cumberland was presented by Dr. Hamat Hamdi.

This was a study done at HUKM, recruiting patients with acute coronary syndrome (heart attack), gave them a high loading dose of statin (cholesterol drug) which was rosuvastatin 40mg at the Emergency Department, just at the same time they are given aspirin and clopidogrel, followed by maintenance dose of 20mg daily. They were compared to standard treatment group, where the patients will be given statin in the ward, dose and type of statins up to to the discretion of the treating physician.

The hypothesis behind this trial was statin has pleiotrophic effect of reducing periprocedural myocardial infarction, or even reducing incidence of contrast induced myopathy among patients undergoing coronary angiogram or percutaneous revascularisation (PCI).

Though the short term result of the study was neutral, the strategy proved safe, and did reduce the LDL by 48% (ie potentially more patients can reach target goal of LDL cholesterol). There was also statistically significant improvement in the left ventricular ejection fraction in the treatment arm, which will have to be explored further in a larger scale trial.

Since latest guidelines advocate giving high dose statin in all patients with acute coronary syndrome, the study support the policy of early loading (and proved its safety), even before we know patient’s lipid status.

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Our abstract – presented by Dr. Hamat Hamdi

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NHAM President Dr. Ng Wai Kiat paid a visit at our poster.

 

Five new guidelines

The ESC Congress has become an ideal occassions for the ESC to promote their popularly known clinical practice guidelines. This year during the congress, five new guidelines covering Heart Failure, Atrial Fibrillation, CVD prevention, Dyslipidaemia and Cardio-Oncology were released.

Cardio-Oncology is interesting, as the guidelines told us that cardiovascular disease is one of the most frequent untoward events happening among cancer patients. As cardiologists we do frequently receive referral ranging from cardiotoxicity cases, arrhythmia or even acute coronary syndrome. They are a special group since the approach in treating them will differ, but now we are made aware, with this guidelines that they are a group that we should focus due to their added vulnerability. The aim of this guidelines is to prevent, optimize and treat those patients. Complications like cardiotoxicity (frequently in the form of cardiomyopathy, heart failure) from treatment can happen acutely, subacutely or even late. But then there are spectrum of other diseases such as arrhythmia (and QT prolongation), hypertension (can be as much as 45%!), coronary artery disease, arterial and venous thrombosis, valve and vasculopathy etc. There were also guidelines recommendation on how to do monitoring on patients receiving various potentially cardiotoxic chemotherapy. Echocardiography and other imaging such as MRI, biomarkers including highly sensitive troponins, natriuretic peptides (BNP/ProBNP) can be useful tools besides other routine cardiology tests.

There are four other guidelines. The Dyslipidaemia guidelines advocated total CVD risk estimation (European SCORE risk (a colourful chart used to determine one’s CVD risk based on gender, smoking status, blood pressure and total cholesterol level) as before and emphasised that certain factors may modify total risk SCORE including Lipoprotein (a), premature CVD/death, Family history (premature CVD/death) and recurrent events which will automatically place one into the very high risk group. It is recommended to do fasting sample, though a non-fasting sample may give similar prediction of risk for LDL and even Triglycerides, except in diabetics when the non-fasting LDL level could appear lower! The cut off LDL-cholesterol target points are: 1.8 mmol/l – very high risk (those with established CVD, CKD, diabetes with end organ or individuals with European SCORE risk); 2.6mmol/l for high risk group, and 3.0mmol/l for low or moderate risk group. They do advocate ‘maximally tolerated statin dose’ somewhat echoing the Americans high intensity statin in those of the high risk group patients.

Lipoprotein (a)? Is a kind of lipoprotein has some similarity with LDL, believed to be genetically linked and has added value in predicting risk in someone diagnosed with atherosclerotic disease.

Lowering the LDL is recommended using highest tolerated statin dose, how about non-statin role? Cholesterol absorption inhibitor Ezetemibe was given Class IIa recommendation as adjunct to lower LDL on top of statin, or when statin not tolerated. The newer agent, PCSK9 inhibitor (see later), may also be used as a last line or those not tolerating statin (Class IIb for now, awaiting result of outcome studies expected next year). Not to forget life style modifications and diet of course – avoiding trans fat, reducing total saturated fat and increasing dietary fibre etc.

A little note on triglyceride (TG) and (low) HDL. While recognising strong association of both TG and HDL with the risk of coronary artery disease (independent risk factor), the approach in treatment is less stringent comparing to that of LDL, the emphasis still on statin on top of lifestyle measure, and targetting the LDL. As for TG, a level of 2.3mmol/l is considered a treshold for treatment with a target level of 1.7mmol/l or below. No specific target of HDL is recommended, and though some general recommendations were given on approaches to raise HDL level, it was stated that thus far no conclusive evidence of benefit in raising HDL level per se.

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Heart Failure as a preventable and treatable disease – so much that the new guideline in heart failure stands firm with this statement. It advised that in acute heart failure, efforts should be made to shorten time for diagnosis and therapeutic decision, allowing a faster delivery of beneficial treatment to patients. A faster decision time may be aided with the availability of biomarkers like natriuretic peptides (fast rule out of HF), and subsequently rule out cardiogenic shock and respiratory failure. The next step in the protocol is to spare time to rule out obvious underlying treatable cause of heart failure including by remembering the CHAMP acronym that stands for ‘Coronary’- Acute Coronary Syndrome, Hypertensive emergency, Arrhythmia, mechanical causes and pulmonary embolism. This should be followed by immediate initiation of specific treatment. After ascertaining the haemodynamic profile, presence of congestion and adequacy of peripheral perfusion is identified. Further stratifying patients by the level of systolic blood pressure, treatment with vasodilator and pressor agent/inotoropes are recommended. Other therapy including diuretic, vasodilator and mechanical support device including ultrafiltration. Regarding diuretic, Class IB given for the option of either direct bolus or slow infusion depending on patients response and symptoms.

Moving on to chronic HF, it is divided into three subclasses based on their left ventricular ejection fraction whether reduced, preserved or ‘mid-range’ – HFrEF (<40%), HPEF (>50%), HmrEF (40-49%). With regard HFrEF, Class I recommendation now given for all the three agents that are considered disease modifying or potentially improving prognosis – RAAS inhibitors (ACE Inhibitor or ARB), betablockers and mineralocorticoid receptor antagonist, means in any HFrEF, they should be given by default. The new agent, Angiotensin Receptor Neprilysin Inhibitor, Entresto (which showed an overwhelming positive outcome results announced 2 years ago) has now been given a Class I recommendation as replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker and an MRA. While Ivabradin (If channel inhibitor) given IIa as an adjunct to betablocker to optimise heart rate, or alternative in those intolerant to betablockers.

Another revised guideline is on Atrial Fibrillation (AF). Why has AF attracted so much interest? It is a common condition affecting more than 30 million people worldwide, with 1 in every 4 middle-age people in Europe/US estimated to develop AF in their lifetime. It is estimated to be a causal factor of stroke in 20-30% of cases, and may be associated with a higher morbidity and mortality. There has also been rapid development in the area of rhythm control and anticoagulation. Therefore the guidelines cover acute and chronic management of rhythm/rate control, how to assess and manage stroke risk factors. The highlight includes newly approved stroke prevention OAC, edoxaban (high dose only). In essence rate control is the most important priority unless patients have significant symptoms despite optimal medication in which case ablation is recommended.

Therefore in atrial fibrillation early and simple risk stratification is the key. All valvular AF are still treated with the old warfarin, while non-valvular AF, based on CHA2DS2 Vasc score, may be treated with any of the NOAC or warfarin (all given class I indications equally). Low CHA2DS2 Vasc score of 1, given IIaB indication for OAC, while a score of 2 or higher Class IA. Left atrial appendage occluder such as the Watchman device may be considered in those patients with clear contraindication to OAC.

One may ask do the ESC taskforce have preference as to the types of OAC in general. With strong data on safety and efficacy of all the 4 NOAC, it’s no surprise that they are giving a Class I indication of prefering patients to be on NOAC instead of warfarin, providing no contraindication (well, mostly if the patient has mechanical valve, or significant mitral stenosis). No preference as to which NOAC is better, though. When warfarin is the choice, careful monitoring of INR (aiming highest TTR ratio) is mandated.

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Tough battle of NOAC

Whichever of the NOAC is prescribed, the ESC guidelines in general seems to favour them in place of warfarin. An eyeball experience of walking through the exhibition booth during the Congress will immediately make one’s impression of the tough battle between the four NOAC, edoxaban being the newest player. So which one? Since the European are open to all four, it perhaps is more useful to know in brief what strenght do each have based on their clinical landmark trials.

Dabigatran being the first NOAC, it comes in two doses of 110mg and 150mg twice daily, it is a direct thrombin inhibitor, tested in RELY trial. Both doses effective compared to warfarin, the 150mg proved to have superiority in preventing ischaemic stroke.

Apixaban in a dose of 5mg twice daily, tested in ARISTOTLE trial (the only NOAC trial which my centre participated) showed improved all cause mortality when prescribed comparing to warfarin; besides its being the only NOAC that did not cause excess gastrointestinal bleed, and overall is perhaps the one NOAC that causes least bleeding.

Rivaroxaban, tested in ROCKET AF trial – unique since it was the only NOAC given once daily, 20mg being the standard dose. The population of ROCKET had the highest mean CHADS2 score comparing to all other NOAC trials (and highest rate of previous stroke), proven non inferior to warfarin in preventing stroke in AF patients.

Lastly Edoxaban, tested in a trial called ENGAGE. Its another of Factor Xa inhibitor, both doses of 30mg and 60mg proven non inferior to warfarin, and in addition showed superiority in reducing cardiovascular mortality comparing to warfarin. Of note, only the high dose of 60mg approved for AF prevention.

A small personal note, you notice all those NOAC have come up with catchy acronym for their trials….I sometimes imagined that the principal investigators for the NOAC trials pitched themselves against each other to create the most catchy names of their trials acronym (no, nothing like that, just a coincidence)…so that one who has difficulty remembering the trials could simply learn the following pnemonic…

What is the most reliable NOAC – the answer is Dabigatran (RELY); which NOAC do you give to old astronaut if he gets AF – rivaroxaban (ROCKET-AF); if a patient from Greece gets an AF which of the NOAC would he prefer? – answer apixaban (ARISTOTLE); and lastly if a young and single woman got an AF, which NOAC would you give her – edoxaban (ENGAGE).

All the NOAC consistently showed superior reduction of intracranial bleed (ICH) comparing to warfarin, all except apixaban seemed to cause excess gastrointestinal bleed. Dabigatran has the highest renal excretion therefore more caution needed in patients with renal failure. All of them are given twice daily except rivaroxaban which can be given once daily.

Their obvious advantage is not requiring INR monitoring and simple dosing regimen. Overall they are at least as effective as warfarin, simple to prescribe, better in reducing ICH bleed, less drug interaction or with food, therefore the obvious choice, of course provided patients can afford the high cost.

Now that all the above NOAC are available in the market (Edoxaban not yet in Malaysia) the question may arise as how to manage bleeding. The guidelines have clearly documented the prediction and management of bleeding. As regard antidote, dabigatran had come up with their idaruxizumab (Praxbind) which is an Fab antibody specifically binds to dabigatran – released last year. In this ESC congress, a data on new reversal agent for oral Xa inhibitor (all those xabans) called Andexanate alfa was presented, and proven to be effective in acute major bleed.

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Hotline sessions – exploring evidences

In the field of AF, yup we are still not out of the wood, a registry from Norway called the Beyond program (involving over 35000 patiets) was presented. They looked at incidence of bleed among the three NOAC and warfarin, and concluded that apixaban and dabigatran were the two NOAC have lowest bleeding event including ICH, while dabigatran and rivaroxaban were found to do worse comparing to warfarin in term of causing excess GI bleed. No data on mortality or morbidity though, was available, and a brief look at the baseline data did show some dissimilarity among the groups, again this was a registry so must be interpreted with caution, and only a very general conclusion or impression can be drawn up. We shall await full data. Of note there had been several publications of ‘real world data’or evidences on the three NOAC proving their safety and efficacy respectively, some reassurance to all of us cardiologists who prescribe these new and expensive medications to our AF patients.

The was also a study of anticoagulation (warfarin) among cancer patients with AF, and this found similar risk and benefits of warfarin on AF patients with or without cancer; this provides reassurance some reassurance again, not to deprive those cancer patients from stroke prevention treatment when they are diagnosed with AF.

DANISH study conducted in Sweden, a large prospective study investigating the use of ICD among patients with non ischaemic dilated cardiomyopathy, found no survival benefits in the overall population. However, two other findings were noted, there was a survival benefit among the younger patients (below 68), and regarding death, the ICD did reduce incidence of sudden cardiac death (but not total mortality). This new finding called for revision to the guidelines of prophylactic ICD among patients with non-ischaemic cardiomyopathy (especially the older age group). It must be noted that, in this Swedish trial, all patients were treated with optimal medical therapy and 60% already on CRT (cardiac reshyncronization therapy), so they may be a slightly different subjects that we found in clinical practice.

Regarding these device treatments in heart failure, there are manufacturers who advocate the remote monitoring element in their ICD or CRT device when they are implanted among those eligible cardiomyopathy patients. The question is whether this sophisticated module brings any additional benefit? A trial called More-Care showed no additional benefit in clinial outcome (death, cardiac events), except some decrease in rehospitalisation.

Another research in cardiac regenerative therapy in advanced heart failure was presented, called CHART 1 trial comparing mesenchymal stem cells direct injection to myocardium (catheter based treatment) with control. This yielded a neutral result in term of clinical outcome. So we are still in search of firm evidence to support the use of regerative therapy in heart failure.

In the field of critical care, a registry data of patients surviving cardiac arrest in a large Danish population was presented. This showed several variables that favoured survival eg. Bystanders who are trained with cardiopulmonary resuscitation (CPR) skill, and a transfer to a cardiac centre with cardiac intervention facility both improve survival significantly. Unshockable rhythm, age, comorbidity were non-favourable factors for survival.

ECMO ongoing cardiac arrest metaanalysis looked at the 30 day survival among patients treated with the extracorporeal membrane oxygenation life support ECMO, which showed favourable trend of survival and improved neurological outcome comparing to control, or Intraaortic balloon pump (IABP), but not Impella or Tandemheart.

Among those comatose or mechanically intubated patients undergoing percutaneous intervention (PCI), one viable alternative of giving P2Y12 inhibitor as part of the dual antiplatelet (DAPT) strategy, is administering crushed ticagrelor, which was proven effective by measurement of the platelet reactivity testing. This would be a good alternative especially if you do not have access to other method of giving P2Y12 antiplatelet, such as cangrelor which can be administered intravenously.

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Another classic landmark the Vatican City…I just managed to walk by the place. The enjoy the visit fully, entrance to the Museum is a must

New in Acute Coronary syndrome (ACS) and interventional cardiology

Among patients presenting with non-ST elevation MI ACS, those who have intermediate or high risk score are unfortunately getting less opportunity to invasive procedures such as coronary angiogram or PCI. This was shown by the large European GRACE registry. As a result, among this intermediate or high risk group, compared to those receiving the optimal care, those who didn’t, have a 1.7 times higher risk of mortality. This is a European observation (real world data), which we believe in our own setting, it is much more so, especially those patients with ACS who are of higher risk score, are typically patients with higher commorbidities like heart failure, renal or multiorgan failure which put them in a more complex situation and not feasible to subject them to interventional procedures.

Next in line is the antiplatelets trials. There were a few highlighted. ANTARCTIC, a study involving total over 900 patients (elderly) with ACS studied the value of platelet testing using Verifynow machine among patients given prasugrel 5mg daily for their post PCI. There were randomised 1:1 to control or monitoring group (group who was subjected to platelet reactivitiy testing). This monitoring group were further subdivided into three – those with suboptimal platelet suppression (PRU), given 10mg daily, those with normal value were maintained on 5mg while those with very low PRU (means very well suppressed platelet activities) were given clopidogrel 75mg daily. Final result – no significant difference between all the groups in term of clinical endpoint. Therefore, based on this trial, there is little value in monitoring for platelet reactivity in clinical practice.

Another trial called PRAGUE-18 compared ticagrelor vs prasugrel among patients with STEMI undergoing primary PCI. The trial failed to recruite targeted number of subjects and due to circumstances, a high number of dropout from both groups up to 30% (driven mainly by financial – converted to open clopidogrel) ended up with 367 patients maintained on ticagrelor and 458 patients on prasugrel to the end of study or death. The result: no significant difference in the primary endpoint of CV death, MI or stroke between the two groups. It was concluded that the study did not have enough power to draw firm conclusion on the safety or efficacy comparison between the two new P2Y12 antiplatelet.

Drug eluting stents (DES) vs Bare metal stents (BMS) still an ongoing debate? Sounds a bit odd when most interventionists these days are moving towards 100% DES practice in their daily PCI strategy (including primary/emergency PCI). A multicentre trial in Norway called NORSTENT recruited over 9000 patients undergoing PCI (stable CAD or ACS) and randomised the patients either receiving DES only or BMS only, followed up both groups for a mean up to 5 years. This is investigator recruited trial, over 95% of the DES used were of the 2nd generation or later such as Xience, Promus, Resolute compared with the latest BMS technology such as the new Driver, Integrity & Liberte stents. Surprise surprise, the result: No difference in the primary endpoint of death or MI; or all cause mortality. When revascularisation or stent thrombosis were compared, there was a significant difference (reduction) of absolute reduction 3.3% and 0.4% respectively favouring DES. This translate into nnt of 30 and 250 respectively in favour of DES. Caveat? While it is a largely robust conclusion of the ‘similarity’ in performance between DES and BMS, its probably nothing new to expect, ie the DES is not expected to give superiority over BMS in mortality nor MI reduction. However, the relatively low TLR rate among the BMS patients (6 year rate of 19.8%) is impressive for these new generation BMS.

So how do you interprete the above astounding result and apply it in clinical practice. First of all, looking at the inclusion criteria and the procedural characteristics in the trial one could almost make a conclusion that it is only in a ideal world that you can replicate such trial outcome in a real world practice. Of course the study did not involve any left main stenting, no complex bifurcation, no previous stenting, not a real multivessels PCI as proven by the low mean number of lesions per patient treated (1.4 lesions/patient) and only 1.7 stents/patient. A mere 6% of patients have multiple procedure/staged PCI. In a real world practice we are treating more complex lesions and multivessels disease involving bifurcations or even Left main (selected cases), these days the practice (to apply the recommendation) is to evaluate the SYNTAX score, a low SYNTAX score in a multivessel disease patient means potentially good outcome even with multivessels, multistent approach.

Nevertheless, the current study (which has been published in NEJM) does highlight the excellent performance of new bare metal stent technology and may still be applicable when economic situation demands (though, currently the cheapest DES costs as little as a BMS!)

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Night time walk around the city

Hypertension/risk factors and the value of prevention

A researcher from US presented a striking finding on the value of long term exposure to lower LDL and BP in CV outcome. Though it is not a randomised interventional study it threw an important concept that allows us to understand further why trials such as HOPE, HOPE 3 gave such an impressive CV outcome result by simply prescribing antihypertensive or/and statin to our patients. The trial is called NATURE’S RANDOMIZED TRIAL OF BLOOD PRESSURE AND CHOLESTEROL LOWERING. It is a long term population cohort study that involved over 100,000 people. They looked at several genetic scores that were associated with low LDL and low BP. What was presented, the presenter (B Ference) emphasised had nothing to do with genetic study, it was merely an observation on how low LDL and low BP population compared to those ‘normal’ones. To simplify the result, expressed in Odd Ratio term (simply the lower the ratio, the less the risk, and vice versa, 1 being the reference point). A low SBP (by 3mmHg) gave OR of 0.821, low LDL (by 12mg/dl) 0.758 and a low SBP combined with low LDL gave ones an OR of 0.542. In a simple term, means comparing to control, someone with 3mmHg lower SBP and 12mg/dl lower LDL will have 54% less chance of developing major vascular events. Extrapolating from this finding, a person with 1mmol/l lower LDL and 10mmHg lower SBP will have an odd ratio of 0.139 comparing to control. The conclusion: SBP and LDL-C have independent, multiplicative and cumulative effects on CVD risk.

While talking about low BP, many of us would have been aware of the result of intensive BP lowering in SPRINT trial which demonstrated favourable CV outcome with lowering of BP to 120/80mmHg. However, the commentator noted, the method of BP measurement in SPRINT was unique and perhaps not reproducible in daily practice – the so-called ‘unattended BP measurement’ the subjects were left in a quiet room to self measure BP. Therefore, in daily practice, the corresponding ‘SPRINT’ level SBP, or a more realistic reading is <130mmHg. CLARIFY was a study to investigate whether there is ‘J’curve effect of BP among patients diagnosed with stable ischaemic heart disease. The study found that the ideal BP for IHD patients were in the range of 130-139/70-79 mmHg (in contrast to SPRINT finding), this applied to all subgroups except in stroke patients (who would benefit from a lower BP).

The deleterious effect of sleep apnoea (OSA) is well known in worsening CV outcomes, and strong association with heart failure and hypertension. The Sleep Apnoea CV outcome study (SAVE) sought to determine if CPAP treatment of moderate to severe OSA in patients with CV disease would reduce the incidence of CV events. The Australian based study randomised over 3000 subjects with OSA to sham control or CPAP and followed them up to 7 years. There was no difference in primary endpoint – A composite of death from CV disease, CVA, or hospitalization for unstable angina, heart failure or TIA. Nevertheless CPAP significantly improved daytime alertness, mood, quality of life, and reduced work-days lost because of ill-health.

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Dinner at a Halal restaurant in Terminal

Over the horizon, new and coming soon

I have elaborated a good bit on those new anticoagulants most of which are already being in the market in Malaysia since the last good 2-3 years. Edoxaban is perhaps coming soon though I haven’t heard of any development yet.

Any other new kid in the block? They may have been mentioned in last year’s highlight, but worth repeating since they are now coming up soon for clinical use.

Empagliflozin, an inhibitor of sodium-glucose cotransporter 2

(SGLT2) diabetic drug, had shown an impressive result of reduction in mortality and heart failure among patients with Type II diabetes (EMPAREG). Thus far no other drug of this class has produced similar result though trials are ongoing. The drug gives modest reduction in blood sugar and HbA1C. There had been a few sessions during this congress highligting the importance of this new finding. Is it a blockbuster drug? Well, so far, for any antidiabetic to be proven safe in diabetic patients is already a big challenge, leading to withdrawal of some of the drug classes due to unfavourable post marketing adverse events. However, the case was different with Empaglifazone, which surpassed the safety requirement and beyond, making it a potential cardiovascular protective drug for diabetics, who by default are at increased risk of CV events. What are the possible mechanism? Analysis of the study result showed there was a significant difference in the blood pressure in the Empagliflozin arm. Together with significant reduction in heart failure events, these two mechanisms could well be the positive attributes leading to its positive CV outcome result.

Not long before the Congress, we were pleased to hear the news on the result of LEADER trial – another diabetic drug called Liraglutide (Victoza – a glucagon-like peptide GLP-1 analog) which had similarly (though less profoundly) showed reduction in CV death among Type II diabetics.

Thus these two new diabetic drugs offer new hope in improving the prognosis in our Type II diabetic patients. The European and Canadian guidelines have incorporated recommendation on the use of Empagliflozin ‘to be considered’ in Type II diabetics in order to delay the onset of heart failure and prolong life.

PCSK9 inhibitor

Lower LDL? Thus far there hasn’t been a J curve phenomena such was found in hypertension study (ie no so-called low cut off point of LDL that could be dangerous, while evidence favouring lowering the level beyond 1.8mmol/l is growing, one recent one was from the IMPROVE IT study on statin/ezetimibe combination). There are three PCSK9 inhibitors currently undergoing phase III trial for clinical outcome result – Alirocumab (ODYSSEY OUTCOME), Alirocumab (FOURIER) and Bococizumab (SPIRE 2) to test safety and efficacy in high risk subjects aiming reduction of LDL beyond 1.8mmol/l. Evidence of safety has been accumulated now among the three agents, and last year a publication of ODYSSEY Long Term Trial in NEJM showed promising result of not only impressive LDL reduction (62%), there was also statistically significant difference in the CV events favouring Alirocumab (on top of statin combination) comparing to control. The European has made a proactive step of putting it into their recommendation as IIb (in combination with statin +- ezetimibe). Alirocumab is expected to be available in Malaysia soon, which opens up the horizon to further improve patient’s LDL level. Possible use including those with Familial hyperlipidaemia; secondary prevention in high CV risk patients whose LDL is suboptimal; and those statin intolerant patients.

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This famous seafood restaurant that we visited twice…shhh I hope Tan Sri won’t tell anyone about the Pokemon thing…

Entresto to improve prognosis in heart failure

The new agent, Angiotensin Receptor Neprilysin Inhibitor, Entresto (landmark trial PARADIGM-HF published & presented 2 years ago, demonstrated significant reduction in total and CV death & hospitalization for heart failure – 16%, 20% & 21% absolute reduction comparing to standard treatment with ACE inhibitor) has now been given a Class I recommendation as replacement for an ACE-I to further reduce the risk of HF hospitalization and death in systolic heart failure patients who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker and an MRA. Keeping in mind, the drug it may be given to a naïve HF patient (reduced systolic function with symptomatic/high risk Class II or III NYHA) it has to be given during a stable phase (not during the acute heart failure/in patient treatment). Starting dose may be low among naïve patients – 50mg twice daily, to maximum of 200mg BD. Caution in patients with low BP, since in the trial a 100mmHg systolic BP cut off was used as safety requirement (95mmHg before randomisation).

Statement of Conflict of Interest: Lastly – this summary and highlight of the congress is purely my personal work the information which was gathered from the sessions as well as online materials from the Congress (ESC Congress 365). I attended the Congress under the sponsorship of Sanofi Malaysia, nevertheless I was under no obligation to represent any companies or authorities.

10 Human Regrets

From “The Leader Who Had No Title” by Robin Sharma

Human Regret #1.
You reach your last day with the brilliant song that your life was meant to sing still silent within you.

Human Regret #2.
You reach your last day without ever having experienced the natural power that inhabits you to do great work and achieve great things.

Human Regret #3.
You reach your last day realizing that you never inspired anyone else by the example that you set.

Human Regret #4.
You reach your last day full of pain at the realization that you never took any bold risks and so you never received any bright rewards.

Human Regret #5.
You reach your last day understanding that you missed the opportunity to catch a glimpse of mastery because you bought into the lie that you had to be resigned to mediocrity.

Human Regret #6.
You reach your last day and feel heartbroken that you never learned skill of transforming adversity into victory and lead into gold.

Human Regret #7.
You reach your last day regretting that you forgot that work is about being radically helpful to others rather than being helpful only to yourself.

Human Regret #8.
You reach your last day with the awareness that you ended up living the life that society trained you to want versus leading the life you truly wanted to have.

Human Regret #9.
You reach your last day and awaken to the fact that you never realized your absolute best nor touched the special genius that you were built to become.

Human Regret #10.
You reach your last day and discover you could have been a leader and left his world so much better than you found it. But you refused to accept that mission because you were just too scared. And so you failed. And wasted a life.

And someone added in comment: Human Regret #11: You reach your last day and realized the existence of the 10 above…
Thanks to Wan Muhd Firdaus for posting this on his FB

Sindrom Kematian Mengejut – Sediakah kita?

Dikhabarkan dari harian Metro seorang lelaki berhenti di R&R dengan enjin kereta hidup, ditemui dalam keadaan tidak bernyawa setengah jam kemudian. Semoga rohnya diampunkan dan sejahtera di alam barzakh, takziah buat keluarga semoga dipanyungi kesabaran atas ujian ini.

Sindrom kematian mengejut memang sesuatu yang biasa kedengaran dari masa ke semasa. Tidak mustahil, beberapa insiden kemalangan yang berlaku di jalanraya, mungkin disebabkan oleh pemandu mengalami sindrom kematian tiba-tiba ini yang menjadi punca berlakunya kemalangan – yang mungkin melibatkan nyawa orang lain.

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Darah beku dari saluran koronari, kerap ditemui semasa prosidur PCI untuk merawat pesakit mengalami serangan jantung

Walaupun statistik di negara ini tidak diketahi secara pasti, di seluruh dunia, terdapat sebab-sebab yang biasa dikaitkan dengan kematian tiba-tiba. Secara umumnya ada 5 atau 6 sebab utama (yang lainnya adalah sebab yang terjangka contohnya kemalangan maut baik di jalan raya atau situasi lain). Sebagai petua mudah, kematian tiba-tiba adalah sebab jantung, sehingga dibuktikan sebaliknya. 90% atau lebih kematian mengejut adalah disebabkan jantung, sementara lebih dari 70-80% penyakit jantung ini dikaitkan dengan serangan jantung (heart attack- myocardial infarction). Ada sebab-sebab lain yang dikaitkan dengan jantung abnormal yang boleh berlaku pada usia amat muda – contoh yang biasa ialah HOCM – Hypertrophic Cardiomyopathy di mana jantung menebal (biasanya keturunan) ia antara punca kematian tiba-tiba yang lebih biasa di kalangan usia muda.

Oleh itu – fatal arrhythmia – gangguan rentak jantung yang bahaya seperti ventricular fibrillation/tachycardia adalah satu dari sebab utama. Ia boleh berlaku dalam konteks serangan jantung atau penyakit jantung kongenital tadi atau HOCM, walaupun terdapat sebab-sebab lain yang boleh membawa serangan ‘cardiac arrest’ ini, samada dikaitkan dengan struktur jantung tak normal, atau boleh jadi normal (ada gangguan elektrik, electrolyte dsb).

Seterusnya Serangan Jantung – dijangka sebab utama kematian pada usia muda 30an ke atas, malah ada yang lebih muda, 20an, jika ujudnya faktor risiko seperti sejarah keluarga atau kolesterol tinggi berketurunan (familial hyperlipidaemia). Ianya mungkin didahului dengan sakit dada, tetapi ada kes yang terlalu drastik di mana mangsa boleh terus rebah tiba-tiba, jangkamasa antara sakit dan pengsan terlalu cepat. Kematian disebabkan serangan jantung boleh berlaku kerana ‘pump failure’ iaitu jantung berhenti berfungsi akibat tisu jantung mati, atau gangguan rentak jantung (arrhythmia) seperti disebut di atas.

Oleh kerana serangan jantung ini merupakan sebab yang paling kerap, eloklah jika kita sentiasa memastikan terjauh dari risiko dengan menjalankan saringan serta amalkan gaya hidup sihat. Jauhi rokok, pemakanan sihat serta senaman adalah resepi yang baik. Jika ada darah tinggi, diabetes atau kolesterol, juga buat yang pernah mengalami sakit jantung pastikan mendapat rawatan dan pemantauan berterusan

Stroke yang besar (massive intracranial haemorrhage/stroke) boleh menyebabkan kematian mendadak. Simptom awal mungkin sakit kepala teruk, tetapi banyak kes yang berlaku secara mengejut, penderita terus pengsan (collapse) dan tak sedar. Di kalangan usia muda ‘sub-arachnoid haemorrhage’ – salurang darah (aneurysm) pecah menyebabkan pendarahan otak. Mungkin ada kaitan dengan sejarah keluarga. Sementara itu kes yang berlaku pada usia yang lebih matang mungkin banyak kaitan dengan darah tinggi, tekanan yang terlalu tinggi adalah satu risiko besar boleh berlakunya stroke/pendarahan tadi.

Darah beku di saluran paru-paru (Massive Pulmonary Embolism) boleh berlaku secara tiba-tiba menyebabkan kematian mengejut. Ia menyebabkan oksigen/darah tidak sampai ke jantung dan seluruh badan membawa situasi ‘shock’ yang membunuh. Mungkin didahului dengan simtom bengkak kaki (DVT) walaupun ada kes yang berlaku terlalu mendadak – PE dikaitkan dengan beberapa faktor risiko seperti pasca pembedahan, perjalanan jauh atau lama terlantar (tiada mobilisasi). Antara simtom awal ialah sesak napas, sakit dada dan pengsan berkali-kali.

Aortic dissection – luka saluran pembuluh utama (aorta) antara sebab lain membawa kematian mendadak. Ia mungkin berlaku pada seorang muda, ada kaitan dengan penyakit kongenital seperti Marfan’s syndrome, atau sejarah keluarga. Lebih kerap di kalangan usia pertengahan atau lewat, di mana ia juga dikatikan dengan darah tinggi yang tak terkawal. Simtom awal ialah sakit dada yang boleh menyerupai serangan jantung.

Senarai sebab-sebab kematian mendadak ada panjang lagi, yang lain mungkin kurang kerap menjadi penyebab. Pokoknya, jantung adalah penyebab utama, oleh itu saringan penyakit jantung terutamanya di kalangan mereka yang ada sejarah keluarga (ahli keluarga mengalami kematian mengejut) perlu dibuat untuk memastikan seseorang itu bebas risiko, atau jika ada dapat ditangani melalui pencegahan atau rawatan spesifik. Risiko atau penyakit jantung koronari yang menyebabkan kematian mungkin agak mudah untuk disaring, tetapi risiko penyakit-penyakit lain di atas kadangkala tidak mudah untuk dikesan dan memerlukan ujian rapi dan berulang.

Akhir kata, saya ulang kata-kata seorang bapak kardiologis Indonesia: Sudden death is a bad news, but it may be not as bad after all, think about the other way of death? Mungkin ada betulnya, cuma yang menjadi perhatian utama ialah mengesan dan mengurangkan risiko kematian mendadak pada usia muda atau pramatang. Selebihnya baik kita sentiasa menyediakan diri kerana tiada seorang pun tahu bilakah masanya akan tiba.
“Sesungguhnya ketetapan Allah apabila telah datang tidak dapat ditangguhkan, kalau kamu mengetahui” (Nuh: 4)