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)

A historic journey of a father and son on their Triumph bikes touring the Peninsular in 4 days

Not to forget their awesome company, a Golf GTI singly driven by the mother

It was a great delight and a sigh of relief as both of us arrived in front of the house gate on Thursday evening at 7.34pm on two Triumph bikes (a Street Triple and a Bonneville T214), shortly followed by the Golf GTI. A duo of father and son who have just completed 4-day tour of Peninsular Malaysia, accompanied by the rest of the family driven by their mother on a Golf GTI which acted as a backup vehicle as well.

Altogether we rode a total distance of 1668.5km, starting from Petronas Hulu Klang covering the following destinations:
Parit Sulong, Batu Pahat – mother’s house
Kampung Maju Jaya, Skudai Johor – Sekolah Islam HIdayah & nearby homestay
Mersing Jetty & town
Cherating Pahang
Dungun Trengganu
Sungai Tong, Trengganu
Jeli, Kelantan
East-West Highway stop at Royal Belum Resort
Gerik, Perak
Ipoh Perak
Yup, we missed Perlis, Kedah and Penang completely! though the initial intention was to stretch the route northworth covering the three states, however due to some circumstances, we changed plan in the last minute…nevertheless this was a fascinating experience and a real breakthrough in my relatively new riding history. Prior to this, I had never been out on a long ride longer than two days.

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The machines, that have made history…Triumph Bonneville T214 and Street Triple ABS. The car, as you know Golf GTI

The inception
No big activity could have taken place without proper planning. I have been dreaming of taking this Peninsular tour for quite a while, and waited for the best opportunity to invite the son, Harith to join. This was going to be our, two of us, ride. Well, other people might join or be invited, since I always wanted assurance and guidance in tackling such an arduous journey. Bearing in mind, we had never toured the Peninsular by any means, including cars, for the whole lenght of my life. This was a history.

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The Route, courtesy of Route4Me iPAD version, this apps greatly help to chart your journey, draw as many checkpoints or stops and you can edit or change the sequence as you like

The son was just finishing his works at the Espresso lab, so the timing was just right. This also coincided with the wife having a meeting among school principals in JB. Then I needed to visit the mother in Batu Pahat. I have always wanted to do this Peninsular tour on the bike, but time never permitted. With a little bit of adjustment here and there, I thought all can be accomplished this time at once. Knowing from friends who have done the road tour, three days is a good duration for quick, light tour – longer time needed depends on the particular purpose of the tour, say if for tasting local delicacies and enjoying scenic views on every town then you definitely will need a week or so.
I began by drawing the plan, starting from home, each of the major checkpoints drawn up. The route was constructed using an app called Route4Me, downloaded on the iPAD – it came on similar version on Android, though not as flexible. My aim was to follow as much of the trunk road that run along the coast – on the East especially, as I had never been through this route before (well technically, yes I did once or twice before, on a car, driving – between Johor and Trengganu).
The big issue is tackling the unknown. I have done several long trips alone before, therefore have a good confidence of my endurance and patience on the road. The machine – be it the Street or the Bonneville, both have been tested and I have good confidence in them for long distance ride, they are not dedicated touring bikes, but they are rather ideal day to day  bikes, and now I would like to take my day to day machine for a long distance tour, why not? In fact I had taken the son along once or twice, that’s apart from other group convoy with the MyIkram Bikers that he joined. Therefore, I have a good feel of how to deal with the different roads on a long journey. What I mean by the unknown, in such a long trip (exceeding 1000km), you have to be ready to face issues like correct timing, where to stop/overnight, what are the roads like, and more importantly potential technical problems with your bike.
There is nothing more convenient than consulting friends/groups in order to reassure yourself of the plan. Immediately after I have drawn the route, I posted the map on MIB facebook, asking the members for advice and feedback. Many were pleasantly surprised at my intention – they had always been teasing me as a frequent traveler on the two wheels despite my insistence that I mainly ride for work (!). They offered advice and helped to refine the plan. Some gave advice about preparation – emergency kits (basic tools including puncture repair kits – which would only work for the tubeless Street tyres), where best to stop or eat, which best route to take or even offering to meet up if I pass by their towns.

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Both riders and bikes were tested riding various terrains and weather over the 4 days period

Though I have driven on some of these roads before, riding is a totally different game. This is where experienced friends come in handy. They told me what the each of the routes are like and what special precautions need to be taken on each of the route, especially the coastal road between Johor Bahru-Mersing-Kuantan. Then the famous East-West highway linking Kelantan to Perak, which I had never traveled by in the past.
Two most important concerns were the timing and distance to be covered so that I could complete the journey within the intended time. In general my aim was to cover not more than 500km a day, may be slightly more or less. Technically 500km can be tackled within a full 5 hours riding, add in the stopping time for refuelling and rest, this would come to at least 7 hours total time, easy riding that is. Syed hinted that the optimum speed would be 130-140km/hr which was my target too, though I aimed slightly less when riding at night time, or through the more challenging route, it would be safer to ride at your own comfortable pace. On a long journey like this, high speed would only make you tired faster especially with strong wind gust, furthermore most of the journey was going to be on trunk road, giving less chance for speeding anyway.
In the beginning we left the checkpoints very flexible – having fixed the first two which was Batu Pahat and Johor Bahru, the subsequent one could be anywhere as near as Mersing or as far as Kuala Trengganu! I had a little concern though about the East-West highway, and because the Golf is part of the team, we have to consider the traffic condition to suit our plan. I asked the friends what would be the best time to start the journey from the East so we could reach Grik before night time. At this moment there was some anxiety and uncertainty, from hearing the story of other people who have traveled the road during night time. The particular hazard or fear was with wondering elephants! And now one friend said we may encounter the beast even during the daytime. That prospect worried us a bit, so I sought a workable solution by asking if Su Yan (Wan Sufian, my wife’s uncle) who is a biker, to accompany us. We could not confirm this until we met him during our night stay at his house. As a precaution we changed plan a bit so that we shall start crossing the highway by 3pm – giving plenty of time for the Golf in case there would be long traffic ques along the way.
The two machines – Street and Bonneville have been known to be reliable, no major mechanical problems thus far. The only thing that ever immobilised the vehicle – the Street Triple in this case, were tyre punctures and flat battery. With over 20,000 km clocked on both, I had full confidence that both bikes should be able to tackle the entire journey with a breeze. I brought the Street for a quick check at Fastbike PJ, in case of any anticipated issues. Everything seemed fine, I was told, nevertheless the brake pads were a bit more than halfway worn (40%), which should be safe enough to proceed the journey without replacing. I brought the emergency puncture repair kits (plugs) and a home manual bike pump which we loaded into the car due to its large size. I also took a set of electronic jump starter (worked with a power bank). We have contacts in case the vehicles encountered serious problems that required towing.

The Round Tour began
Night riders…Ampang-Batu Pahat
Distance 225km. Travel time: 3 hours 10 minutes (25 minutes break)
It was not the intention at all, but partly may have been due to poor planning plus fatigue. I had planned to begin the journey on Sunday evening, immediately after the meeting that took place at the Space Bukit Jelutong, aiming to complete the ride before dark, mostly. This proved impossible, as the meeting ended past 5pm, we have to ride back home, get the kids ready and only then start the trip. Then I was feeling drowsy due to lack of sleep the previous night, so on reaching home I took a quick nap, woke up at maghrib time. In the end we did not start moving until 9pm. Yes despite my earlier worries and trying to avoid riding at night, here we were pressed by circumstances, so around 9pm we started the ride from Petronas Hulu Klang. The Golf had started slightly earlier, we caught up with them somewhere past Cheras, both bikes cruised handily amid the traffic congestion.
Leaving at this hour, with much to catch up, I tried to keep everything calm and told Harith to take his time. We got all the gears ready, refueled and quietly began the ride. Traffic was heavy but both riders were used to this kind of situation, we moved smoothly, applying the skill of lane splitting. Occasionally we had to slow down manouvering along tight vehicle gaps. Once passed the Sungai Besi Tol things were fine. Weather was good and the cool night time temperature allowed us to enjoy the ride better, though I kept the speed down, increasing it gradually as the traffic eased off. Riding on the PLUS highway down South has been a fairly regular affairs for me, not less than 4-5 times before, and perhaps a hundred times driving, therefore this section of the road was among the most familiar to me, including the B road from the Pagoh exit to Parit Sulong. This probably was the main reason for having confidence to begin the journey at night, besides the time factor.

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As it goes, the only obstacle to smooth and straight riding on the highways is the volume of traffic, plus those fast lane parkers nuisances – even at the four lane highway between Seremban-Melaka, we still have to ride between cars on fastlane, which did affect the speed somehow. We took a stop at Ayer Keroh for refuelling and quick bite. The wife decided to continue with the journey hence we were left for a good distance behind.
The most tricky part of the ride at this hour was the B road on exit at Pagoh. Most part of the journey was unlit, with not so much of sharp corners, and few slopes. We took it easy, maintaining speed between 100-120km/h (at corners the speed might drop considerably due to poor vision!). For Harith this would be considered his first experience of long ride at night, he seemed to be doing fine, closely following behind. I kept track of his movement every few minutes by glancing at the side mirrors, when I spotted the double spotlights (or ‘bug-eyes’ trademark of the Street Triple) that meant he was there following close behind.
We arrived at Parit Sulong and rode further, climbing the famous tall bridge crossing the river and took the right turn at Parit Jalil. Kampung Parit Abdul Hadi is located somewhat in the middle between Parit Sulong and Tongkang Pechah. The turn to the village was a narrow tarmac runs along a canal, but there was no highly visible signboard to the village, and shamingly even after having passed by this route for hundreds of times I could stll miss the turn to my own village! It was not difficult for me to realise I have gone too far from my mother’s kampung turn, as the road (Jalan Parit Jalil) leading to the village is all a straight one, once the road started turning I instantly knew I have well passed it! So off we went, made a U-turn and slowly rode back up toward the village, keeping close eyes on the barely visible signboard and hut facing the village.
Riding on the small tarmac road along the canal, only a few seconds before turning right to ride on gravel towards my mother’s house. Earlier my sister in law warned us of a fallen log (from the dead palmtree) blocking most of the road. Indeed there was just a narrow passage around it, it did allow a car to pass with most of the body has to roll over the grass. This should be a job for me in the morning, I reminded myself.

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At mother’s house we rode both bikes under the shelter for the overnight parking. This was not the first time father and son arrived here on the bikes, yet my mother was still baffled as usual, she must be impressed how the little boy had grown up fast and now able to bring himself to travel the distance to visit the grandmother. This was the first mission – visit the mother, pass her some medicine for my brother, met by younger brother, and the next morning used my bare hands to lift that big log that was blocking the road. My younger brother left for work early in the morning, so I did the job removing the log mysef and all the women were pleased now the passage is clear.

Ride 2 – Batu Pahat – Johor Bahru
Distance 123km. Time: 2 hours (10 mins break)
Since we did not have to be in Johor Bahru so early I took the morning time to rest, had a nap and only started the journey at 1pm.
We followed the Jalan Parit Jalil-Tongkang Pechah heading to Yong Peng towards the Yong Peng Tol Plaza to join the PLUS highway JB direction. We stopped at Machap for refuel, again the Golf left us. We followed the highway passed Skudai exit, towards Kempas tol plaza then followed the B road heading to Sekolah Islam Hidayah. This time we arrived slightly ahead of the Golf, as we parked the bikes across the road we spotted the Golf coming from the opposite direction driven straight to the school ground.
This was mission 2: accompany the wife attending school Principal’s meeting, and the daughter Nawal attending the Musleh school competition. We stayed at a homestay nearby, this was a village slightly bigger and developed than my kampung. In the evening we rode around the village to the nearby warong. There was a nearby Surau which I went for the maghrib prayer, and at Subuh I joined the congregation at the mosque nearby the Hidayah.
There was nothing peculiar about the ride, highway was straight road with modest traffic. We did not have to pass by the very dense and crazy traffic of Johor Bahru since we zoomed straight after the Kempas exit to the Hidayah school, the road were small and fairly busy with many potholes here and there. Going the homestay direction was even smaller tarmac road, and turning in toward the homestay we rode over rough gravel gently manouvering the healy and uneven surfaces with rocks splattered everywhere, this could be some hazard to the tyres if we were to press hard. Fortunately the passage was fairly short and we mostly used the car to go in and out of the house. Yes, I admit, this is an advantage of having a car in the convoy without which your movement would be much different perhaps.

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Ride 3: Johor Bahru – Mersing- Pekan – Cherating – Dungun
Goal 3: Visiting Wan’s uncle. Goal 4: Coastal ride Mersing-Dungun Goal 5: Meet up Ahmed (not done)
Distance 493km. Travel time (minus break): 7 hours 40min
This was the longest ride covering three states of Johor, Pahang and Trengganu all in one day. First of all I was a bit exhausted from lack of sleep the night before. We stopped for two and a half hours at Pekan Pahang, for prayers, quick bite and long nap. With the exception of short stint at Kuantan-Cherating bypass, all the other rides were not highways, this has given us a unique experience on the bikes, the car had to cope much with traffic and narrow road forcing Wan to go at slower speed I believe. Throughout the journey the rides have given advantage over the car I supposed, when we consistently arrived earlier than the car, if not much earlier. Hilly roads, bends and rough surfaces at many points especially JB-Mersing route, we kept speed below 130km/hr mostly, traffic was quite busy, at times we were forced to sneak through the narrow ‘motor’ lane (technically hard shoulder!), which was the only option for overtaking. When doing this I ensure the boy can see enough (me) in front of him, speed is kept low, and I tried to spend as little time on this hard shoulder. On small road like this there was always the possibility of encountering vehicles including motorbikes parked over the hard shoulder therefore blocking smooth access, or even caught us by surprise – in order to avoid this hazardous situation, I always try to stay on the hard shoulder (when necessary) on the straight part only, whenever there is a bend, I quickly moved in. One more, all these hard shoulders tend to disappear or get extremely narrow when it comes to a bridge, so you are well advised to move in on sighting a bridge ahead. Here I start to sense the boy has developed his own instinct, which he sometimes did not follow my tempo completely, like going over the hard shoulder, though I noticed he would not go over the hard shoulder by himself, means he has made sense of the potential danger.

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We left around 8am heading towards Mersing. I made one stop for refuel. We headed towards the Mersing Jetty then made a round and stopped by at Chamek cafe for breakfast. Wan who arrived a bit later parked the car in front of Chamek to join us. The cafe is facing the Mersing river. We had nasi lemak for breakfast which lasted almost an hour. I intentionally gave a longer break, anticipating a long and undulating journey ahead. Then we realised the car was parked at the town council spots and before we managed to do anything the uniformed staff had issued a summonse ticket! I later rode to their office and paid the summonse of RM10 (discounted), there you go, RM10 for an hour parking in Mersing was a bit much you guessed! Wan left earlier, so we took a round towards the beach, took a photo snaps, then hit the road towards Cherating.

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The Mersing-Pekan route was a fascinating coastal ride, the roads were much wider and smoother, with quite a few bends in between. Here we enjoyed empty roads at several parts, lovely views and at certain points we could clearly see the blue sea on the right. We arrived in Pekan town, rode slowly passing the modest traffic and stopped at Masjid Sultan Ahmad Shah. Here we had a long break, allowing the afternoon hot weather to subside. It was adjacent to the royal cemetery and the historic muzeum. Then we crossed the Sungai Pahang and rode the remaining of the coastal road heading to Cherating.
Though the initial plan was to follow the coastal road all the way, the Gmaps had somewhat mislead me to follow the Kuantan bypass instead. Here we rode past the reminiscent of red bauxite mining site, the pollutants can still along the highway. Pekan-Cherating was a good 2 hour ride, almost.
We stopped at Petronas Cherating for refuel and evening tea. At 6pm we hit the road heading the destination for the day in Dungun. This was slightly less than 90 minutes ride along the scenic route of Jalan Kemaman-Dungun. We stopped at the oil depot to capture the evening sunset view of the area. It was near sunset, we continued riding and arrived at the mosque nearby Su Yan’s house just when the Azan was called. Here we stopped for maghrib and isya prayer combined, after which we rode the bike to Su Yan’s house. Now everyone was almost flat after enduring such a long ride or drive. We chatted for a while, mostly about bikes and rides. Su Yan is a season rider, he currently owns a BMW GS1200 (latest version with low seat). Prior to this he started with an ER6, then a Yamaha FJR, then Honda VFR before changing to the GS. After much persuasion he agreed to accompany us for part of the journey heading to Gerik. We agreed now to skip Kota Bahru (therefore dropping Goal 6: visiting Wan’s grandmother).

Miracle of a sick child
The day did not just end there. In fact the day did not end, it was another sleepless night when our daughter Nawal complained of severe stomach ache. She had it for two days, I have tried some medicine and today we bought some other medicine for antispasm and sickness. She did not settle completely but I saw her falling asleep so we left her in the other room. Suddenly just past midnight she came awaking us crying, seemed to be the worst one. All the medicines were given. Hmmm a bit more paracetamol, I groaned. She never stopped sobbing. I woke up and sat beside her, told her to drink water. But she refused saying that the pain got worse when she drank water. I immediately summoned the wife to look for milk, there was no fresh milk in the house, so we went out to the nearby 7-eleven, get some milk and bread, noting that Nawal had not eaten much during the day. We gave her the milk and prayed she will get better. She slept for a wink then awoke and complained again. Now its a failure of a home doctor, and time to move on to next step. We take her to the hospital then, I said to the wife. It could be appendix, I murmured (recalling the past experience how I diagnosed my wife of having appendicitis, she successfully underwent the operation).
Many things came in mind then, maybe, I thought, this is the end of the tour then. We have to scap everything and focus on getting our daughter treated. The wife even suggested she drove home straight away, bring poor Nawal to a local hospital in KL where it will be near our home, and furthermore better facilities and experties. I on the other hand, as a doctor, thought we should get her diagnosed then make plan after discussing with the doctors.
We asked the young girl to put on her dress and tudung, meanwhile I asked my wife if we have her birth certficate or Mykid for identification when registering. Both negative. So, I sat down while browsing my old emails and folders contained in Gdrive, after a little while found her birth cert and passport scanned. Hmm that will do I thought. As we were doing all that I asked Nawal about ther pain. Kind of sharp and in the middle of her stomach, earlier on I felt no tenderness, now there was some tenderness. I pressed a bit to elicit rebound but negative. Then pressed again…and read Al Fatihah and prayers. Then not long after she felt asleep. Just as we got up and ready to move, she was lying in bed, deep asleep. So I thought, maybe we can wait, if she did not complain anymore we can take her in the morning. I woke up just at Subuh, and Nawal was not there, apparently she went back to her room. Later when I asked how she was, she said fine, and asked me a strange question: Ayah, what did the doctor do last night? Taken by surprise, I paused a while, and quizzed her: Did you remember going to the doctor? ‘Yes, his name so and so….and he said I did something wrong and has to pay a fine or something…’ that was a bit baffling. We kept asking her later and she told us of having a dream and met this nice doctor who had done something that cured her.
I kept close eye on her daily, and she never complained of the pain anymore, the severe stomach ache had completely gone! Praise be to God.

Ride 4: Dungun – Sg. Tong – Gerik (Royal Belum)
Distance: 362 km Ride time: 4.5 hours (Dungun-Sg. Tong 3 bikes including GS)
We started a bit later than planned, at 0730 we were ready on the bike and the Golf left after a brief photo session. Su Yan asked me if I wanted to ride the GS and he will ride my Bonneville. That will be great I thought. This is a low version GS and I could comfortably reach both feet on the ground, tip toeing that is. Otherwise I was quite familiar with the bike, in term of handling at least, as I had already done a test ride previously at Motorrad. We first rode to nearby petrol station for refuel of the two Triumph. The GS has got a near full tank when I started it, with one bar less on the fuel indicator. Su Yan lead the journey heading towards Kuala Trengganu/LPT.

I stayed in the middle, and soon could not cope with the temptation, so once we hit the highway I cruised passed Su Yan revving the throttle hard, and soon the speedo topped past 180km/hr. But I could not last long, as I have to wait fot the two bikers anyway. Harith attempted to follow suit whenever I sprinted at speed. The GS is a wonderful machine, it is light, powerful and quick. I have to be careful with the throttle, in fact there was less of a feel as to what speed you are, that happened when I hit past 200 mark and the bike did not show any sign of fatigue. It was a real breeze, putting the Bonnie in shame I supposed. By now, I guessed Su Yan may be wondering why he bothered switching bike! I tried to tempt him by riding close, and he did reach close to 160km/hr, thats it, no sign he is going faster, indeed he kept his speed around 150km/hr, so I had to follow his pace, and sprint ahead once in a while, then slowed down to wait for them again.

As I experienced before, standing still you could feel the vibration from the twin cylinder engine, it has got short gearing for first to third, a third one could take you to 100plus and good for rolling slowly, feels steady and fourth can take you all the way beyond 160 though screaming exhaust notes will come fast, so you better take from the 5th gear onward. Sure its a speed demon, with an average of 180km/hr is reportedly the ‘normal’ speed for all those GS users. What more, the new bike has a sleek design, the pannier bracket is hardly visible if you take out the pannier boxes. And it is designed to take loads, plus passengers, and can cope well with various terrains! Other less able competitor, from Triumph like the Tiger XC or XR, of a smaller capacity of course, and does not have that high sprinting ability (as far as I have tested the Tiger which was great for ‘lower speed’ travel per se, understandably with lower cc). The Triumph Explorer would be the matching competitor, though not available yet, and no guarantee it can fit my height. Or Sports touring, which again I will be faced with height contraint… The only lacking in GS, its not a sportsbike, a little lack of characters, thats it. So for now, I can only dream….yup, I have got two wonderful Triumph bikes now about proving their worth by completing this tour.
We had tasty local breakfast Trengganu style (nasi berlauk – rice with fish) at Sungai Tong. Here I took the wife for a quick spin on the GS, she seemed a bit scared with the high sitting position and could not adjust herself comfortably, well maybe I went a bit rough on the ride, trying to push hard to a high speed too fast on that small and bendy road!
Now we parted with Su Yan and continued our journey heading to Gerik, via the LPT. We stopped at Jeli for refuel – this is a must since there will be no refuel station between Jeli and Gerik (about 124km). The ride was kept at much lower speed due to high traffic volume and small road, hardly any hard shoulders. We were stopped twice at the Police roadblocks – cleared on both occassions and I had to apologise to the cops for not having P plate on Harith’s bike, they seemed not bothered by that…so when we stopped at Petronas Jeli, I bought two pairs of P plates and put them on both bikes front and rear.

From Jeli, we exchanged bikes – I rode the Street Triple and Harith the Bonnie. That was a world difference riding a sportsbike going around corners, well, the Street is the perfect answer for those brave enough, I was only half brave, yet it was definitely more enjoyable, keep at low gears and the bike roared loudly snapping corners one after another. I noticed Harith was left far behind, and on a few occassions I had to stop on the roadside and wait. This did not happen when he was riding the Street, well, maybe familiarity, that also proved the boy is a careful rider, he knows how to suit the ride according to the bike.
The fantasy ended as we reached the R&R (banjaran Titiwangsa), we changed back to our own bikes. I was still able to manouver the corners nicely with the Bonnie of course, in a slightly different style. Riding this highway is fun, and perhaps the only way you can pass by the congested road caused by many heavy vehicles like the military trucks. We started at the same time with the Golf as we left the R & R, soon the Golf was left behind along with the strings of vehicles. There were quite a few overtaking lanes along the way thankfully, but the big difference for the bikes, we did not have to wait for those lanes! Whenever there was little ‘clearance’ we could march forward for quick overtaking, especially most of the vehicles were going at fairly slow pace around the corners.

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The two beasts standing proudly ever willing to take the owners anywhere they wish…

Overtaking at corners can be a bit tricky though, one has to aim for the correct timing and good throttle control otherwise you are looking for for an overshoot soon. I did have that once (almost) when, without realising, after passing a corner the road surface suddenly changed to a much irregular one with some gravel here and there….the bike kind of veered straight heading to the ditch, I quickly countersteered to lean on the opposite site. That remedied the situation but with one other problem. The boy who followed too close behind was caught by surprise and had to swerve rightward to the opposite lane (by inches), lucky the road was clear or no speeding junkies coming from the opposite! Since my policy was to give ‘room’ for escape everytime I passed other vehicles, that did help to keep us clear of the potential hazards.
Perhaps due to the preoccupation with tackling the bends, we missed the next checkpoint at Royal Belum resort! and when I realised, we were already 30km away…you are just 15mins to Gerik town, sir, the girl at the BHP station told me. They have however run out of petrol so we could not refuel. But no urgency as yet, we still have over 100km to cover with the tank half full, so we made a U turn heading back to the Belum. This time I put on the GPS, which was not used earlier, due to poor network signal.

At the Belum Resort, night with elephants and all that…
The most important reason to stay in Belum, is its scenic view which only from the resort viewing plane you can enjoy the beautiful landscape of the forest, mountain and the lake (Tasik Temenggor). Besides, you can stay till midnight when it is time for elephant watching, if you wish. We did that, drove out around the midnight heading towards the R & R, and spotted the elephants on the way going and coming back.

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Apart from this, the resort is quite decent, perhaps a 3-4 star quality, food so-so, its got a lovely yet shallow pool, and quite ‘isolated’ from all amenities, which is not less than half an hour away if you are talking about Gerik. The cost? very dear at close to RM400 per night. For us as a family, and first time experience traveling via this highway, it was just the perfect solution for an overnight stay, for the above purposes.

Ride 5: The journey home
Due to the elephant watching, we had so little sleep at night, therefore we started the next day a little late. Starting at 10.30am, we had another stint of cornering lesson, and stopped at Rahim Mydin restaurant for breakast.
Our next destination was Ipoh, with a brief stop somewhere past Gerik town for refuel. In Ipoh we visited Wan’s friend who just lost her 19 year old son out of a sudden (sudden death). There were discussion with the family who were still grieving the loss, and a bit of medical consultation about screening the family members took place.
From the house we visited, we headed towards the highway (PLUS) and rode till Ulu Bernam for prayers, late lunch and refuel.
It was not till we passed Tapah (the refuel was in Tapah R & R) when heavy rain started, both of us were drenched! This was the only rain experience throughout the ride. I was quite used with dealing with rain, wore a rainproof gears (leather jacket/trousers) though this time was a real heavy, forcing many vehicles to move slowly (below 80km/hr! though some remain in fastlane which was a big nuisance), we still have to observe every caution when the rain became too heavy somewhat impairing good visibility. Though I managed to keep dry my socks were half wet, that needed change at the stop.
We only managed to leave Ulu Bernam R & R around 6.30pm, and reached home at 7.34pm (the Golf followed suit a little later).

Successful tour, 3 awesome machines accomplished the mission!
We spent in total just over 24 hours on the bike from the start to the end.
Both bikes, the Triumph Bonneville T214 and Triumph Street Triple have proven their worth and reliability for completing the tour without any problem at all. They have afforded the riders so much thrill and adventure.
Not to forget of course, similarly the Golf GTI driven by an unbeatable woman, a strong performance car giving endless joy and comfort
Thanks God, everyone was safe and sound and back as welcome heroes after completing the challenging journey.

(For short video depicting our experience click here)

Ramadan datang lagi…jom sediakan diri!

Simple tips seperti yang terkandung dalam Riadhussalihin yang kami baru mentalaah semasa usrah tadi.
Puasa adalah kewajipan yang telah difardukan kepada umat terdahulu – Yahudi/Nasrani, dengan tujuan yang sama, untuk membina Taqwa. Oleh itu tema puasa adalah pembinaan Taqwa. Taqwa menggambarkan dekatnya hamba kepada Allah, dan terpelihara (dari melanggar batasan/murka Allah). Ayat al Baqarah 183
Hadis yang jelas menyebut keistimewaan puasa: Hadis Qudsi: Semua amal anak Adam dapat untuknya kecuali puasa, maka itu untukKu (sahaja), dan Aku sendiri yang akan membalasnya. Dan puasa itu sebagai perisai…untuk orang yang berpuasa dua kegembiraan – ketika berbuka puasa, dan ketika mengadap Allah nanti. Memang benar, seseorang boleh dilihat bersembahyang, bersedekah, haji, jihad dsb, tetapi kita tak boleh melihat seseorang itu berpuasa! Anda puasa? Ya jawabnya, apa buktinya? Kerana anda tak makan dan minum, di hadapan saya. Tetapi kalau anda mahu, anda boleh sahaja makan minum di belakang saya. Pasti anda tidak mahu melakukannya, kerana tahu ALLah Maha Melihat! Itulah istimewanya puasa, ia melatih kita untuk taat kepada Allah walaupun orang tak melihat kita.
Hadis Abi Hurairah juga menyebut: Siapa yang puasa bulan Ramadan kerana percaya dan benar-benar mengharapkan pahala dari Allah (Imanan wahtisaban), maka diampunkan dosanya yang lalu.
Puasa melatih jiwa/hati supaya dapat mengawal jasmani/nafsu/akal. Semasa puasa inilah yang berlaku, tubuh badan menyuruh anda berbuka, lidah menyuruh anda lagha, tetapi anda menentang, demi untuk menjaga puasa. Oleh itu, bila puasa dah berlalu, jiwa kita dah bersedia untuk terus kuat mengawal nafsu dan jasmani kita insyaAllah. Itulah konsep Taqwa yang letaknya di dada. Ujian pertama ialah bila berbuka, dapatkah jiwa yang telah dilatih dengan puasa itu mengawal nafsu dari makan berlebihan, atau mementingkan diri sendiri sahaja seperti berebut-rebut makan membelakangkan orang lain dll.

Iman dan mengharapkan pahala/keredaan Allah, adalah inti puasa seorang itu, berlapar dahaga dengan satu tujuan – keimanan dan mengharapkan reda Allah. Ini adalah asas puasa kita. Puasa mempunyai banyak kebaikan-kebaikan fizikal, sosial dan kesihatan. Tetapi yang dikehendaki seorang itu berpuasa hanya kerana keImanan kepada Allah dan semata-mata mengharapkan balasanNya. Begitu juga setiap amalan soleh yang dibuat di bulan puasa, dengan tujuan yang sama, dengan itu bulan ‘training’, latihan ini akan menghasilkan taqwa.

Sebagai madarasah Taqwa, seorang ulama ada menyebutkan, hari pertama kita berpuasa, seperti kanak-kanak masuk tadika, baru belajar huruf/membaca dan berjinak dengan sekolah. Hari terakhir puasa, kita ibarat seorang graduan yang telah mendapat ijazah tertinggi – itulah ijazah Taqwa.

Biarpun tujuan puasa dan Ramadan untuk membina Taqwa yang letaknya di hati, di dada, Allah swt telah mensyariatkan keseluruhan bulan Ramadan ini dengan berbagai aktiviti/amalan lahir demi untuk membina hati yang bertaqwa itu. Oleh itu perlaksanaan puasa dengan sebaik-baiknya – menjaga kualiti puasa dari sebarang rafas (lagha), disertai dengan amalan-amalan soleh yang lain akan memperkuatkan pencapaian Taqwa tersebut.

Disunnatkan bersahur. Simpel sahaja, bersahur itu memang keperluan zahir, tetapi bila seseorang bersahur dengan ‘Imanan wahtisaban’ tadi, ia akan mendapat pahala yang besar kerana memenuhi sunnah. Lebih elok melewatkan sahur ke penghujung malam, dan berhenti kira-kira sepuluh minit (50 ayat pendek) sebelum subuh. Paling minima bersahur adalah meminum segelas air atau seulas tamar.

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Disunnatkan untuk menyegerakan berbuka. Memang bila dah berpuasa dan letih sepanjang hari kita sentia ‘looking forward’ untuk berbuka. Sedangkan, bila kita memulakan berbuka dengan niat memenuhi sunnah tuntutan berpuasa ianya akan mendapat ganjaran, dan digalakkan untuk tidak melengahkan berbuka. Untuk orang berpuasa, bila sudah masuk waktu maghrib, hendaklah berbuka, tiada lagi pahala dalam memanjangkan puasa. Itulah praktikalnya Islam.

Banyakkan bersedekah, infaq, zakat dan lain-lain kebajikan di bulan Ramadan. Rasulullah adalah seorang yang pemurah, dan di bulan Ramadan beliau lebih lagi bersifat pemurah, amat mudah memberi. Membayar hutang, di bulan Ramadan pun akan mendapat pahala berganda.

Tiga amalan yang menjadi tunggak untuk memperbanyakkan ubudiyah di bulan Ramadan ialah solat, Quran dan itikaf. Yang pertama layaklah untuk menjaga amalan solat jamaah setiap solat fardu, terutamanya Isya dan Subuh – bahkan minima KPI untuk beribadah di malam Lailatul Qadar itu sendiri ialah solat Isya dan Subuh secara berjamaah. Seterusnya solat malam & tarawih. Terlalu banyak peluang untuk melakukannya jangan lepas satu malam pun tanpa tarawih. Minima dua rakaat solat malam pun sudah memadai, dan seeloknya menyempurnakan sebelas rakaat termasuk witir, atau lebih. Banyakkan solat sunnat juga menjadi galakan dan ‘refresher training’ untuk kita lebih gemar solat sunnat ini di luar Ramadan juga.

Ramadan adalah bulan Quran oleh itu penuhi dengan membaca Quran, minima khatamkan tiga puluh juzu sekali, atau lebih dari itu. Di bulan Ramadan ini amat digalakkan membaca sebanyaknya alQuran, melebihi dari mengkaji tafseer dan sebagainya, kerana inilah tuntutannya di bulan Ramadan ini.

Seterusnya beriktikaf di masjid, ini amalan Rasulullah terutamanya sepuluh malam yang terakhir. Tidur di masjid, inilah di bulan Ramadan, tidur pun menjadi ibadah yang akan mendapat ganjaran besar. Termasuk juga memburu Lailatul Qadar, sama iaitu terutamanya di sepuluh malam yang terakhir.

Tidak lupa aspek jamai/kemasyarakat di bulan Ramadan. Sebab itu, selain di atas, antara amalan digalakkan ialah memberi makan orang berbuka di mana menurut hadis Nabi, seorang yang memberi makan orang berpuasa akan mendapat pahala ganjarannya sama dengan orang yang berpuasa. Juga kesempatan untuk mengeratkan talian keluarga dengan berbuka bersama keluarga, atau ukhuwah dengan mengadakan iftar jamaí maupun menjamu orang berbuka. Juga amalan sedekah – boleh diperluaskan dengan contohnya memberi juadah berbuka, hadiah kurma, sedekah kepada fakir miskin selain zakat dan fitrah. Dan solat tarawih secara jamaí juga memperkuatkan ikatan sosial dalam masyarakat walaupun harus menjaga tidak terlalu banyak masa dihabiskan dalam berborak kosong atau makan berlebihan.

Inilah konsep mujahadah (Iman dan mengharapkan redha Allah), bersungguh-sungguh di bulan Ramadan, memenuhkan bulan ini dengan puasa yang berkualiti dan meningkatkan amal soleh supaya akan ‘graduate’ dengan tingkatan Taqwa yang lebih tinggi.