Monday, August 22, 2016

NAMIC 2016

               I was lucky to be able to attend the NAMIC (National Acute Myocardial Infarction Course) held in Grand Dorsett, Subang Jaya. It was organised by the Serdang Cardiology Department with the aid of drug company Boehringer. Thanks to my MO, i was introduced to this course which i had to self pay RM 250 for the course. While most of the participants were sponsored by the department, I had no qualms about forking out my own money for the wonderful course.

The grand ballroom of the Grand Dorsett Hotel, Subang Jaya. Ambience was nice.

The schedule of the course. As you can see, the lectures were quite packed. There was one German, Japanese and Indonesian speaker each.

Roti canai was served for breakfast

The reception and the exhibition booths. There were many companies showing their latest brands of stents and balloons. Too bad I wasn't trained in a centre with a catheterization lab (known as cath lab), it was quite difficult for me to figure out what those things were. All seem so alien to me haha.

Lunch was provided. As expected, it was not disappointing. Black pepper chicken drumstick with grilled saugage and potato wedges. It was served in the grand ballroom itself as the lunch symposium carried on. As expected, many people were busy munching their food  taking down notes from the talk. 

So what do you say about lunch on day 2. Amazing isn't it? Salmon with fried rice and steamed chicken pieces. The salmon was so juicy that I became too obsessed with the food. 

Dr Oliver is a consultant anaesthesiologist from Germany who gave the lecture regarding the reversal of oral anticoagulants. He spoke about the prothrombin complex concentrate, which is not widely available in Malaysia. Afterall, who is Malaysia compared to Germany? Hah...

So this was the card that every delegate was given. Obviously isn't it? There were almost 500 participants from all over Malaysia. I met a friend from Hospital Umum Sarawak Cardiology Department too! All the way from Sarawak. There were also people from the health side (even a family medicine specialist attended the course), from the cardiology centres and people like me who do not even standout in the crowd. There were registrars and specialists among the participants. 

My UKM senior all the way from Cardio Centre Sarawak =) Glad to catch up with each other!

So now for the academic part of the course. You might want to skip this part if you are not medically trained. These are the brief summaries and take home messages from the whole course.

On lipids
- Malaysia is still the fatest and  sweetest nation in Asia: Prevalence of Dyslipidaemia 40%, DM 30%
- Fenofibrate and Statins are the best combination for treating dyslipidaemia as they 
   = reduce LDL
   = increase HDL
   = reduce TG
- Fenofibrates are compatible with statins, unlike Gemfibrozil, which has to be taken separately with statins as they cause rhabdomyolysis

- in PCI capable centres, door to balloon time (DTBT) is 90 mins
- in non-PCI capable centres, if u wish to send a patient to a PCI capable centre, DTBT is 120 mins
- in other words, door in door out time is 30 mins. Door in door out means timing starts when the patient enters you ED and being sent out to PCI capable centre. That includes triage, clerking, ECG, referral and preparation of transport.

On chest pain
- ST elevation (STE) is defined by new onset of ST elevation at J point for 2 or more contiguous leads
- significant STE is defined as
   = ≥ 0.1mV in all leads, except
   = for lead V2-3  , in males -- ≥ 40 y/o ≥ 0.2mV; 
                                                 < 40y/o ≥ 0.25mV
                               in females ≥ 0.15mV
- J point: point between the termination of the QRS complex and the start of ST segment
- STE in lead aVr is always sinister. Together with widespread ST depression, it signifies Left main coronary artery disease
- not all STE are MI! They can be 
   = early repolarisation
   = acute pericarditis
   = Brugada syndrome
   = Stress cardiomyopathy
   = LBBB
- in the event of STEMI, Dual antiplatelet therapy (DAPT) must be given for ≥ 12 months

On cardiac biomarkers
- Troponin is always elevated in renal patients. HD clears CKMB but not troponin
- Causes of non MI increased Trop T
   = ICB - esp SAH                                            = tachyarrhythmias
   = Pulmonary embolism                                  = myocarditis
   = Pulm HPT                                                   = aortic dissection     
   = SIRS/ sepsis/ septic shock                          = heart failure
   = hypothyroidism

On lytic therapy
- plasminogen is activated, activates plasmin which degrades the fibrin
- given within 12H onset of MI is best.
- give is unable to perform PCI within 90 mins, or delay in primary PCI > 120mins
- thrombolysis should be given with either UFH/ LMWH/ fondaparinux
- AHA recommends thrombolysis at INR ≤ 1.7. Any other interventions other than that is individual decision, with either trial of alternative e.g. aspirin or T/O tertiary centre. 

Post MI rehab
- Driving
   = 1/52 post PCI with EF >40%
   = 4/52 post MI with no operative intervention + stress test acceptable
   = 6/52 for large vehicles post MI with no operative intervention + stress test acceptable
- Return to work
   = not more than 3/12
   = not more than 6/12 if CABG/cardiac arrest
         (*too long a return will cause patient to be very reluctant to return to work. The aim of rehab is to get the patient to go back to work as a normal being and serve the country)

MI with heart block and LBBB
- complete heart block with
   = inferior involvement - temporary, allow 24-48H. Unlikely to be permanent, no intervention needed
   = anterior involvement - a/w massive infarct, temporary pacemaker till 1/52, then usually require permanent pacemaker
- normal LBBB: discordance (discordance is good, concordance is bad) 
- LBBB with concordance QRS and ST = bad. Use modified Sgarbossa's criteria
- Sgarbossa's criteria
   i) any leads concordant STE ≥ 1mV (5 marks)
   ii) leads V1,2 or 3 , ST depression ≥ 1mV (3 marks)
   iii) Any leads discordant ST ≥ 5mV (2 marks)
- A score of ≥3 is very specific for AMI (90%), but not very sensitive (20%) = if ≥ 3, it is very likely to be MI
(* please read here for more detailed explanation)

Cardiac rehab
- aerobic exercise is recommended
- prescribed exercise is more useful. E.g. say, walk 30 mins x 5 days, instead of saying, exercise lah, mayb can walk around lo, runing can also ah, mayb u swim everyday and see....
- 6 mins walk test is a good short test to gauge patient's ability - can walk at own pace
- For MI patients, aim 60% of max HR, 20-30mins, 3-5x/week
- For normal individuals, aim 85% max HR
(*max HR = 220 - age )

Do inform me if you find some of the information here misleading and I will try to verify it. Hope this gives everyone a small insight of what we usually miss out when dealing with patients in the crampy emergency department and the sweaty medical wards.

Overall, it was just so worth the RM250. I even got to catch some pokemon in the streets of selangor meet with my uncle and aunty for a small family gathering =)

Signing off

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