LOOKING AFTER THE HEARTS OF SARAWAK: BRIDGING THE GAP IN HEART FAILURE (HF) CARE IN SARAWAK

By Dr Chung Bui Khiong

Clinical Cardiologist, Sarawak Heart Centre

 

Sarawak is Malaysia’s largest state, spanning around 800 kilometres along its northwest coast. As of 2021, it is home to 2.8 million people from almost 40 different sub-ethnic groups across varied socioeconomic backgrounds. The state of Sarawak is divided into 11 divisions with its capital, Kuching city, on its southwest tip. Sarawak Heart Centre, Sarawak’s sole cardiology centre, is located in Kota Samarahan with a limited number of cardiologists to provide care for HF patients throughout the state. Owing to the expansive size of the state, access to cardiologists is constrained by logistical challenges. The care is often shared by other hospitals without cardiology specialty.

 

HF is a disease of the heart when it does not pump as well as it should. As a result, our body does not get enough of the oxygen-rich blood it needs to function properly. As the heart’s pumping becomes less effective, blood may back up in other areas of the body causing fluid to build up in the lungs and other areas, leading to symptoms such as shortness of breath, difficulty sleeping, swollen abdomen and feet, and fatigue.

 

The prevalence of HF is increasing due to an ageing population as well as improved survival of patients with heart attacks, high blood pressure and other chronic illnesses. However, HF mortality remains high with a 67% mortality rate within 5 years following diagnosis. One of the key components in reducing mortality and HF hospitalisation is the optimization of guideline directed medical therapy (GDMT) among patients with HF. The latest European and American management guidelines of HF recommend early initiation and dose optimization of 4 different pillars of medications namely renin-angiotensin system inhibitors (RASi), beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose co transporter inhibitor (SGLT2i) in management of HFrEF.

 

A prospective observational study (SGH-HF) in 2020 led by Dr Ling Hwei Sung on the characteristics of patients with acute heart failure admissions in Sarawak, showed that prescription of GDMT is challenging following acute admission in a non-cardiology centre, Sarawak General Hospital (SGH), as shown in Figure 1. The most common challenge is the management of the side effects of HF medications, like low blood pressure, increased potassium levels and deranged kidney function. In addition, with the overcrowding of patients in the hospital, it is nearly impossible to adequately optimise medications prior to discharge. The average wait period for an appointment at clinic is three months and some patients will either be readmitted or succumb to death. The adverse effects of HF therapy may also result in disruption of GDMT during follow-up and lead to delayed optimisation of GDMT. 

 

One of the models of HF clinics, namely, the outpatient Multidisciplinary team heart failure (MDT-HF) clinic, has been introduced to overcome the limitation in the optimisation of GDMT. Sarawak Heart Centre HF clinic is the first MDT-HF clinic in Sarawak established since 2016 led by Dr Cham Yee Ling. It has served to improve HF service and patient care. It has proven to improve HF patients GDMT prescription and clinical outcome and its data was recently presented at ASEAN Federation of Cardiology Congress (AFCC) 2024. 

 

An initiative was started to set up physician-lead HF clinics across other district hospitals in Sarawak, to improve management of HF patients who had limited access to cardiology care. In 2020, the first physician-lead heart failure clinic in Sarawak was started in SGH in the city of Kuching, 20km away from Sarawak Heart Centre. Over the next three years, physician-lead HF clinics were started in neighbouring district hospitals in Miri, Sarikei, Serian, Sibu, Bintulu, Sri Aman, Kapit and Limbang, focusing on GDMT optimisation. 

 

Multiple heart failure workshops were carried out by cardiologists at the respective hospitals to educate medical officers and physicians about HF management and basic echocardiogram to improve heart failure care. 

 

Limitations

However, the healthcare system in our setting has limitations in mirroring MDT-HF clinics due to shortage of manpower. Apart from that, limited drug availability also results in lower usage of newer medications. Many studies have shown the benefits of home management programmes and home telemonitoring but it remains challenging in our setting due to geographical reasons and the limited accessibility to telecommunication networks in the rural areas.

 

Despite these challenges, a retrospective study multi-centre consisting of 10 HF clinics across Sarawak (Sarawak-HF) showed improvements in GDMT prescription and clinical outcome. The data was presented at National Heart Association of Malaysia (NHAM) Congress 2024 and AFCC 2024 (Figure 2). This is consistent with a recent study (Strong-HF) which showed an intensive strategy of rapid up-titration of guideline-directed medical therapy (GDMT) combined with close follow-up helped to reduce HF re-admissions and mortality. 

 

The success of the HF clinics is attributed to dedicated physicians serving as HF lead in their districts and guiding their team to improve HF care. Each district heart failure clinic is unique – some are bound by rivers and mountains, some are in the middle of jungle while some are located between the two halves of foreign countries. Before the road link, many districts were only accessible by boat or air. Rapid up-titration GDMT would have been near impossible if patients were required to travel for three hours by ferry and express boat. This makes the Sarawak HF demographic and its characteristics very distinct. The 10 HF clinics will continue to serve and expand in Sarawak for HF patients across varied socioeconomic backgrounds and logistical challenges.

 

The Future

Many studies reported that nursing and pharmacist-guided titration of GDMT based on a titration protocol showed improvement in HF outcomes. This will be something we look forward to exploring and implementing in the near future.