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European Journal of Heart Failure 2003 5(4):569-574; doi:10.1016/S1388-9842(03)00013-8
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© 2003 European Society of Cardiology

Heart failure in a multiethnic population in Kuala Lumpur, Malaysia

Aun-Yeong Chong, Ratna Rajaratnam, Nur-Run Hussein and Gregory Y.H. Lip*

University Department of Medicine City Hospital, Birmingham B18 7QH, UK

* Corresponding author. Tel.: +44-121-5075080; fax: +44-121-554-4083 E-mail address: g.y.h.lip{at}bham.ac.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Background: There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of congestive heart failure (CHF) in non-white populations is scarce.

Objectives: To document the prevalence of CHF in the multiracial population of Malaysia, and to describe the clinical features and management of these patients.

Setting: Busy city centre general hospital in Kuala Lumpur, Malaysia.

Results: Of 1435 acute medical admissions to Kuala Lumpur General Hospital over the 4-week study period, 97 patients (6.7%) were admitted with the primary diagnosis of CHF. Coronary artery disease was the main aetiology of CHF, accounting for almost half (49.5%) the patients, followed by hypertension (18.6%). However, there were variations in associated aetiological factors between ethnic groups, with diabetes mellitus affecting the majority of Indians—as well as underutilisation of standard drugs for CHF, such as the angiotensin converting enzyme (ACE) inhibitors, which were only used in 43.3%.

Conclusion: Amongst acute medical admissions to a single centre in Malaysia the prevalence of CHF was 6.7%. Coronary artery disease was the major aetiological factor in heart failure accounting for almost half the admissions. The under-prescription of ACE inhibitors was similar to other clinical surveys carried out amongst Caucasian populations in the West.

Key Words: Heart failure • Management • Malaysia

Received October 28, 2002; Revised December 16, 2002; Accepted January 15, 2003


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Much of the clinical epidemiology of cardiovascular disease and stroke has been based on predominantly Caucasian populations in the western world, mainly due to the availability of economic and personnel resource. There are very limited published data on non-Caucasian populations and indeed, whether treatment trials conducted in different racial groups can be generalised remains a difficult question to answer. There is also some hesitation as to whether certain trials can be repeated ethically as the evidence is conclusive albeit in some racial groups and not others.

The data on heart failure and ethnicity are limited [1]. For example, hypertension is thought to be more prevalent as an aetiological factor amongst black patients with heart failure, the prevalence of left ventricular hypertrophy was at least 42% in Afro-Caribbean patients with systolic dysfunction in one study [2]. The data in Indo-Asians are more limited. Certainly, a poor response to validated (at least in Caucasian populations) treatments such as the angiotensin converting enzyme (ACE) inhibitors is evident amongst black patients with heart failure [3].

In addition, cardiovascular risk factors differ among ethnic groups. For example, in Birmingham, United Kingdom, the prevalence of hypertension was 30.8% amongst Afro-Caribbeans, 19.4% amongst Caucasians, and 16.0% amongst Indo-Asians [4]. Amongst a Malaysian population, diabetes mellitus is least common in Chinese, followed by Malays and Indians, with associated hypertension and chronic renal failure being most common in Malay diabetics [5]. In our survey of hospital admissions with congestive heart failure (CHF) in Birmingham, UK, the commonest aetiological factors amongst the different ethnic groups were ischaemic heart disease amongst Indo-Asians and hypertension amongst Afro-Caribbeans [6].

In view of the lack of information on CHF in non-Caucasian populations, the aim of the present survey was to study the prevalence of CHF in the multiethnic population of Malaysia, and to describe the clinical features and management of these patients.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
We conducted a prospective survey of acute medical admissions to a busy city centre general hospital in Kuala Lumpur, Malaysia over a 4-week period. The Kuala Lumpur General Hospital is the main government hospital with 2502 beds, serving a 1.4 million catchment population of the city of Kuala Lumpur. It caters to a multiethnic society that comprises 59% Malays, 32% ethnic Chinese, 9% Indians and numerous indigenous peoples that make up the population of Malaysia, which totals 22.2 million. The life expectancy in Malaysia is 69.8 years for males and 74.8 years for females.

During the study period, acute admissions through the Accident and Emergency Department were screened for CHF. Subjects were included if their primary diagnosis was CHF as the cause of admission. Data on aetiology, cardiovascular risk factors, duration of hospital-stay, investigations performed, in- and out-patient management, and in-patient mortality were collected retrospectively from case records as well as in-patient interviews. Ischaemic heart disease was defined as previously documented myocardial infarction and/or angina, hypertension as a blood pressure of >140/95 mmHg (or on antihypertensive treatment), whilst diabetes and stroke were defined using standard criteria.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
There were a total of 1435 acute medical admissions through the Accident and Emergency Department over the 4-week study period. Of these, 97 patients (6.7%) (62.9% male, mean age 63.6 years) were admitted with a primary diagnosis of either newly diagnosed or decompensated CHF: 18 patients were previously known to have CHF and 79 patients were newly diagnosed with CHF. Only 4 patients had atrial fibrillation of which, 1 was Malay, 2 were Chinese and 1 was Indian. Patient characteristics are summarised in Table 1a and b.


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  		Table 1 Clinical features amongst heart failure admissions in a multiethnic population in Malaysia

 
3.1. Associated medical history
The three most common associated non-cardiac medical conditions were diabetes, asthma and chronic obstructive airways disease, which accounted for 28 (28.9%) patients, 13 patients (13.4%) and 9 patients (9.3%), respectively.

Despite the small number of patients, it appears that Indians have a higher prevalence of hypertension and diabetes as cardiovascular risk factors associated with CHF. Unsurprisingly, ischaemic heart disease was the predominant cause of CHF, accounting for 49.5% of patients from all ethnic groups. Of the CHF patients, 22.3% were smokers, whilst 45.7% were ex-smokers.

3.2. Clinical features
The main presenting complaint was dyspnoea (93.8%), followed by chest pain (55.7%) and orthopnoea (45.4%). The majority of patients admitted had NYHA II and III symptoms, accounting for 53.7% and 38.9% of the total admissions for decompensated CHF.

3.3. Investigations
All patients had a chest X-ray performed on admission. However, only 90 patients (95.7%) had an ECG, but 45 patients (47.9%) had in-patient echocardiograms and a further 30 (31.9%) had echocardiograms arranged as out-patients. No patient underwent coronary angiography or had 24 h ECG monitoring during hospital stay.

3.4. Treatment and outcomes
On admission, only 6 patients with previously documented CHF were already on an ACE inhibitor. A further 12 patients were already on an ACE inhibitor for different indications. Only 42 (43.3%) patients left hospital with an ACE inhibitor prescribed and only 2 patients were discharged on a statin, despite ischaemic heart disease being the underlying aetiology of heart failure in 49.5% (48 of 97) of patients admitted (Table 2).


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  		Table 2 Drug treatment in patients admitted with heart failure

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
It is often thought that CHF affects different ethnic groups differently and that there are discrepancies in its aetiology as well. In one study, for example, Afro-Americans had the highest hospitalisation rates whereas Latin Americans and Asians had hospitalisation rates similar, or slightly lower than that of the white Caucasian population [7]. However, this did not translate to an overall better prognosis, as whites had the highest post-hospitalisation mortality rate [7]. Another prospective study did not show a significant difference in the prevalence of CHF among older whites, African Americans and Hispanics [8], whilst one other study showed that Hispanics had the highest prevalence [9]. However, the data may not be comparable as the mean ages of the subjects in these studies were quite different. Data from both the Studies of Left Ventricular Dysfunction (SOLVD) prevention and treatment trials also suggest that blacks with mild to moderate left ventricular dysfunction had a higher risk for progression of heart failure and all-cause mortality compared to whites [10]. Data on other ethnic groups, especially within South East Asia, are glaringly deficient.

The under-prescription of ACE inhibitors in the present survey is universal but falls below some recent figures from similar surveys from the western world [11]. In the survey by McDermott et al., the rate of prescription of ACE inhibitors between 2 different intervals, i.e. 1986–1987 and 1992–1993 were 43 and 71%, respectively; however, there was a large variation in rates of prescription of ACE inhibitors, ranging from 40 to 90% [12,13]. Furthermore, the use of evidence-based management appears to decline with patient age [14]. Evidence from one comparative study on the prescription of ACE inhibitors in 1992 and 1995 shows an increasing rate of prescription but this still falls far below the 80–90% drug tolerance rate [15]. In the same study, prescription of ACE inhibitors was associated with lower age group, lower ejection fraction, lower creatinine, prescription of diuretics, non-prescription of alternate vasodilators and calcium antagonists [15]. However, elderly patients (>70 years old) with CHF have a worse prognosis and such patients often present with more advanced stages of CHF although they also more frequently have preserved systolic function (defined as ejection fraction >40%) [14].

The population in the present survey has a comparatively low mean age, and therefore, one would have expected a more prevalent use of ACE inhibitors. The high incidence of diabetes and hypertension, especially in the Indian subgroup, may predispose this particular group to renal impairment, which results in reluctance to prescribe ACE inhibitors. However, studies have shown that this particular group of patients actually benefit more from ACE inhibition compared to patients without diabetes or renal impairment [16,17]. In a retrospective analysis of the SOLVD trials, even moderate degrees of renal insufficiency was found to be an independent predictor of all-cause mortality in patients with CHF, mainly as a result of disease progression [18]. Another reason could be the high prevalence of persistent cough with ACE inhibitors in Chinese, with studies quoting a prevalence as high as 53%, compared to 18% in Caucasians [19,20] although these data were unfortunately not obtained in this study.

There are also data to suggest that the neurohormonal stimulation and pharmacological response in CHF differs depending on racial background. For instance, in the V-HeFT I and V-HeFT II (Vasodilator-Heart Failure Trial) studies, white Caucasians and blacks differed in their response to enalapril and a combination of hydralazine and isosorbide dinitrate. In whites, enalapril was superior to hydralazine and isosorbide dinitrate, and the latter was no better than placebo. In contrast, blacks showed a mortality benefit from the combination of hydralazine and isosorbide dinitrate but not enalapril [21]. In SOLVD, enalapril was associated with a reduction in blood pressure and the risk of hospitalisation for heart failure only in white, but not black, patients [22]. Racial differences in response to drugs in heart failure is, however, not universal. Data derived from the retrospective analysis of the US Carvedilol Heart Failure Study showed that there was no significant difference in the magnitude of benefit from Carvedilol between black and non-black patients with ejection fractions of less than 35% [23].

There is significant variation in polymorphism of the ACE gene in Chinese compared with Caucasians. The DD genotype frequency is low in Chinese and does not seem to be associated with ischaemic or idiopathic dilated cardiomyopathy, unlike in Caucasians [24]. Despite this variation, data from different ACE inhibitor trials show that it does not influence the pharmacokinetics of ACE inhibitors [20]. In addition, there is evidence that drug binding (e.g. propanolol) is different between Chinese and Caucasians, which may account for an increased response of certain drugs in Chinese [25–27].

In an epidemiology study performed in Hong Kong, where the population is predominantly Chinese, 85% of patients admitted to hospital with a primary diagnosis of CHF were older than 65 years, with the largest group made up of patients aged 75–84 years. There was, however, a female preponderance overall, perhaps because of the longer life span of women [28]. This was also reflected in another study where 56% of patients admitted with CHF were females, who were also comparatively older than males [29].

Indians have a significantly higher prevalence of diabetes and ischaemic heart disease compared to other ethnic groups. This is also borne out in other epidemiology studies looking at cardiovascular risk factors and acute admissions with CHF in a multiethnic population [6,30]. However, large-scale treatment trials, as well as epidemiological and outcome data in this ethnic group are limited.

Although there are some data on ethnic Chinese and Indians (South Asians) elsewhere, whether this can be generalised to the population in Malaysia is unknown. One cannot entirely ignore the effects of the environment and local culture, as well as the gene pool. For instance, despite the majority of the population in Hong Kong and Singapore being made up of ethnic Chinese, the mortality from ischaemic heart disease is approximately 3 times higher in Singapore compared to Hong Kong. Singaporeans also tend to have higher total cholesterol and LDL levels but lower HDL levels compared to Hong Kongers [31]. Certainly, a Medline search (October 2002) was devoid of data on heart failure in the Malay population. This does not mean that data is not available but simply that it is not published in Medline-cited journals.

This study is limited by the short duration and, therefore, the small study population. Small numbers from ethnic groups make it difficult to make precise statements about inter-ethnic group comparisons, although some trends may be noted. The fact that this is a hospital based study means that the data are difficult to extrapolate to the general Malaysian population because of selection bias, particularly in view of the fact that many of this population may first try traditional medicines before presenting to hospital. The present survey would suggest that a similar number of acute medical admissions with CHF are seen in the Malaysian population to western populations, which would indicate that the importance of this condition in terms of costs, patient morbidity and mortality as well as healthcare expenditure.


   Acknowledgements
 
We thank the staff of Kuala Lumpur General Hospital for assistance in conducting our survey.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

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