I am currently working as a professor in Sunway University, Malaysia. My main research interest is on Hypertension and other cardiovascular diseases. I also run the Postgraduate Diploma in Primary Care for the Elderly at Sunway aspiring to teach and equip primary care doctors with added knowledge and skills when managing older persons
Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients'... more Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients' values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia. The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers. Th...
Prevalence, awareness and control of hypertension in Malaysia from 1980-2018: A systematic review... more Prevalence, awareness and control of hypertension in Malaysia from 1980-2018: A systematic review and meta-analysis
American Journal of Physiology-Heart and Circulatory Physiology, 2021
MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifi... more MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifications. These noncoding RNAs are usually ferried by extracellular carriers such as exosomes or other protein and lipid carriers inside a range of body fluids including plasma and urine. Due to their ability to withstand harsh external conditions, exosomal miRNAs possess enormous potential as noninvasive disease biomarkers for, notably hypertension, whereby exosomal miRNAs have been implicated in its pathophysiological processes. More importantly, alterations in the microenvironment as a result of disease progression can induce active and selective loading of miRNAs into exosomes. In this paper, we first review the mechanisms of miRNA loading into exosomes, followed by the roles of exosomal miRNAs in the development of hypertension, and the potentials of exosomal miRNAs as biomarkers in comparison with other free circulating miRNAs. Finally, challenges and future research surrounding exo...
Background Information regarding the knowledge on the action to be taken during stroke and good r... more Background Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community. Methods This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms. Results Out of 4096 respondents, 82.9–92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%...
ObjectiveTo determine the salt content in instant noodles sold in Malaysia.Study designA cross-se... more ObjectiveTo determine the salt content in instant noodles sold in Malaysia.Study designA cross-sectional survey was done involving 707 different flavours and packaging of instant noodles sold in six hypermarkets and retailer chains in Malaysia and the corresponding brand’s official websites in 2017.MethodsThe salt content (gram per serving and per 100 g) was collected from the product packaging and corresponding brand’s official website.ResultsOf the 707 different packaging and flavours of instant noodles, only 62.1% (n=439) provided the salt content in their food label.The mean (±SD) salt per 100 g of instant noodles was 4.3±1.5 g and is nearly four times higher than the salt content of food classified in Malaysia as a high salt content (>1.2 g salt per 100 g). The salt content for instant noodle per packaging ranged from 0.7 to 8.5 g. 61.7% of the instant noodles exceeded the Pacific Salt Reduction Target, 11.8% exceeded the WHO recommended daily salt intake of <5.0 per day ...
Objectives: Blood pressure variability (BPV) has been shown to be an independent predictor of car... more Objectives: Blood pressure variability (BPV) has been shown to be an independent predictor of cardiovascular mortality and morbidity. BPV can vary from minute-to- minute, within a day, day-to day or on a longer term of visit to visit variability. This study aims to examine the relationship of day-to-day BPV based on home BP measurements with long term visit-to-visit clinic BPV. Methods: Adult hypertensive patients who attended a primary care clinic were recruited. Visit to visit BPV was based on BP readings of each clinic visit captured retrospectively from patient records over the past 10 years from 2007 to 2017. In 2017, patients were also instructed to do home blood pressure monitoring twice a day in the morning and evening using validated electronic blood pressure sets for a week. The first day's HBPM were discarded. Systolic BPV was measured using standard deviation (SD) and coefficient of variation was determined for both clinic and home BP separately. Results: 306 patients with hypertension were recruited. The mean age in 2017 was 67 ± 9.7 years old with 53.3% female. Mean systolic blood pressure (SBP) of all clinic visits was 141 ± 11mmHg while mean home SBP was 129 ± 14mmHg. Visit to visit SBP variability was also higher as compared to home SBP variability (15.4 ± 10.0 mmHg vs 7.7 ± 2.9 mmHg). The coefficient of variation of visit to visit SPB variability and home SBP variability was 10.8 ± 6.1 mmHg and 6.0 ± 2.2 mmHg respectively. There is significant correlation between SD and coefficient of variation of visit to visit and home SBP variability (r = 0.148 and r = 0.117, p < 0.05,respectively). Conclusion: This study shows a significant correlation between visit to visit and home SBP variability. Therefore, home BP monitoring may be used as a surrogate monitoring in lieu of long term (office) monitoring.
Objectives: Guidelines recommend that the first day's home blood pressure (HBP) be discarded ... more Objectives: Guidelines recommend that the first day's home blood pressure (HBP) be discarded and the remaining BP readings done over a week be averaged to derive the mean awake BP. However patients were not compliance due to time consuming. Hence our study to identify the difference in mean awake BP between discarding or retaining the first day's BP readings. Methods: This is a cross-sectional study done in a primary care clinic in Malaysia. A convenience sampling method was used to recruit patients. Patients were educated on how to measure HBP using a validated oscillometric BP device according to standardised procedure. Patients performed three consecutive BP measurements three times a day (morning, evening before dinner and at bedtime for seven days). We used only the first two readings at each sitting and only the morning and evening BP readings to derive the mean awake BP. Our mean awake BP was based on a total of three days of BP readings. We included the first day's HBPM (from day 1–3) and compared it to the mean awake BP when the first day's BP readings were discarded (from day 2–4). Results: A total number of 306 patients were enrolled. The mean age was 67 ± 10 years, 46.6% were males. The mean duration of hypertension was 15 ± 10 years. The mean and its mean difference of the Home Systolic BP (HSBP) and Home Diastolic BP (HDBP) were summarized in the table below. Conclusion: The mean awake HSBP and HDBP were higher when the first day's BP measurements were not discarded. This difference is statistically significant but likely not to be clinically significant. We recommend that it is perhaps of not necessary to discard the first day's measurements as it will be less time consuming and improve patients’ adherence in doing HBPM. However larger randomized studies are needed to confirm our findings.
This study aims to determine the relationship of long term visit to visit variability (VVV) of SB... more This study aims to determine the relationship of long term visit to visit variability (VVV) of SBP and cardiovascular disease (CVD) in a primary care setting. This is a retrospective study of a cohort of 1416 patients over a period of 10 years (1998-2007). Demographic data, three monthly clinic BP readings and CVD events were captured from patient records. We derived the mean BP and VVV of SBPs for each subject and divided them into three groups defined as non hypertension, developed hypertension along the 10-year follow-up and persistent hypertension. We examined differences in cardiovascular events across these groups. Mean age of the participants at baseline was 56.5 ± 10.1 years, 34.6% were males. Table 1 describes mean SBP, BPV and CVD events of the study population.Those with both low mean SBP and low BPV have the lowest CVD events, conversely those with both high mean SBP and high BPV have highest CVD events. In those patients with the same mean SBP, whether high or low, those with higher BPV have more events than those with lower BPV. However patients with low mean SBP but high BPV have more CVD events compared with those patients with high mean SBP but low BPV (p = 0.04) suggesting BPV is more important than mean SBP in causing CVD events.We used ROC of VVV SBP to identify the cut off point of 12.9 mmHg as the indicator for increase in CVD events. In our study, we found that patients with hypertension have higher BPV than normotensive subjects. Furthermore those with higher BPV also had more CVD events. As such, we should prioritize lowering not only mean systolic BP but lowering BPV as well. Long term VVV SBP should be another target in the management of patients with hypertension.
Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients'... more Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients' values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia. The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers. Th...
Prevalence, awareness and control of hypertension in Malaysia from 1980-2018: A systematic review... more Prevalence, awareness and control of hypertension in Malaysia from 1980-2018: A systematic review and meta-analysis
American Journal of Physiology-Heart and Circulatory Physiology, 2021
MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifi... more MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifications. These noncoding RNAs are usually ferried by extracellular carriers such as exosomes or other protein and lipid carriers inside a range of body fluids including plasma and urine. Due to their ability to withstand harsh external conditions, exosomal miRNAs possess enormous potential as noninvasive disease biomarkers for, notably hypertension, whereby exosomal miRNAs have been implicated in its pathophysiological processes. More importantly, alterations in the microenvironment as a result of disease progression can induce active and selective loading of miRNAs into exosomes. In this paper, we first review the mechanisms of miRNA loading into exosomes, followed by the roles of exosomal miRNAs in the development of hypertension, and the potentials of exosomal miRNAs as biomarkers in comparison with other free circulating miRNAs. Finally, challenges and future research surrounding exo...
Background Information regarding the knowledge on the action to be taken during stroke and good r... more Background Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community. Methods This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms. Results Out of 4096 respondents, 82.9–92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%...
ObjectiveTo determine the salt content in instant noodles sold in Malaysia.Study designA cross-se... more ObjectiveTo determine the salt content in instant noodles sold in Malaysia.Study designA cross-sectional survey was done involving 707 different flavours and packaging of instant noodles sold in six hypermarkets and retailer chains in Malaysia and the corresponding brand’s official websites in 2017.MethodsThe salt content (gram per serving and per 100 g) was collected from the product packaging and corresponding brand’s official website.ResultsOf the 707 different packaging and flavours of instant noodles, only 62.1% (n=439) provided the salt content in their food label.The mean (±SD) salt per 100 g of instant noodles was 4.3±1.5 g and is nearly four times higher than the salt content of food classified in Malaysia as a high salt content (>1.2 g salt per 100 g). The salt content for instant noodle per packaging ranged from 0.7 to 8.5 g. 61.7% of the instant noodles exceeded the Pacific Salt Reduction Target, 11.8% exceeded the WHO recommended daily salt intake of <5.0 per day ...
Objectives: Blood pressure variability (BPV) has been shown to be an independent predictor of car... more Objectives: Blood pressure variability (BPV) has been shown to be an independent predictor of cardiovascular mortality and morbidity. BPV can vary from minute-to- minute, within a day, day-to day or on a longer term of visit to visit variability. This study aims to examine the relationship of day-to-day BPV based on home BP measurements with long term visit-to-visit clinic BPV. Methods: Adult hypertensive patients who attended a primary care clinic were recruited. Visit to visit BPV was based on BP readings of each clinic visit captured retrospectively from patient records over the past 10 years from 2007 to 2017. In 2017, patients were also instructed to do home blood pressure monitoring twice a day in the morning and evening using validated electronic blood pressure sets for a week. The first day's HBPM were discarded. Systolic BPV was measured using standard deviation (SD) and coefficient of variation was determined for both clinic and home BP separately. Results: 306 patients with hypertension were recruited. The mean age in 2017 was 67 ± 9.7 years old with 53.3% female. Mean systolic blood pressure (SBP) of all clinic visits was 141 ± 11mmHg while mean home SBP was 129 ± 14mmHg. Visit to visit SBP variability was also higher as compared to home SBP variability (15.4 ± 10.0 mmHg vs 7.7 ± 2.9 mmHg). The coefficient of variation of visit to visit SPB variability and home SBP variability was 10.8 ± 6.1 mmHg and 6.0 ± 2.2 mmHg respectively. There is significant correlation between SD and coefficient of variation of visit to visit and home SBP variability (r = 0.148 and r = 0.117, p < 0.05,respectively). Conclusion: This study shows a significant correlation between visit to visit and home SBP variability. Therefore, home BP monitoring may be used as a surrogate monitoring in lieu of long term (office) monitoring.
Objectives: Guidelines recommend that the first day's home blood pressure (HBP) be discarded ... more Objectives: Guidelines recommend that the first day's home blood pressure (HBP) be discarded and the remaining BP readings done over a week be averaged to derive the mean awake BP. However patients were not compliance due to time consuming. Hence our study to identify the difference in mean awake BP between discarding or retaining the first day's BP readings. Methods: This is a cross-sectional study done in a primary care clinic in Malaysia. A convenience sampling method was used to recruit patients. Patients were educated on how to measure HBP using a validated oscillometric BP device according to standardised procedure. Patients performed three consecutive BP measurements three times a day (morning, evening before dinner and at bedtime for seven days). We used only the first two readings at each sitting and only the morning and evening BP readings to derive the mean awake BP. Our mean awake BP was based on a total of three days of BP readings. We included the first day's HBPM (from day 1–3) and compared it to the mean awake BP when the first day's BP readings were discarded (from day 2–4). Results: A total number of 306 patients were enrolled. The mean age was 67 ± 10 years, 46.6% were males. The mean duration of hypertension was 15 ± 10 years. The mean and its mean difference of the Home Systolic BP (HSBP) and Home Diastolic BP (HDBP) were summarized in the table below. Conclusion: The mean awake HSBP and HDBP were higher when the first day's BP measurements were not discarded. This difference is statistically significant but likely not to be clinically significant. We recommend that it is perhaps of not necessary to discard the first day's measurements as it will be less time consuming and improve patients’ adherence in doing HBPM. However larger randomized studies are needed to confirm our findings.
This study aims to determine the relationship of long term visit to visit variability (VVV) of SB... more This study aims to determine the relationship of long term visit to visit variability (VVV) of SBP and cardiovascular disease (CVD) in a primary care setting. This is a retrospective study of a cohort of 1416 patients over a period of 10 years (1998-2007). Demographic data, three monthly clinic BP readings and CVD events were captured from patient records. We derived the mean BP and VVV of SBPs for each subject and divided them into three groups defined as non hypertension, developed hypertension along the 10-year follow-up and persistent hypertension. We examined differences in cardiovascular events across these groups. Mean age of the participants at baseline was 56.5 ± 10.1 years, 34.6% were males. Table 1 describes mean SBP, BPV and CVD events of the study population.Those with both low mean SBP and low BPV have the lowest CVD events, conversely those with both high mean SBP and high BPV have highest CVD events. In those patients with the same mean SBP, whether high or low, those with higher BPV have more events than those with lower BPV. However patients with low mean SBP but high BPV have more CVD events compared with those patients with high mean SBP but low BPV (p = 0.04) suggesting BPV is more important than mean SBP in causing CVD events.We used ROC of VVV SBP to identify the cut off point of 12.9 mmHg as the indicator for increase in CVD events. In our study, we found that patients with hypertension have higher BPV than normotensive subjects. Furthermore those with higher BPV also had more CVD events. As such, we should prioritize lowering not only mean systolic BP but lowering BPV as well. Long term VVV SBP should be another target in the management of patients with hypertension.
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