Dr. Refli Hasan, SpPD, SpJP(K) Dept. Cardiology and Vascular Medicine Fac. Medicine USU / Adam Malik Hospital
Pengertian Ateosklerosis Aliran darah koroner dan Iskemi Miokard Angina Pektoris (Stabil)
Accumulation of macrophages
Blood Flow
Intraplaque thrombus
Lipid pool
Clinically Silent
Cardiovascular Death
Increasing Age
3
Cerebrovascular disease
Transient ischaemic attacks, stroke
Structure of Lipoproteins
Free cholesterol
Phospholipid
Triglyceride
Apolipoprotein
Cholesteryl ester
Classification of Lipoproteins
Based on density: Chylomicrons Very low-density lipoprotein (VLDL) Intermediate-density lipoprotein (IDL) Low-density lipoprotein (LDL) High-density lipoprotein (HDL)
LDL-Cholesterol
Strongly associated with atherosclerosis and CHD events 10% increase results in a 20% increase in CHD risk Risk associated with LDL-C is increased by other risk factors: low HDL-cholesterol smoking hypertension diabetes
Triglycerides
Associated with increased risk of CHD events Link with increased CHD risk is complex
may be related to:
low HDL levels highly atherogenic forms of LDL-cholesterol hyperinsulinaemia/insulin resistance procoagulation state hypertension abdominal obesity
May have accompanying dyslipidaemias Normal triglyceride levels <150 mg/dL Very high triglycerides (>1000 mg/dL, 11.3 mmol/L) increase pancreatitis risk
HDL-Cholesterol
HDL-cholesterol has a protective effect for risk of atherosclerosis and CHD The lower the HDL-cholesterol level, the higher the risk for atherosclerosis and CHD
low level (<40 mg/dL) increases risk
HDL-cholesterol tends to be low when triglycerides are high HDL-cholesterol is lowered by smoking, obesity and physical inactivity
Apolipoproteins
Chylomicron Chylomicron LP LP lipase lipase Skeletal Skeletal muscle muscle FFA Chylomicron Chylomicron remnant remnant Liver Liver
LPL LPL Lipoprotein Lipoprotein lipase lipase HL HL LDL LDL LDL LDL receptor receptor LPL HL IDL IDL HL LPL Hepatic Hepatic lipase lipase
Liver Liver
SRB1
CE ABCA1
FC LCAT HDL HDL3
CE CETP TG
LDL receptor
VLDL, IDL, LDL
Peripheral tissues FC TG CE LCAT CETP Free cholesterol Triglycerides Cholesterol esters Lecithin cholesterol acyl transferase Cholesteryl ester transfer protein
Lifestyle advice Aim: TC<5 mmol/L and LDL-C <3.0 mmol/L Follow-up at 5-year intervals
Measure fasting lipids, give lifestyle advice, with repeat lipids after 3 months
TC <5 mmol/L and LDL-C <3.0 mmol/L Maintain lifestyle advice with annual follow-up
TC 5 mmol/L and/or LDL-C 3 mmol/L Maintain lifestyle advice with drug therapy
Uses Framingham projections of 10-year absolute CHD risk to identify certain patients with 2 risk factors for more intensive treatment Raises persons with diabetes without CHD to the level of CHD risk equivalent Identifies persons with multiple metabolic risk factors (metabolic syndrome) as candidates for intensified TLC*
*TLC: therapeutic lifestyle changes
National Cholesterol Education Program, Adult Treatment Panel III, 2001. JAMA 2001:285;24862497
Identifies LDL-cholesterol <100 mg/dL (2.6 mmol/L) as optimal Raises categorical low HDL-cholesterol from <35 to <40 mg/dL (<0.9 to <1 mmol/L) Lowers TG cutpoints to: normal: <150 mg/dL (<1.7 mmol/L) borderline high: 150199 mg/dL (1.72.2 mmol/L) high: 200499 mg/dL (2.25.6 mmol/L) very high: 500 mg/dL (5.6 mmol/L)
National Cholesterol Education Program, Adult Treatment Panel III, 2001. JAMA 2001:285;24862497
Patients with
130 mg/dL
<130 mg/dL
100 mg/dL
<100 mg/dL
100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160 mg/dL = 4.1 mmol/L
2 risk factors
190 -
160
160 -
Target mg/dL
130
130 -
Target mg/dL
100
100 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160 mg/dL = 4.1 mmol/L
National Cholesterol Education Program, Adult Treatment Panel III, 2001. JAMA 2001:285;24862497
NCEP ATP III Guidelines Increase the Number of Patients Eligible for Treatment
Risk NCEP ATP II
8,612 19,555 1,264
Total
29,431
39,640
35
Indonesia : Thn 2001 29,7% kematian di Jawa Bali akibat peny.jantung dan p.darah
ANGINA PEKTORIS
INFARK MIOKARD
Faktor risiko adalah keadaan yang ada pada seseorang yang membuatnya lebih berisiko menderita penyakit dibandingkan dengan orang lain yang ciri-cirinya sama dengan dia tetapi tidak memiliki keadaan itu
Contoh: seorang pria perokok berusia 40 tahun mempunyai risiko terkena serangan jantung 2 kali dibanding pria seusia dia tetapi tidak merokok. Tetapi bisa saja pria perokok itu meninggal karena kecelakaan sedangkan si pria tidak perokok bisa meninggal karena serangan jantung
Cigarette smoking Hypertension: BP 140/90 mm Hg or on antihypertensive medication Low HDL-C: 40 mg/dL* Family history of premature CHD (1st-degree relative):
male relative age 55 years female relative age 65 years
Age
male 45 years female 55 years
*HDL-C 60 mg/dL is a negative risk factor and negates one other risk factor.
2001, Professional Postgraduate Services www.lipidhealth.org
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
obesity physical inactivity atherogenic diet Emerging risk factors: can help guide intensity of risk-reduction therapy; do not categorically alter LDL-C goals
lipoprotein(a) impaired fasting glucose subclinical atherosclerotic factors disease
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Efek Faktor Risiko Multipel Terhadap Kemungkinan Penyakit Jantung Koroner: Studi Framingham
42 36 30 24 18 12 6 0
10-Year % Probability of Event 40 21 10 4
+ -
14
+ + -
+ + + -
+ + + + -
+ + + + + -
+ + + + + +
MONICA JAKARTA
1988 1993 2000 ==================================================== Tot Cholesterol 250mg% pria 12.3% 14.8% 12.2%
wanita
Hipertensi wanita pria
15.8%
16.0% 13.6
17.8%
17.0% 16.5%
17.1%
12.2% 12.1%
Merokok
wanita pria
5.9% 59.0%
6.2% 56.9%
10.3% 3.6%
1.8% 38.5%
12.0% 6.2%
FAKTOR RISIKO PADA PENDERITA Infark Miokard Akut RS JANTUNG HARAPAN KITA
FAKTOR RISIKO PERSENTASE 68.0% 50.5% 31.4% 21.4% 63.1% 62.1%
usia 28-72 tahun
MEROKOK HIPERTENSI DISLIPIDEMIA RIWAYAT KELUARGA STRES TIDAK PERNAH atau KURANG OLAHRAGA
Subclinical Atherosclerosis
Primary Prevention
Low Risk
Courtesy of CD Furberg.
Iskemia miokardial : merupakan ketidak seimbangan antara suplai oksigen dan kebutuhan miokardial. Ketidaksembangan akibat :
Reduksi aliran darah koroner Suplai oksigen Sekunder akibat peningkatan tonus vaskuler, agregasi platelet,atau trombus
Kontrol neural
Faktor humoral
Fase diastolik
Frekuensi jantung
Kapasitas Membawa O2
SUPLAI
DEMAND
Angina
Merupakan rasa tidak nyaman di dada atau daerah sekitarnya disebabkan oleh iskemia miokardial Dicetuskan oleh aktivitas fisik/aktivitas atau emosional dan berkurang atau hilang dengan preparat nitrogliserin
EKG
ECG merupakan salah satu instrumen pengukuran medik tertua dalam sejarah. Alat ini bermula dari percobaan Waller di tahun 1889 yang merekam sinyal jantung pada anjing peliharaan menggunakan elektrometer kapiler [5]. Secara total, pengukuran ECG terdiri atas pengukuran gelombang depolarisasi dan gelombang repolarisasi. Gelombang radio yang digunakan memiliki intensitas atau energi yang rendah sehingga tidak membahayakan. Tahap evolusi terbesarnya terjadi di saat sistem ECG diintregasikan dengan micro processor yang hasilnya adalah peningkatan efisiensi pengukuran dan digitasi yang membuka cakrawala baru terhadap peralatan analitik dan intrepetasi data medik.
EKG
Conduction System
P Wave
P Pulmonale
P Mitrale
PR Interval
QRS Complex
ST Segment
T Wave
Normal Sinus Rhythm Rhythm : Regular Rate : 60 100 P wave : Normal in configuration; precede each QRS PR : Normal ( 0. 12 0.20 seconds ) QRS : Normal ( less than 0.12 seconds )
First-degree AV block Rhythm : Regular Rate : Usually normal P wave : Sinus P wave present; one P wave to each QRS PR : Prolonged ( greater than 0.20 seconds ) QRS : Normal
Second -degree AV block, Mobitz I Rhythm : Irregular Rate : Usually slow but can be normal P wave : Sinus P wave present; some not followed by QRS complexes PR : Progressively lengthens QRS : Normal
Second-degree AV block, Mobitz II Rhythm : Regular usually; can be irreguler if conduction ratios vary Rate : Usually slow P wave : Two, three, or four P waves before each QRS PR : PR interval of beat with QRS is constant; PR interval may be normal or prolonged QRS : Normal if block in His bundle; wide if block involves bundle branches
Third-degree AV block
Rhythm : Regular Rate : 40 60 if block in His bundle; 30 40 if block involves bundle branches P wave : Sinus P wave present; bear no relationship to QRS; can be found hidden in QRS complexes and T waves PR : Varies greatly QRS : Normal if block in His bundle; wide if block involves bundle branches
Wolff-Parkinson-White syndrome
Bentuk segmen ST :
up-sloping ( tidak spesifik ) horizontal ( lebih spesifik untuk iskemia ) down-sloping ( paling terpercaya untuk iskemia )
Perubahan gelombang T pada iskemia kurang begitu spesifik Gelombang T hiperakut kadang2 merupakan satu-satunya perubahan EKG yang terlihat
Treadmill Test
Digunakan untuk menegakkan diagnosa pasien dengan penyakit jantung koroner khususnya dan penyakit jantung pada umumnya sehingga pencegahan dapat dilakukan, kematian dapat dihindari dan harapan kualitas hidup dapat ditingkatkan. Cara noninvasif untuk mengkaji berbagai aspek fungsi jantung, dengan mengevaluasi aksi jantung selama dilakukan stress fisik, respon jantung terhadap peningkatan kebutuhan oksigen dapat ditentukan.
Membantu mendiagnosa penyebab nyeri dada, Menentukan kapasitas fungsional jantung setelah miokard infak atau pembedahan jantung, Mengkaji efektivitas terapi pengobatan antiangina dan antidisritmia, Mengidentifikasi disritmia yang terjadi selama latihan fisik, dan Membantu mengembangkan latihan fisik selama rehabilitasi.
Holter Monitor
Adalah hasil evolusi dari perkembangan klinis dan teknis yang ditujukan untuk memenuhi kepentingan mobilitas dan pengukuran. Teknologi ini mampu mengerjakan pengukuran secara kontinu dan merekamnya selama 24 jam untuk tujuan analisis terhadap pasien yang denyut jantungnya tidak normal. Dari kemampuan rekaman yang dimilikinya, penggunaan Ambulatory ECG berlanjut untuk kepentingan observasi PVC (Premature Ventricular Complexes) dan pengobatannya. Saat ini terdapat banyak sekali unit Ambulatory ECG sebagai alat diagnosis yang dilengkapi micro processor, RAM, dan disk drive dengan kapasitas sampai 400 Mbytes.
Utk evaluasi fungsi jantung dengan radionuklir angiografi dan ekuilibrium radionuklid ventrikulografi
Gated blood pool study First pass study at rest Exercise first pass study
Coronary Angiography
Color-coded Doppler ultrasound of the popliteal cavity: the red flow towards the probe codes the artery, the blue flow away from the probe codes the vein
Doppler Ultrasound
ABI =
Oscillography
Above knee Below knee
Oscillations
Normal
Abnormal
Oscillography
Oscillations at the ankle
Normal
before After exercise
Abnormal
I.
Angina Stabil Angina Tidak stabil Infark Miokard Akut Gagal Jantung
Kematian
Tujuan manajemen : mengurangi simtom /gejala/keluhan angina dan iskemia berulang (kualitatif) mencegah infark miokard akut dan kematian (mengurangi morbiditas dan mortalitas )
Manajemen farmakologis
Antiplatelet (Aspirin, Klopidogrel, Glikoprotein IIb/IIIa, Adenosine Diphosphate Inhibitors) Antiangina (Beta bloker, Ca antagonis, Nitrat) ACE Inhibitor Penurun Kolesterol (statin)
aspirin - Class I
Aspirin 75 to 325 mg daily should be used routinely in all patients with acute and chronic ischemic heart disease with or without manifest symptoms in the absence of contraindications aspirin exerts an antithrombotic effect by inhibiting cyclooxygenase and synthesis of platelet thromboxane A2 in >3,000 patients with stable angina, aspirin reduced the risk of adverse cardiovascular events by 33% in patients with unstable angina, aspirin decreases the short and long-term risk of fatal and nonfatal MI in the Physicians' Health Study, aspirin (325 mg), given on alternate days to asymptomatic persons, was associated with a decreased incidence of MI
ACC/AHA Guideline of Chronic Stable Angina 2001
Clopidogrel
Platelet
ADP
Fibrinogen Binding Site
Fibrinogen
Fibrinogen Binding Reduced Acts by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platelet aggregation
ADP secreted by platelets (activates/aggregates platelets) P2T cell surface receptors Ticlid (ticlodipine) versus ASA Plavix (clopidogrel) CAPRIE trial Neutropenia, thrombocytopenia
50,000 receptors per platelet Aggregation final common pathway Passivation; stops deposition Abciximab (Reopro); tirofiban (Aggrastat); eptifibatide (Integrilin) and lamifiban (Canada) Pre-PCI/ Procedural Coronary Intervention
BETA-BLOCKERS
Mechanism of Action
reduction in inotropic state and sinus rate
slowing of AV conduction
decreased myocardial oxygen demand, increased diastolic perfusion time
Clinical Effectiveness
improve the survival rate of patients with recent MI improve the survival rate and prevent stroke and CHF in patients with hypertension adjust the dose of -blockers to reduce heart rate at rest to 55 to 60 bpm increase in heart rate during exercise should not exceed 75% of the heart rate response associated with onset of ischemia
Calcium Antagonists
Mechanisms of Action
reduce the transmembrane calcium transport (L-, T-, or N-type channels) alter myocardial oxygen supply and demand
dilate epicardial coronary arteries reduce cardiac contractility
nifedipine >> amlodipine and felodipine verapamil and diltiazem (heart rate-modulating calcium antagonists) can slow the sinus node and reduce AV conduction
PREPARAT NITRAT
Nitrat sublingual atau spray diberikan untuk mengurangi keluhan angina dengan cepat Nitrat jangka panjang dan Ca antagonis diberikan sbg terapi awal apabila terdapat kontraindikasi Beta bloker Nitrat jangka panjang dan Ca antagonis diberikan bila terapi dng Beta bloker tidak berhasil Nitrat jangka panjang dan Ca antagonis bila Beta bloker memberikan efek samping yang tidak diinginkan
ACC/AHA Guideline of Chronic Stable Angina 2001
ACE INHIBITOR
Kelas I : pasien CAD yang juga menderita DM dan atau penurunan fungsi ventrikel kiri
Tangani Hipertensi Stop merokok Atasi diabetes Program rehabilitasi yang komprehensif Penurunan kadar LDL pada suspect CAD atau penderita CAD dengan kadar LDL > 130 mg/dl ,dng target <100mg/dl Penurunan berat badan pada penderita obesitas
Primary PCI, refractory post infarct symptom, treatment complication (VSD ruptured). refractory symptom, high risk clinical features high risk clinical symptoms
Stable angina
Severe Asymptomatic ischemia Valvular heart diseases Congenital heart diseases Unexplained heart failure, Malignant Arhythmias or resuscitated cardiac arrest Cardiomyopathy
Cerebrovascular accident Arrhythmias Vasclar complication Contrast reaction Hemodynamic complication Perforation of heart chamber Other complication
Equipment
Equipment
Catheters
AVG
VCSL
VCI
Hemodynamic & EKG data of Pt with AS as seen on the TV monitor in Oxygen Saturation measurement In Patients with VSD, RV O2 step up
Modified Seldingers technique for percutaneous catheter sheath introduction Left heart Cathetherization
Transseptal
Qp
Qs
QP
Cardiac Output =
O2 comsumption (ml/min)
AVO2 differences (ml O2/100ml blood) x 10
AVO2 = O2 content =
K (4.33) x C x MVG
CO (ml/min) Diastolic filling period (sec/min)
= Diastolic period (sec/beat) x HR CO (ml/min) Systolic ejection period (sec/min) Systolic ejection period (sec/beat) x HR
= =
C = Emperical Constant (1=semilunar valve), (0.85=mitral valve) MVG = Mitral valve gradient
++
Aortic regurgitation
+++
+++ +
Mitral regurgitation
Coronary Angiography
Anterior View
LAO View
RAO view
Pre-Dilatation
Dilatation
Post-Dilatation
Post- Stenting
Early indications Angina Pectoris, myocardial ischemia In : Relatively stable Patients Good LV function Simple Stenotic Lesion 1 VD, proximal Dicrete, Concentric, nonCalsified
Advance in Techical, equipment & medications : enable to performed PCI in more complicated setting
APTS Acute Coronary Syndrome Poor LV function Elderly Post CABG Complicated Lesion ; bifurcatio, calcified
Restenosis
PTCA
Treatment
Coronary stenting
Intimal area Lumen
Stent
Angioplasti /PCI
Keberhasilan Primer : 85 - 95 % Kematian : 0.3 - 1.3 % Infark Miokard : 1.6 - 6.3 % Operasi By-pass darurat :1 - 7 % Stenosis lebih lanjut
sblm era stent: 30 - 40 % era stent : 15-20% Drug eluting stent : almost 0%
PTCA
Benefits: ICH 0%, Complications: experience counts >100 cases/yr/ea provider; >600/yr/hospital Mortality: reinfarction 5 vs 12% for TPA; 30 day same as TPA; but in AWMI; age>70 pulse >100 rates 2% vs 10% for TPA Trials: RITA, PAMI (93); MITI (96)
Platelet
GP IIb/IIIa inhibitor
Balloon
Antiplatelet Rx
Stent
DES
Thank you