Penyakit Jantung Didapat

Idrus Alwi
Divisi Kardiologi
Departemen Penyakit Dalam FKUI-RSCM
Content

Cardinal Symptoms

pidemiology

Spesi!i" Diseases

CAD/Penyakit Jantung Koroner

Hypertension and Hypertensive Heart

Disease(Penyakit Jantung Hipertensi)

Rheumatic Fever (Demam Rematik)# R$D%dan

Penyakit &antung Rematik %Katup'

Penyakit &antung (iroid

Penyakit &antung Paru

Penyakit )askular Peri!er

ndokarditis# Miokarditis# Perikarditis# Kardiomiopati

Disritmia

Aneurisma Aorta
MMP

Sakit dada %"*est dis"om!ort'

Sesak na!as %+reat*lessness'

,erde+ar-de+ar %palpitasi'

Pingsan %di--y#+la"k out.syn"ope'

,engkak %edema'

Cepat "apek %!ati/ue'

MMP
World Health Report 1997. World Health Report 1997.
Cardiovascular Disease:
A Worldwide Epidemic

Cir"ulatory diseases are t*e num+er 0 "ause

o! deat* worldwide

01 million deat*s# or 234 o! annual total

CAD a""ounted !or 567 million deat*s worldwide in

0889

0:4 o! glo+al total deat*s

;ne t*ird o! deat*s in industriali-ed "ountries

Cere+rovas"ular disease a""ounted !or :69 million

deat*s

$ypertension o""urs in 983 million people

worldwide

Developing "ountries< pro=e"ted 7>4 in"rease in

"ardiovas"ular deat*s
Gloal !urden o" Cardiovascular
Gloal !urden o" Cardiovascular
Disease
Disease
!n "##"$

C%D contri&uted to appro'imate(y a third o) a((

g(o&a( deaths (*+ mi((ion)

,#- o) &urden is in (o. and midd(e/income

countries
0y "#"#$

CHD and stroke .i(( &ecome the (eading cause o)

death and disa&i(ity .or(d.ide

1orta(ity )rom C%D .i(( increase to "# mi((ion

C(inica( care o) C%D is cost(y and pro(onged
International Cardiovascular Disease Statistics 2005; AHA.
PJ di #ndonesia $%&'

2343- (!HD)PJ!

*+45- RHD(PJR)

*246- Heart Dis o)

Hypertension(PJH)

03654 Cong
$D%P&,'

5604Pulm $D% P&P'

0> per 0333

penduduk

;t*ers

ndokarditis(Right
HD and Drug
A&use)

Kardiomiopatia
Boedi Darmojo et al,1978
Buku Laporan Seminar Kardiologi Sosial,hal 5!,"K#$,%akarta,%anuari 1987
Violence
Self-inflicted injuries
Stroke
Road traffic accidents
Tuberculosis
Coronary heart disease
HIV/Aids
227
!"#" years
Coronary heart disease
Stroke
$iabetes
Hy%ertensi&e heart disease
Trachea' bronchus' lun( cancers
)o*e res%iratory infections
Chronic obstructi&e %ul+onary disease
7,"
7"-
2.
!,/
2,
-/.
".2"
0/1 years
2o of deaths
3thousands4
Deat(s "rom Coronary )eart
Deat(s "rom Coronary )eart
Disease Compared wit( *t(er
Disease Compared wit( *t(er
Causes +,--,.
Causes +,--,.
WHO Cardiovascular Atlas 2002
-7,
/72
7.,
.!-
!1,/
!,,2
227
Categories o" /isk
0actors

Ma=or# independent risk !a"tors

?i!e-*a+it risk !a"tors

merging risk !a"tors

1a2or /isk 0actors +E3clusive o"
4D4
C(olesterol. 5(at 1odi"y 4D4 Goals

Cigarette smoking

$ypertension %,P 0:3.83 mm$g or on

anti*ypertensive medi"ation'

?ow $D? "*olesterol %@:3 mg.d?'

A

Family *istory o! premature C$D

C$D in male !irst degree relative @11 years

C$D in !emale !irst degree relative @91 years

Age %men :1 yearsB women 11 years'

&
'DL (holesterol !) mg*dL (ounts as a +negati,e- risk
.a(tor/ its presen(e remo,es one risk .a(tor .rom the total
(ount0
4i"e6)ait /isk 0actors

;+esity %,MI 23'

P*ysi"al ina"tivity

At*erogeni" diet
The future?
The future?
Emerging /isk 0actors

?ipoprotein %a'

$omo"ysteine

Prot*rom+oti" !a"tors

Proin!lammatory !a"tors

Impaired !asting glu"ose

Su+"lini"al at*eros"lerosis
/isk Assessment
Count ma7or risk )actors

For patients wit* multiple %7C' risk !a"tors

Per!orm 03-year risk assessment

For patients wit* 3D0 risk !a"tor

03 year risk assessment not re/uired

Most patients *ave 03-year risk @034

5dds ratio adj for a(e' se6' s+oke
Yusuf S, et al. Lancet. 200;!"#$!%&'$!()52
#75E/)EA/5
#75E/)EA/5
: /isk o" A1#
: /isk o" A1#
Associated wit( /isk
Associated wit( /isk
0actors
0actors
1a2or 1ani"estations o" Vascular
Disease and At(erot(romotic Events
Cerebral
$s(hemi( stroke
1ransient is(hemi( atta(k 21$34
5as(ular dementia
Cardiac
M$
3ngina pe(toris 2sta6le, unsta6le4
Peripheral arterial disease (PAD)
7laudi(ation, (riti(al lim6 is(hemia
C)D6/isk
in
/elation
to )D46C
and 4D46C
Coronary heart disease (n 8 ",#)
Position in mode( %aria&(e P va(ue
*
st
9D9/C :#4###*
"
nd
HD9/C #4###*
6
rd
Hemog(o&in A
*c
#4##""
2
th
;ysto(ic 0P #4##3<
<
th
;moking #4#<3
'
D
L

7
1))
2,58
1!)
4,13
88)
5,68
),)
1,)
8,)
9,)
85
:5
!5
85
7'D;isk
LDL7
The
The
7ra+in(ha+
7ra+in(ha+
Heart Study
Heart Study
89:$S
89:$S
23dapted .rom 5ers(huren et al, 19954
95
9)
85
8)
15
1)
5
)
D
e
a
t
h

r
a
t
e

f
r
o
m

C
H
D
/
1
0
0
0

m
e
n
80!) 9085 909) :05) 5015 508) !0:5 701) 7075 80:) 90)5
Serum total cholesterol (mmol/L)
Northern urope
!nited States
Southern urope" inland
Southern urope" #editerranean
$apan
Serbia
%elationship of serum cholesterol
to mortalit&
(Se'en Countries Stud&)
1ultiple Studies S(owed a /elations(ip
!etween 4D46C /eduction 8 C)D /elative
/isk
M$ < m=o(ardial in.ar(tion0
;o6inson %> et al0 J Am Coll Cardiol. 8))5/:!?1855@18!80
1( )0 )( *0 *( +0
,)0
0
)0
+0
-0
.0
100
LDL/C reduction" 0
N
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n
f
a
t
a
l

#
1

a
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0
+S CA%DS
P3SCH ASC34/LLA
NHL51 P%3SP%
L%C AL%4
!p6ohn HPS
Los An7eles A8/4e9CAPS
#%C L1P1D
3slo CA%
London :3SC3PS
3dapted .rom Pepine 7%0 Am J Cardiol. 8))1/882suppl4?5K9K0
Me(hanisme and progression o. 75D
;isk .a(tors
ABidati,e stress
"un(tional alterations
3theros(lerosis
Clinical se;uelae
Age, gender, smoking,
inactivity, obesity,
cholesterol, BP, glucose
>eneti( .a(tors
Cndothelial .un(tion
CP7s
CP7s < endothelial progenitor (ells
The Progression from CV Risk Factors to
The Progression from CV Risk Factors to
Endothelial Injury and Clinical Events
Endothelial Injury and Clinical Events
Risk factors
56idati&e stress
;ndothelial dysfunction
25 )ocal +ediators Tissue AC;-An( II
:AI-! VCA<
ICA< cytokines
;ndotheliu+ =ro*th factors
+atri6
:roteolysis
)$)-C
>: Heart failure S+okin( $iabetes
Vasoconstriction
Vascular lesion
and re+odellin(
:la?ue ru%ture Infla++ation Thro+bosis
Clinical end%oints
25 2itric o6ide
*i++ons *H, D,au -.. N Engl J Med /$$;,,1;/!/0/!%.
$9Coronary Artery Disease
+Synonim.

Is"*emi" $eart Disease

At*eros"leroti" $eart Disease

Coronary Artery Disease

Indonesia E Penyakit &antung Koroner

Ctiolog= o. 73D
1ost Common

;+stru"tive Coronary artery disease%CAD'

!rom At*eros"lerosisA;HDischemia
8 !HD
=ther causes

Coronary Arteritis %S?#R* Art*ritis66'

Si!ilisarteritis o! Ao

Congenital
MM
P
1ulti 0actorial/isk
0actor o" At(erosclerosis
A4 >n/modi)ied RF
Age%PF:1BGF11'#SeH#Fam *istory%Keluarga
langsung P&K%P@11#G@91'
04 1odi)ied RF
;moking?D1@CAD?9ipid(HD9?9D9?AB)?01!C6
#kg/m"?9ack o) e'cercise?0P C*2#/5# mmHg
(=n 0P treatment)
C6merging RF
?p%a'#$omosistein#Prot*rom+oti"
Fa"tor#Proin!lammatory !a"tor#IFI6
MMP
8oam 8oam
Cells Cells
8att& 8att&
Strea2 Strea2
1ntermediate 1ntermediate
Lesion Lesion
Atheroma Atheroma
8ibrous 8ibrous
Pla;ue Pla;ue
Complicated Complicated
Lesion/%upture Lesion/%upture
ndothelial d&sfunction
Smooth muscle
and collagen
8rom first decade 8rom first decade 8rom third decade 8rom third decade 8rom fourth decade 8rom fourth decade
<ro=th mainl& b& lipid accumulation
Thrombosis,
haematoma
Adapted from Star& HC et al> Circulation 1??(@?)A1*((/1*B+>
At(erosclerosis 5imeline
MMP
Dislipidemia 66666
At(erosclerosis 66666 CVD
A Progressive Disease
7;P<7rea(ti,e protein/ LDL7<loDdensit= lipoprotein (holesterol0
Li66= P0 Circulatio. 8))1/1):?9!5978/ ;oss ;0 ! "#l J $ed. 1999/9:)?11518!0
#onoc&te
LDL/C
Adhesion
molecule
#acropha7e
8oam cell
39idiCed
LDL/C
Pla;ue rupture
Smooth muscle
cells
C%P
Pla;ue instabilit&
and thrombus
39idation 1nflammation
ndothelial
d&sfunction
Li++1 2. Circulation /$$5;!'2%)2%50.
5(e Synt(esis and
!reakdown o" At(eromatous
Pla:ues
At(erot(romosis: 5(romus
Superimposed on At(erosclerotic
Pla:ue
Adapted %rom "alk C, et al0 Circulatio. 1995/98?!57!710
4hic2" DS#C/rich
fibrous cap
1he Sta6le 3theros(leroti(
PlaEue Sta6le 3P
MMP
4hrombus 4hrombus
8e= 8e=
S#Cs S#Cs
MMP
Pla:ue rupture leading to
t(romotic occlusion +A.
1ani"estation o" CAD

AsymptomaticDch*?2<DPrimary
Prevent

;ta&(e Angina Pectoris (Chronic

CAD)ch<2

STEMI = total oclusion (ch 50,51)

UAP and NSTEMI = partial occlusion

(ch53)

Suddn !ath (ch3")

Arr#th$ias (ch31,3%)

$eart Failure %A"ute or C*roni"

Congestion'
MMP
Pat(ology 8 ECG
MMP
Diagnosis o" Acute 1#
S5E1# ; 7S5E1#

At least 7 o! t*e
!ollowing

Is"*emi" symptoms

Diagnosti" CI
"*anges

Serum "ardia"
marker elevations
Diagnosis o" Angina

(ypi"al anginaJAll t*ree o! t*e !ollowing

Su+sternal "*est dis"om!ort

;nset wit* eHertion or emotional stress

Relie! wit* rest or nitrogly"erin

Atypi"al angina

7 o! t*e a+ove "riteria

Kon"ardia" "*est pain

0 o! t*e a+ove
Diagnosis o" <nstale
Angina

Patients wit* typi"al angina - An episode o!

angina

In"reased in severity or duration

$as onset at rest or at a low level o! eHertion

Unrelieved +y t*e amount o! nitrogly"erin or rest

t*at *ad previously relieved t*e pain

Patients not known to *ave typi"al angina

First episode wit* usual a"tivity or at rest wit*in

t*e previous two weeks

Prolonged pain at rest

Acute 1anagement

Initial evaluation L
sta+ili-ation

!!i"ient risk
strati!i"ation

Fo"used "ardia"
"are
Evaluation

!!i"ient L dire"t *istory

Initiate sta+ili-ation interventions

Plan !or moving rapidly to
indi"ated "ardia" "are
4ime is muscle
A((urs A((urs
simultaneousl= simultaneousl=
C(est pain suggestive o"
isc(emia

07 lead CI

;+tain initial
"ardia"
en-ymes

ele"trolytes#
"+" lipids#
+un."r# glu"ose#
"oags

CMR
$mmediate assessment Dithin 1) Minutes

Csta6lish
Csta6lish
diagnosis
diagnosis

;ead C7>
;ead C7>

$denti.=
$denti.=
(ompli(atio
(ompli(atio
ns
ns

3ssess .or
3ssess .or
reper.usion
reper.usion
$nitial la6s
$nitial la6s
and tests
and tests
Cmergent
Cmergent
(are
(are
'istor= F
'istor= F
Ph=si(al
Ph=si(al

$5 a((ess
$5 a((ess

7ardia(
7ardia(
monitoring
monitoring

AB=gen
AB=gen

3spirin
3spirin

Gitrates
Gitrates
0ocused )istory

Aid in diagnosis and

rule out ot*er "auses

Palliative.Provo"ative
!a"tors

Nuality o! dis"om!ort

Radiation

Symptoms asso"iated
wit* dis"om!ort

Cardia" risk !a"tors

Past medi"al *istory

-espe"ially "ardia"

Reper!usion
/uestions

(iming o!
presentation

CI ".w S(MI

Contraindi"ation to
!i+rinolysis

Degree o! S(MI risk

5argeted P(ysical

Re"ogni-e !a"tors t*at

in"rease risk

$ypotension

(a"*y"ardia

Pulmonary rales# &)D#

pulmonary edema#

Kew murmurs.*eart
sounds

Diminis*ed perip*eral
pulses

Signs o! stroke

Hamination

)itals

Cardiovas"ular
system

Respiratory
system

A+domen

Keurologi"al
status
ECG assessment
S1 Cle,ation or neD LBBB
S1 Cle,ation or neD LBBB
S1CM$
S1CM$
Gonspe(i.i( C7>
Gonspe(i.i( C7>
#nsta6le 3ngina
#nsta6le 3ngina
S1 Depression or d=nami(
S1 Depression or d=nami(
1 Da,e in,ersions
1 Da,e in,ersions
GS1CM$
GS1CM$
7ormal or non6diagnostic
E=G
S5 Depression or Dynamic 5
wave #nversions
S56Segment Elevation 1#
Definition and at13ical features of
an4ina 3ectoris 3ain
%eferred Pain
MMP
Angina >E:uivalent?

Dyspnea

&aw and Ke"k dis"om!ort

S*oulder# el+ow.arm dis"om!ort%le!t'

pigastri" dis"om!ort

,a"k %inters"apular' dis"om!ort

MMP
Canadian Cardiovascular
Society 0unctional
Class+CCS.

I6;rdinary p*ysi"al a"tivity does not "ause

angina

II6Slig*t limitation o! ordinary a"tivity

III6Marked limitation o! ordinary p*ysi"al

a"tivity

I)6Ina+ility to per!orm any p*ysi"al a"tivity

wit*out dis"om!ort6Angina may +e present
at rest6
MMP
Cor Angiograp(y
MMP
Patogenesis AP Stail
Resistensi
Vaskular
Coronary
Flow
suplai
HR
Kontrraktility
Wall stress
Demand
iskemia
Oxygen
carrying
capacity
MMP
5reatment

Redu"e symptoms %Anti-angina'

Prevent deat* and MI

MMP
Emergency in CAD:
Acute Coronary Syndrome

UAP

KS(MI

S(MI

C) mergen"yInitial (reatmentRe!er

G*y<Unpredi"ta+leSudden Deat*
MMP
Guidelines

ACC guideline 733>

SC guideline 733>
MMP
CV Prevention

Premordia( Prevention

redu"tion o! risk !a"tor levels in a population

Primary Prevention

Primary prevention involves redu"ing t*e

in"iden"e o! disease in t*ose at *ig* risk o!
developing it# in ot*er words# people wit*
signi!i"ant risk !a"tors

;econdary Prevention

involves preventing re"urrent disease in people

w*o already *ave t*e disease
Pais Prem> Pre'entin7 ishaemic heart disease in de'elopin7 countries> 'idence/based Cardio'ascular #edicine
5olume 1), $ssue 8 2%une 8))!4 7op=right H 8))! 7hur(hill Li,ingstone, $n(0
MMP
/isk 0actor and
#ntervention
MMP
Prediction@@5otal CV
/isk

Framing*am Risk S"ore

,ritis* $ypertension Si"iety

SC.S$

G$;.IS$ L &KC )II

Kriteria Met Syndrome

http?**hp8)1)0nhl6ihin0net*atpiii*(al(ulator0aspIusert=pe<pro.
3ge? 58
>ender? male
1otal 7holesterol? 88) mg*dL
'DL 7holesterol? :8 mg*dL
Smoker? Go
S=stoli( Blood Pressure? 18) mm*'g
An medi(ation .or 'BP? Go
%is2 Score resultsE 1)J
0raming(am /isk Score
Clinical #denti"ication o" 1et6
Synd
7CEP6A5P ###A,--$
+1odi"ied Asia @Paci"ic ,---.
Gaist "ir"
FM<83"mBFF>3"m

(IF013mg.dl

$D? M@:3#F@13mg.dl

,PF023.>1mm$g

F,IF003mg.dl

---MSE---F.2RF

A(P III
M F037"mBFF>>"m

ADA<F,I 033-071
7$r;I(( 0:3-733
,9)ypertension
De"inition

5<- Primary E ssential $ypertensionB t*e

"ause is not identi!i+le

<- ;econdary Hypertension 8

identi)ia&(e

At t*e organ-system level# *ypertension "an

result !rom a gain in !un"tion o! pat*ways t*at
promote vaso"onstri"tion and renal retention
o! salt and water and.or a loss in !un"tion o!
pat*ways t*at promote vasodilatation and
renal eH"retion o! salt and water
)ypertensionA coronary (eart
disease
and stroke
%
e
l
a
t
i
'
e

r
i
s
2

o
f

C
H
D

o
r

s
t
r
o
2
e
+>00
)>00
1>00
0>(0
0>)(
B- .+ ?1 ?. 10(
Appro9imate mean usual diastolic blood pressure (mmH7)
Stro2e
CHD
#ac#ahon S et al. Lancet 1??0@ **(A B-(,
BB+
MMP
G*A4 : CA/D#*VASC<4A/ /#S=
S5/A5#0#CA5#*7

%0' +lood pressure level#

%7' "omor+idity#%Asso"iate Condition' and

%2' target organ damage

MMP
ES)6ESC ,--& 8 J7C
V##
ESH-ESC
BP Classification
BP BP !C V""
Bp Classification
#ptimal $%&' ( $)' $%&'($)' !ormal
!ormal %&'-%&* ( )'-)+ %&'-%&* ()'-)+ Pre,ypertension
Hi-, normal %.'-%.* ( )/-)* %.'-%.* ( )/-)* Pre,ypertension
0rade % Hypertension
1mild2
%+'-%/* ( *'-** %+'-%/* ( *'-** Sta-e %
Hypertension
0rade & Hypertension
1moderate2
%3'-%4* (%''-%'*
5%3' ( 5%''
Sta-e &
Hypertension
0rade . Hypertension
1se6ere2
5 %)' ( 5%%'
"solated Systolic
Hypertension
"solated Systolic
Hypertension
F 1+0 G ?0
G*A4 B: #DE75#0#CA5#*7 *0 SEC*7DA/C
+#DE75#0#A!4E. CA<SES *0 )CPE/5E7S#*7
S7SPEC8ED D"90!#S"S S7SPEC8ED D"90!#S"S C:"!"C9: FE987RES C:"!"C9: FE987RES D"90!#S8"C 8ES8"!0 D"90!#S8"C 8ES8"!0
Renal Renal
parenc,ymal parenc,ymal
,ypertension ,ypertension
Ele6ated serum creatinine or a;normal Ele6ated serum creatinine or a;normal
urinalysis urinalysis
24-Hour urine creatinine and protein, renal ultrasound 24-Hour urine creatinine and protein, renal ultrasound
Reno6ascular Reno6ascular
disease disease
!ew ele6ation in serum creatinine< marked !ew ele6ation in serum creatinine< marked
ele6ation in serum creatinine wit, initiation of ele6ation in serum creatinine wit, initiation of
9CE" or 9RB< refractory ,ypertension< flas, 9CE" or 9RB< refractory ,ypertension< flas,
pulmonary edema< a;dominal ;ruit pulmonary edema< a;dominal ;ruit
Captopril Captopril renogram, duplex Doppler sonography, magnetic renogram, duplex Doppler sonography, magnetic
resonance or CT angiogram, invasive angiogram resonance or CT angiogram, invasive angiogram
Coarctation of t,e Coarctation of t,e
aorta aorta
9rm pulses 5le- pulses< arm BP 5le- BP< c,est 9rm pulses 5le- pulses< arm BP 5le- BP< c,est
;ruits< ri; notc,in- on c,est radio-rap, ;ruits< ri; notc,in- on c,est radio-rap,
MRI, aortogram MRI, aortogram
Primary Primary
aldosteronism aldosteronism
Hypokalemia< refractory ,ypertension Hypokalemia< refractory ,ypertension
lasma renin and aldosterone, 24-hour urine potassium, 24-hour lasma renin and aldosterone, 24-hour urine potassium, 24-hour
urine aldosterone and potassium a!ter salt loading, adrenal CT urine aldosterone and potassium a!ter salt loading, adrenal CT
scan scan
Cus,in-=s Cus,in-=s
syndrome syndrome
8runcal o;esity< purple striae< muscle 8runcal o;esity< purple striae< muscle
weakness weakness
lasma cortisol, urine cortisol a!ter lasma cortisol, urine cortisol a!ter dexamethasone dexamethasone , adrenal , adrenal
CT scan CT scan
P,eoc,romocyto P,eoc,romocyto
ma ma
Spells of tac,ycardia< ,eadac,e< diap,oresis< Spells of tac,ycardia< ,eadac,e< diap,oresis<
pallor< and an>iety pallor< and an>iety
lasma metanephrine and normetanephrine, 24-hour urine lasma metanephrine and normetanephrine, 24-hour urine
catechols, adrenal CT scan catechols, adrenal CT scan
#;structi6e sleep #;structi6e sleep
apnea apnea
:oud snorin-< daytime somnolence< o;esity :oud snorin-< daytime somnolence< o;esity
"leep study "leep study
37C$ < angiotensin(on,erting enK=me inhi6itor/ 3;B < angiotensin re(eptor 6lo(ker/ BP < 6lood
pressure/ 71 < (omputed tomograph=0
Modi.ied .rom Kaplan GM? 7lini(al '=pertension, 8th ed0 Philadelphia, Lilliams F Lilkins, 8))80
Prevention 85reatment o"
)ypertension

?IFS(O? M;DIFICA(I;KS

P$ARMAC;?;IIC ($RAPO
)ypertensive Emergency

&#prtnsi' $r(ncis are acute#

severe e(evations in &(ood pressure that
are accompanied &y progressive target
organ dys)unction such as myocardia( or
cere&ra( ischemia/in)arction? pu(monary
edema? or rena( )ai(ure4

&#prtnsi' ur(ncis are acute? severe

e(evations in &(ood pressure .ithout
evidence o) progressive target organ
dys)unction
H4N
Smo2in7 Smo2in7
D&slipidemia D&slipidemia
3besit& 3besit&
Diabetes Diabetes
Normal LD Normal LD
structure structure
and function and function
LD LD
remodelin7 remodelin7
Subclinical Subclinical
LD LD
d&sfunction d&sfunction
Clinical Clinical
H8 H8
Hears / Hears / #onths #onths
Hears Hears
#1
LDH
H8
S&stolic
d&sfunction
Diastolic
d&sfunction
Adapted from Levy et al. JAMA !!"#$%&'&&% Adapted from Levy et al. JAMA !!"#$%&'&&%
Pro-ression of H8! to HF Pro-ression of H8! to HF
Pro-ression of H8! to HF
MMP
5(e Cardiovascular
Continuum
3dapted .rom DKau 5, BraunDald C0 Am Heart J0 1991/181?18::18!90
%is2 factors
Dia6etes, h=pertension
Atherosclerosis
and LDH
#&ocardial
infarction
%emodelin7
Dentricular
dilation
Heart failure
nd/sta7e
heart disease
Death
!ene"it o" 4owering !P
Average Percent Reduction
Stroke incidence 3540%
Myocardial infarction 2025%
Heart failure 50%
MMP
J7C V##: 1anagement o"
)ypertension y !lood Pressure
Classi"ication
37C$ < angiotensin(on,erting enK=me inhi6itor/ 3;B < angiotensinre(eptor 6lo(ker/ BB < 6eta
6lo(ker/ 77B < (al(ium (hannel 6lo(ker0
7ho6anian 35 et al0 7ho6anian 35 et al0 JA$A. JA$A. 8))9/889?85!)85780 8))9/889?85!)85780
Drug2s4 .or the (ompelling
indi(ations/ other
antih=pertensi,e drugs
2diureti(s, 37C$, 3;B,
BB, 77B4 as needed
Drug2s4 .or the (ompelling
indi(ations/ other
antih=pertensi,e drugs
2diureti(s, 37C$, 3;B,
BB, 77B4 as needed
5P Classification
Lifest&le
#odification
1nitial Dru7 4herap&
:ithout Compellin7
1ndication
:ith Compellin7
1ndication
Normal
M18)*8) mm 'g
Preh&pertension
1)0/1*?/.0/.? mm H7
Sta7e 1 h&pertension
1:)159*9)99 mm 'g
Sta7e ) h&pertension
N1!)*1)) mm 'g
Cn(ourage
Hes
Oes
Oes
No dru7 indicated Dru7(s) for the
compellin7 indications
1hiaKidet=pe diureti(s
.or most/ ma= (onsider
37C$, 3;B, BB, 77B, or
(om6ination

8drug (om6ination .or most
2usuall= thiaKidet=pe diureti(
and 37C$, 3;B, BB, or
77B4
513e 2 Dia+etes CHD 67uivalent
,@Ahy $iabetes
is so I+%ortantB
MMP
At(erosclerosis #s Common
in 7ewly Diagnosed Diaetes
1ellitus

Cardiovas"ular diseases< "ommon "auses o!

mor+idity L mortality in dia+eti"s

C<#- o) newly diagnosed type " dia&etics

sho. evidence o) cardiovascu(ar disease

At*eros"lerosis<
ma7or cause o) death among dia&etics
+<- )rom coronary atherosc(erosis
"<- )rom cere&ra( / periphera( vascu(ar disease

C+<- o) hospita(iEations o) dia&etics

atherosc(erotic disease
3dapted .rom 3mos 3" et al &ia'et $ed 1997/1:?S7S85/ 'ill >olden S Ad( )tud $ed 8))8/8?9!:97)/
'a..ner SM et al ! "#l J $ed 1998/999?88989:/ Spra.ka %M et al &ia'ete* Care 1991/1:?597
5:90
MMP
3dapted .rom 3leBander 7M, 3ntonello S +ract &ia'et 8))8/81?81880
5wo65(irds o" People wit(
Diaetes Die o" Cardiovascular
Disease

Among dia+eti"s#
ma"rovas"ular "ompli"ations %in"l6 C$D# stroke and
perip*eral vas"ular disease'# are t*e leading
"auses o! mor+idity and mortality6-954

724 Mi"rovas"ular
MMP
S
u
r
v
i
v
a
l
#
8
&
Year
6sti9ates of 3ro+a+ilit1 of Deat: ;ro9 CHD
in /05$ su+<ects =it: 513e 2 Dia+etes and /!(% >ondia+etic
Su+<ects =it: and =it:out 2rior ?I
Haffner,et al, N Engl J Med 1998; 339:229-34
MMP
B9/)D

Classi" (riad o! agent#*ost L environtment6

Start !rom A"ute R* Fever

F033 su+types antipago"iti" M ProtJ7weeks

stay in tissue untill anti+ody are "reated

M Anti+ody%K-a"etylglu"osamine' mimi"
myosyn#tropomyosin#*eart
valvels#synovia#skin "audate nu"lei in +rain-
multi organ involvement

Agent<IA,$S%Strepto" group A%(*roat

In!e"tion'--- Autoimmune disorder w*ole
+ody-Conne"tive tissue *eart##vas"ular
and =oint%Art*ritis'
Pat(ogenesis

(onsillop*aryngitis-Anti+ody respons---
Ieneti" predisposition-Conne"tive
tissue disease.Collagen vas"ular
disease-damage to "ollagen !i+ril and
"onne"tive
tissue%ndo"ardium#myo"ardium#peri"ardi
um'--Repeated R$D

)ulvitis#Stru"ture "*ange and Clini"al

Mani!estation
MMP
Decreasing o" /0
Pat(o /)D

)alvulitisMR.AR

Stru"tural "*ange< Fi+rinoid deg"lot

-edema
-Mononu"leus in! %As"*o! Cells'

Clini"al Mani!estation<
-)alvular in!lammation#
-ndo"arditis#destru"tion---Regurgitation
-$yaline degeneration#valvular stenosis
5(e Jones Criteria "or /0
+/evised $%%,.
#a6or Cirteria #inor Citeria
Carditis 7lini(al
Migrator= pol=arthritis "e,er
S=ndenham (horea 3rthralgia
Su6(utaneous nodule La6orator=
Cr=thema marginatum Cle,ated 7;P
P; intPPP
PL#S
C,iden(e o. a re(ent in.e(tion o. >roup 3 Strepto(o((i21hroat (ulture or
rapid antigen test or ele,ated Strepto(o((al anti6od= test
3'3,%3M3 8!8?8)!9,1998
MMP
D;/(eumatic 0ever
MMP
Valvular )eart Disease
+4ook at t(e 5e3t !ook.

Mitral<MS#MR#M)P

Aorta<AS#AR

(ri"uspid<(S#(R

Pulmonary<PS#PR

Penyakit in!lamasi pada endokard yang +iasanya

meli+atkan katup dan =aringan sekitarnya

ndokarditis in!ekti! %I'< in!lamasi dikaitkan dengan

in!eksi

?esi k*as < vegetasi

%platelet# eritrosit# !i+rin# sel in!lamasi dan M;'

K(asi)ikasi dan Aermino(ogi$

- ,aru %SC 733:'< (a) aktivitas penyakit; (b)
status
diagnosis; (c) pathogenesis; (d) lokasi
anatomis;
(e) mikrobiologi
- ?ama < %a' su)acut )actrial ndocarditis %S,'B
%+' acut )actrial ndocarditis %A,'B %"' kronik
$n.e(ti,e endo(arditis risk?
$n.e(ti,e endo(arditis risk?
Q
$ntra,enous drug a6users 2$5D34 18 R non $5D3
Q
Prostheti( heart ,al,es 51) R nati,e heart ,al,e
Mortalit= ? 715 J
$n(iden(e?
$n(iden(e?
Q
509110! annual in.e(tion per 1)), ))) population
Q
1058) annual (ase *1))) $5D3
Q
;S7M ? 158) J hospitaliKed $5D3
Cpidemiolog=
Cpidemiolog=
Kerusakan
endotel
Deposisi
trom6osit
Cndokarditis
trom6otik
non6akterial
Cndokarditis
men=em6uh
Cndokarditis
in.ekti.
Kolonisasi
GB1C
Patogenesis SBC
Bakterimia
Patogenesis !o'acterial ,hrom'otic "docarditi* 2GB1C4
dan )u'acute -acterial "docarditi* 2SBC4 2Dura(k D14
1ani"estasi =linis Endokarditis
1ani"estasi =linis Endokarditis
#n"ekti"
#n"ekti"
Symptoms Symptoms Percent Percent Si-ns Si-ns Percent Percent
Fe6er )'-)/ Fe6er )'-*'
C,ills +&-4/ ?urmur )'-)/
Sweats &/ C,an-in-(new murmur %'-+'
9nore>ia &/-// !eurolo-ical a;normalities .'-+'
@ei-,t loss &/-./ Em;olic e6ent &'-/'
?alaise &/-+' Splenome-aly %/-&'
Dyspnea &'-+' Clu;;in- %'-&'
Cou-, &/ Perip,eral manifestation -
Stroke %.-&' #sler nodes 4-%'
Headac,e %/-+' Splinter ,emorr,a-e /-%/
!ausea(Vomitin- %/-&' Petec,iae %'-+'
?yal-ia(9rt,ral-ia %/-.' aneway lesion 3-%'
C,est pain )-./ Retinal lesion(Rot, spots +-%'
9;dominal pain /-%/
Back pain 4-%'
Confusion %'-&'
4esi #skemik dan )emoragis
4esi #skemik dan )emoragis
pada Endokarditis #n"ekti"
pada Endokarditis #n"ekti"
Akut
Akut
)um'er . Color +late,Hur*t/* ,he Heart 1994
Vegetasi dengan Per"orasi pada =atup
Vegetasi dengan Per"orasi pada =atup
1itral
1itral
)um'er . Color +late, Hur*t/* ,he Heart 1994

Se+agian +esar *asil positi!

Kultur negati! pada 14 pasien

Kultur dalam 7 set < aero+ dan anaero+

Dara* vena 1-03 ml

Diinku+asi pada su*u 25 C# 1-9 *ari

(erapi anti+iotik dapat ditunda 7-: *ari

%kondisi tidak akut'

Q -a0er et al. Circulatio 1998198.2936248
Q ")C 3uidelie 2444
Predisposing Conditions and 1icroiology o" 7ative Predisposing Conditions and 1icroiology o" 7ative
Valve Endocarditis Valve Endocarditis
Conditions and ?icro;iolo-y C,ildren 1A2 9dults 1A2
!eonates & mo-%/ yr %/-3' yr 53' yr
Predisposin- conditions
RHD
&-%' &/-.' )
CHD 4/-*' %'-&' &
?VP /-%/ %'-.' %'
DHD Rare .'
Parenteral dru- a;use %/-./ %'
#t,er %'-%/ %'
!one 4& &-/ &/-+/ &/-+'
?icro;iolo-y
Streptococci %/-&' +'-/' +/-3/ .'-+/
Enterococci + /-) %/
SB aureus +'-/' &/ .'-+' &/-.'
Coa-ulase ne-ati6e stap,ylococci %' / .-/ /-)
0!B %' / +-) /
Fun-i %' % % Rare
Polymicro;ial + % Rare
#t,er % &
Culture ne-ati6e + '-%/ .-%' /
BraunDald, 8))5
1icroiology o" Endocarditis Associated
1icroiology o" Endocarditis Associated
wit(
wit(
#ntravenous Drug Ause
#ntravenous Drug Ause
#r-anisms
!um;er of Cases 1A2 of Endocarditis Dru- 9ddicts
Ri-,t
Sided
!C.+3
:eft Sided
!C&'+
8otal
!C34/
Spain 1%*44-
%**.2
!C%/&*
"treptococci #$ %&' (# %#&' )* %#2' #(# %)+&'
,nterococci $ %2' 4- %24' &- %-' 2# %#'
Stap,ylococcus aureus &34 1442 +4 1&.2 .*3 1/42 %%.) 14+2
Coagulase negative
staphylococci
- - 44 %('
.ram negative /acilli #$ %&' 20 %#(' 4& %$' 2( %#+&'
1ungi %predominantly Candida
species'
- 2& %#2' 20 %4' #) %#'
olymicro/ial2miscellaneous 2) %)' 2* %#*' 4- %$' 4) %('
Culture negative #* %(' 0 %(' 2* %(' #*0 %$'
BraunDald, 8))5
Pendekatan Diagnosis dengan
Pendekatan Diagnosis dengan
Ekokardiogra"i pada =ecurigaan
Ekokardiogra"i pada =ecurigaan
Endokarditis #n"ekti"
Endokarditis #n"ekti"
3'3 >uideline, 7ir(ulation 8))5/111?e99:8:99
Vegetasi =atup 5rikuspid pada
Vegetasi =atup 5rikuspid pada
Penyala(guna 7A/=*!A
Penyala(guna 7A/=*!A
#ntravena
#ntravena
5dru* Al6i.doc
Vegetasi =atup Aorta pada
Vegetasi =atup Aorta pada
Penyala(guna 7A/=*!A
Penyala(guna 7A/=*!A
intravena
intravena
5dru* Al6i .doc

Anamnesis "ermat

Pemeriksaan !isis teliti

Pemeriksaan penun=ang %ekokardiogra!i#

kultur dara*'

Kriteria Duke yang dimodi!ikasi

- (emuan ekokardiogra!i
- PKI) < dimasukkan se+agai kondisi
premor+id
De"inition o" #n"ective Endocarditis De"inition o" #n"ective Endocarditis
According to t(e 1odi"ied Duke Criteria According to t(e 1odi"ied Duke Criteria
Definite infecti6e endocarditis
Pat,olo-ical criteria
Microorganisms demonstrated /y culture or histological examination o! a vegetation, a
vegetation that has em/oli3ed, or an intracardiac a/scess specimen4 or
athological lesions4 vegetation or intracardiac a/scess con!irmed /y histological
examination sho5ing active endocarditis
Clinical Criteria
& maDor criteriaE or
% maDor criterion and . minor criteriaE or
/ minor criteria
Possi;le "E
% maDor criterion and % minor criterionE or
. minor criteria
ReDected
1irm alternative diagnosis explaining evidence o! I,4 or
Resolution o! I, syndrome 5ith anti/iotic therapy !or 64 days4 or
7o pathological evidence o! I, at surgery or autopsy, 5ith anti/iotic therapy !or 64
days4 or
Does not meet criteria !or possi/le I, as a/ove
De"inition o" 5erms <sed in t(e 1odi"ied Duke De"inition o" 5erms <sed in t(e 1odi"ied Duke
Criteria "or t(e Diagnosis o" #n"ective Criteria "or t(e Diagnosis o" #n"ective
Endocarditis Endocarditis
?aDor Criteria
Pat,olo-ical criteria
8ypical microor-anisms consistent wit, "E from & separate ;lood
culturesF Viridans streptococci, Streptococcus bovis, H8C,9 group,
Staphylococcus aureus< or community-ac:uired enterococci in the a/sence
o! a primary !ocus4 or
?icroor-anisms consistent wit, "E from persistently positi6e ;lood
cultures de!ined as !ollo5s; 9t least & positi6e cultures of ;lood samples
drawn5%& , apart4 or all of . or a maDority of 5+ separate cultures of
;lood %5ith !irst and last sample dra5n at least # h apart'
Sin-le positi6e ;lood culture for Co>iella ;urnetii or anti-p,ase % "-0
anti;ody titer 5%F)''
E6idence of endocardial in6ol6ement
,chocardiogram positive !or I, %8EE recommended for patients wit,
prost,etic 6al6es< rated at least Gpossi;le "EH ;y clinical criteria< or
complicated "E Ipara6al6ular a;scessJE 88E as first test in ot,er
patients2 de!ined as !ollo5s; oscillatin- intracardiac mass on 6al6e or
supportin- structures, in the path o! regurgitant <ets, or on implanted
material in the a/sence o! an alternative anatomic explanation4 or a;scess4
or new partial de,iscence of prost,etic 6al6eE new 6al6ular
re-ur-itation %5orsening or changing or preexisting murmur not su!!icient'
De"inition o" 5erms <sed in t(e
De"inition o" 5erms <sed in t(e
1odi"ied Duke Criteria "or t(e
1odi"ied Duke Criteria "or t(e
Diagnosis o" #n"ective Endocarditis
Diagnosis o" #n"ective Endocarditis

?inor Criteria
PredispositionF predisposing heart condition, or ID=
Fe6erF temperature >()
*
C
Vascular p,enomena; ma<or arterial em/oli, septic pulmonary
in!arcts, mycotic aneurysm, intracranial hemorrhage, con<unctival
hemorrhages, and ?ane5ay@s lesions
"mmunolo-ic p,enomena; glomerulonephritis, Asler@s nodes, Roth@s
spots, and rheumatoid !actor
?icro;iolo-ical e6idence; positive /lood culture /ut does not meet a
ma<or criterion as noted a/oveB or serological evidence o! active
in!ection 5ith organism consistent 5ith I,
Ec,ocardio-rap,ic minor criteria eliminated
Spektrum Ekokardiogra"i
Spektrum Ekokardiogra"i
Endokarditis #n"ekti" pada
Endokarditis #n"ekti" pada
Penyala(guna 7A/=*!A
Penyala(guna 7A/=*!A
#ntravena di /SC1
#ntravena di /SC1
Ukuran vegetasi < 0#5-9#7 "m
Lokasi vegetasi <
- $anya pada katup trikuspid < >3#> 4
- $anya pada katup mitral < 5#5 4
- $anya pada katup aorta < 5#5 4
- Katup trikuspid dan aorta < 2#> 4
Regurgitasi <
- Katup trikuspid < 52 4
- Katup mitral < 5#5 4
- Katup aorta < 5#5 4


Al6i 5 d77, 89+A+&5 :5,)ura'a0a 8)))
=omplikasi dan Penyakit Penyerta
=omplikasi dan Penyakit Penyerta
Endokarditis #n"ekti" pada
Endokarditis #n"ekti" pada
Penyala(guna 7A/=*!A #ntravena
Penyala(guna 7A/=*!A #ntravena
di /SC1
di /SC1

Pneumonia < >7#8 4

Iagal =antung < 0:#9 4

!usi pleura < 0:#9 4

m+oli paru < 5#2 4

Strok < 5#2 4

DIC < 07#7 4

'$5 positi. ? !9,! J
2n ? 884
'75 positi. ? 8!,: J
2 n ? 884
'Bs3g positi. ? 81,: J
2n ? 1:4

Al6i 5 d77, ot pu'li*h

A$rican &art Association ( A&A )

(uidlin

Europan Socit# o* +ardiolo(# (uidlin

%00,
5(erapy o" native valve endocarditis 5(erapy o" native valve endocarditis
caused y caused y
(ig(ly penicillin6susceptile (ig(ly penicillin6susceptile
viridans group streptococci and viridans group streptococci and
Streptococcus ovis Streptococcus ovis
Re-imen Dosa-e and Route Durat
ion<
wk
Stren-
t, of
Recom
menda
tion
Comments
9Kueous crystalline
penicillin 0 sodium
or
%&-%) million 7(&+ , "V
either continuously or
in + or 3 eKually di6ided
doses
4 "9 re!erred in most
patients 53/ y or
patients 5ith
impairment of )t,
cranial ner6e
function or renal
function
Ceftria>one sodium & -(&+ , "V("? in % dose
ediatric dose; penicillin
2** *** =2Cg per 24 h ID
in H e:ually divided doses4
ce!triaxone #** mg2Cg per
24 h ID2IM in # dose
4 "9
3'3 >uideline, 8))5

,akterimia menetap setela* terapi medis

adekuat

Regurgitasi aorta atau mitral akut

dengan gagal ventrikel

Iagal =antung kongesti! yang tak respon

ter*adap terapi medis

Per!orasi atau ruptur katup

)egetasi menetap setela* em+oli

sistemik

kstensi perivalvular
,ayer et al# A$A S"ienti!i" Statement6 Cir"ulation 088>B8><7829-:>

ndokarditis in!ekti! merupakan komplikasi

klasik PKI)

Strptococcus 'iridans merupakan kuman

penye+a+ tersering

Diagnosis ditegakkan +erdasarkan -ritria

-linis !u- #an( di$odi*i-asi

Penatalaksanaan ideal +erdasarkan =enis

kuman dan pola resistensi yang sesuai

Aeicop(anin e)ekti) pada ! gram positi)

k*ususnya Strptoccus 'iridans sesuai
guideline
?ook at t*e (eHt ,ook
Clinical Presentation

Peri"arditis EIn!lammation o! Peri"ardium

par.vis"

a"ute peri"arditis

peri"ardial e!!usion and "ardia"

tamponade

"onstri"tive peri"arditis6
D9Disease o" 1yocardium
4ook at t(e 5e3t !ook

Dilated Cardiomyopat*y

$ypertrop*i" Cardiomyopat*y

Restri"tive Cardiomyopat*y
&9Perip(eral Arteri;Vena
Disease
+4ook at t(e 5e3t !ook.

)arises

(*rom+op*le+itis

Arteritis

Arterial m+oli
'9Pulmonary )eart Disease
+4ook at t(e te3t eook.

Pulmonary $ipertension

Pulmonary m+oli

Cor Pulmonale
Conto(:Sakit Dada
CD%otensial 1atal'
CD%otensial 1atal'
Respiratory%ot 1atal'
Respiratory%ot 1atal'
9n-ina Pektoris<?yo "nfarct <9o 9n-ina Pektoris<?yo "nfarct <9o
Diseksi <?ioperikarditis Diseksi <?ioperikarditis
ulm ,m/oli leuro- ulm ,m/oli leuro-
pneumonia2lo/ar,pneumothoraCs,pne pneumonia2lo/ar,pneumothoraCs,pne
umomediastinum umomediastinum
.I
.I
Ather
Ather
,sophagitis,"pasm ,sophagitis,"pasm
esophagus,Hiatus hernia,ulCus esophagus,Hiatus hernia,ulCus
peptiCum,9oliC peptiCum,9oliC
/ilier,anCreatitis /ilier,anCreatitis
MusCulosCeletal MusCulosCeletal
pain,psiCogeniC,costochondriti pain,psiCogeniC,costochondriti
s,cervical sponylosis s,cervical sponylosis
/e"erences

0raun.a(d 4Approach to the patients .ith C% Disease4

!n$ Harrison AR? Fauci A;4 HarrisonIs Princip(es o)
!ntrena( 1edicine4 *3th dition4 1cBra. Hi((? Fe. Gork?
"##2

Cannon P C? 9ee AH4 Approach to the Pts .ith Chest

Pain4 !n 9i&&y? 0ono.? 1ann? Hipes4 0raun.a(dIs Heart
Disease4 A Ae't&ook o) C% 1edicine?,th ed? vo("?
;aunders? "##,?Ch *?2<?25?<#?<*?<6?<2?36?,6

Kumar P and Clark M#Clini"al Medi"ine#9 ed#lsevier

Saunders#73396www6student"onsult6"om

$S.SC Iuidelines !or t*e Management o! Artrial

$ypertension#7335.ur Heart Journa "##+4
http$//...4escardio4org/kno.(edge/guide(ines/

&KC )II< Management o! $ypertension +y ,lood

Classi!i"ation# C*o+anian A) et al6 .AMA/ 7332B7>8<7193-
7157

*ttp<..www6n*l+i6gov.a+out.!raming*am
MMP