TERAPI NUTRISI PADA

PENYAKIT KARDIOVASKULER

JUHAIRINA
FK-ULM
2017
HYPERTENSION

CORONARY HEART DISEASE

ISCHEMIC HEART DISEASE

HEART FAILURE
HYPERTENSION
 Hypertension

• Refers to a chronic elevation in BP.

• Etiology :
- Primary or essential hypertension : idiopathic.
- Secondary hypertension : renal disease, other
cardiovascular disease, endocrine disorders,
neurogenic disorders.
 Risk Factors

• Diet (excessive sodium intake)

• Exercise
• Smoking
• Stress
• Obesity
The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation and Treatment
of High Blood Pressure (JNC-7) classifies hypertension
 Treatment
The goals :
• Reduction in the risk of cardiovascular and renal disease.
• Reduction of BP to <140/80 mmHg (or to <130/80 mmHg
in those individuals with DM or chronic renal disease).

• Weight reduction
Lifestyle modifications • Physical activity
• Nutrition therapy
Pharmacological therapy • Smoking cessation
Pujol, T.J. Disease of the cardiovascular system. In: Nelms M.H., et al. (eds).
Nutrition therapy and pathophysiology. 2007c
 Nutrition Therapy

Reduction of sodium
and alcohol intake

Dietary Approaches to Stop Hypertension

(DASH)
and the PREMIER trials
In the
past  have revealed that nutrition interventions that
include decreasing sodium, saturated fat, and alcohol
decade
while increasing calcium, potassium, and fiber have
demonstrated significant effects for lowering BP.
Di masa lalu, peneliti mencoba menemukan petunjuk
tentang zat apa yang ada dalam diet yang
mempengaruhi TD melalui pengujian berbagai nutrisi
tunggal, seperti Ca & Mg

Sebagian besar studi telah dilakukan dengan

suplemen makanan, namun hasil penelitiannya
tidak konklusif.

NHLBI, 2001  penelitian "DASH DIET”

(Dietary Approaches to Stop Hypertension)
 PENELITIAN DASH DIET
• 459 orang dewasa
• TDS <160 mmHg dan TDD 80-95 mmHg
• 27% subjek  hipertensi
• 50%  wanita
• 60%  orang Afrika Amerika
• Intervensi selama 2 minggu

DIET Amerika II
DIET Amerika I DIET DASH
(↑ sayur & buah)

Semua diet mengandung

3000 mg Na/hari

TD ↓ TD ↓↓
 DASH
DIET

KAYA AKAN :
Kalsium
Magnesium
Kalium ↓ Lemak jenuh, kolesterol, lemak total
Protein ↑Buah, sayuran, produk susu rendah lemak
Serat Produk gandum, ikan, unggas, kacang-kacangan

Daging merah, permen, dan minuman yang mengandung gula dikurangi

 KALSIUM

Perangsangan pelepasan
↑ kadar magnesium
hormon paratiroid/renin
Asupan kalsium yang ↓
< 600 mg/hari atau
< 2 porsi susu/hari
↑ kalsium intraseluler
VASOKONSTRIKSI
otot polos vaskuler

Society of Obstetricians and Gynecologists of Canada (SOGC). Journal of Obstetrics and Gynaecology Canada.
2008; Vol.30 (3):S1-S52
 KALIUM
Meta-analisis : Suplementasi kalium secara signifikan
dapat menurunkan TDS dan TDD (Geleijnse J, 2003)

Memicu ekskresi natrium (natriuresis) dan

mengurangi retensi natrium dalam tubuh
(Sellmeyer, 2002)

Relaksasi otot polos vaskuler 

↓ Ekskresi Ca & Mg ↓ resistensi perifer
(Sellmeyer, 2002)
(Bussemaker, 2010)

Menghambat agregasi platelet, trombosis arteri

dan proliferasi sel otot polos vaskuler 
resistensi perifer ↓ (Buerni, 2002)
 MAGNESIUM
 Respon vaskuler in vitro  defisiensi Mg pada PE (Altura, 1981)
 Studi epidemiologi pada hewan dan manusia  hubungan terbalik
antara TD & Mg (asupan dan/atau serum)

• Relaksasi dari otot polos  VASODILATASI

• Antikonvulsan
• Antihipertensi dan tokolitik

Duley L. Evidence and practice : The magnesium sulphate story. Clinical Obstetric and Gynaecology. 2005;
19(1):57-74.
Pujol, T.J. Disease of the cardiovascular system. In: Nelms M.H., et al. (eds).
Nutrition therapy and pathophysiology. 2007c
CORONARY HEART DISEASE
 ATHEROSCLEROSIS
Thickening of the blood vessel walls
specifically caused by the presence of plaque.

Will occlude the lumen of the vessel and create

ischemic conditions

Coronary artery disease (CAD)

Myocardial infarction (MI)
Cerebrovascular accident (stroke)
 RISK FACTORS
• Family history • Hypertension
• Age • Diabetes
• Sex • Physical inactivity
• Obesity • Cigarette smoking
• Dyslipidemia
 Treatment
Adult Treatment Panel III Guidelines developed by the National
Cholesterol Education Program (NCEP) and approved
by the National Heart, Lung, and Blood Institute, the American
College of Cardiology, and the American Heart Association (AHA) :
• Medications
• Nutritional therapy
• Surgical intervention :
- Percutaneous transluminal coronary angioplasty (PTCA)
- Laser angioplasty
- Coronary artery bypass graft (CABG)
 Nutrition Therapy
Therapeutic Lifestyle Changes (TLC) Diet

• Low in saturated fat and cholesterol

• Rich in fruits, vegetables, and grain
products that contain some types of
dietary fiber, particularly soluble fiber.

Pujol, T.J. Disease of the cardiovascular system. In: Nelms M.H., et al. (eds).
Nutrition therapy and pathophysiology. 2007c
 Nutrition Therapy
Therapeutic Lifestyle Changes (TLC) Diet
ISCHEMIC HEART DISEASE
 Ischemic Heart Disease

• A sedentary individual may develop an atherosclerotic

plaque that occludes up to 50% of the lumen of a
coronary artery, and remain completely asymptomatic.
• If the individual becomes active they may experience a
symptom, called angina, which is directly associated
with reduced blood flow to parts of the heart.
• When the coronary arteries are occluded to the point
that the blood flow to portions distal to the blockage is
compromised, the individual is said to have myocardial
ischemia.
 Treatment
• The goals :
- Reduce pain
- Reduce the work of the heart
- Stabilize cardiac function
- Prevent or limit complications
• Medical interventions :
- Oxygen
- Aspirin (for antithrombolytic effect)
- Morphine (for pain)
- Fibrinolytic
• Nutrition therapy
Pujol, T.J. Disease of the cardiovascular system. In: Nelms M.H., et al. (eds).
Nutrition therapy and pathophysiology. 2007c
 Nutrition Therapy
• During the immediate post-MI period, oral intake
may be decreased due to pain, anxiety, fatigue,
and shortness of breath.
• Initial oral intake to clear liquids without
• caffeine in order to prevent arrythmias and to
decrease risk of vomiting or aspiration.
• Oral diets usually progress from liquids to soft,
easily chewed foods with smaller, more frequent
meals.
• As the patient stabilizes  TLC Diet
HEART FAILURE
 An impairment of the
HEART ventricles’ capacity to eject
blood from the heart or to
FAILURE fill with blood.
 ETIOLOGY

• Ischemic Heart Disease

• Hypertension
• Dilated cardiomyopathy
• Valvular disease
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 SIGNS & SYMPTOMS
• Blood flow and oxygen supply ↓  dyspnea,
fatigue, weakness, exercise intolerance, poor
adaptation to cold temperatures.
Left-sided failure :
Dyspnea is more predominant and orthopnea.
Right-sided failure :
• Edema in the periphery hepatomegaly,
splenomegaly, ascites, extremitas edema.
• Distended neck veins, headache, flushed face.
 CARDIAC
MALNUTRISI MORTALITAS
CACHEXIA
20-70% ↑
10-16%

Kehilangan 10% lean body mass

Penurunan berat badan > 6% dari BB sebelumnya,
BB tanpa edema selama ≥ 6 bulan
(Bourdel-Marchasson, 2001; Antonione, 2011)
 GAGAL JANTUNG
Gangguan
Stres Gangguan
kontraksi
oksidatif ↑ otot skelet
miokard

DEFISIENSI
MIKRONUTRIEN
DIURETIK
 CoQ10

Mineral
(K,Mg, Zn, Karnitin
Cu, Se) Defisiensi
mikronutrien
pada HF

Vitamin B
Taurin
Vitamin D
 Nutrition problems
• Decreased blood flow to the gastrointestinal tract
causing slowed peristalsis and early satiety.
• Decreased blood flow to the gastrointestinal tract
which may impair nutrient absorption.
• Side effects from drugs such as nausea, vomiting,
and anorexia, which are common with the use of
ACE inhibitors, beta blockers, cardiac glycosides,
and digoxin.
• Nutrient deficiencies are also a common side
effect from the use of diuretics and other
medications.
 Treatment

• The goals :
- To treat the underlying cause of the cardiac
disorder.
- To control the symptoms associated with heart
failure.
- To prevent continued damage to the heart.
 Treatment

• PHARMACOLOGICAL
Diuretic, ACE inhibitors, β-adrenergic blockers,
digitalis, dopamin, dobutamin.
• NUTRITION THERAPY
Nutrition Therapy
 Nutrition Therapy
• Sodium and fluid restriction  IMPORTANT
Sodium : 2,000 mg, 1,000 mg, or 500 mg
Fluid : 1 mL/kcal or 35 mL/kg or 1,500 mL/day.
• Correction of nutrient deficiencies
Water-soluble nutrients : K, Mg, thiamin
Thiamin : 200 mg/day orally for six weeks, or initial
parenteral dose of 100 mg.
• Nutrition education for increasing nutrient density
• Supplementation Arginine, carnitine, and taurine
Arginine  ↑ nitric oxide  vasodilation endothelium
Carnitine  carrying fatty acids intracellularly into the
mitochondria for oxidation.
 CoQ10
Komponen esensial rantai respirasi mitokondria,
bukan protein dan larut lemak, disintesis di hati ,
terletak pada membran inner mitochondrial

FUNGSI
Menstabilkan Mencegah
struktur membran
Pembentukan inner aktivasi Antioksidan &
ATP dan mitochondrial, apoptotic melindungi
transfer energi mengontrol aliran cascades& LDL dalam
elektron & inaktivasi sirkulasi dari
mengatur aliran oksidatif oksidasi
reducing
equivalents protein

Soukoulis, et al. 2009. J Am Coll Cardiol 54: 1660 - 73.

Komponen rantai transpor elektron

Lim, M.Y. 2007. Fatty acid metabolism and lipid transport. In : Metabolism and nutrition. 3rd ed. p. 57-71.
 CoQ10

Terdapat banyak dalam minyak ikan,

kacang-kacangan, ikan dan daging
Disintesis oleh
tubuh dari Asupan Dosis
asam amino rata-rata suplementasi
tyrosine & 5 mg/hari 60-300 mg/hari
mevalonate
 Karnitin
Senyawa nonprotein yang mengandung nitrogen
berasal dari asam amino lisin & metionin

FUNGSI : Carnitine transport shuttle

Bentuk Diambil oleh

Terdapat
Karnitin jaringan otot
dalam
Disintesis di terasetilasi rangka
makanan
hati dan ginjal ditemukan
seperti daging
dalam sirkulasi 90% disimpan
sapi dan babi di dalam otot
dan eritrosit
Carnitine transport shuttle

Lim, M.Y. 2007. Fatty acid metabolism and lipid transport. In : Metabolism and nutrition. 3rd ed. p. 57-71.
 TAURIN
Asam amino semi-esensial disintesis dari metionin
dan sistein

FUNGSI : Antioksidan dan regulator endogen penting untuk

homeostasis kalsium intraseluler,
bukan substrat untuk sintesis protein atau metabolisme
intermediat pada jantung

Menyusun 25% HF kadar Ca

kandungan asam Dosis
amino pada miosit ↑ 
1-3 g/ hari
kardiomiosit cellular injury
Sintesis Taurin

Eby, G. Sintesis taurin. 2013

 Vitamin B1 (Tiamin)

Vitamin larut dalam air dan diekskresi melalui urine

FUNGSI : koenzim untuk reaksi oksidasi-reduksi

khususnya metabolisme glukosa, pentose shunt dan
siklus asam sitrat.
Terdapat di dalam Metabolit aktif : TPP
tepung-tepungan, nasi, (kofaktor pyruvate
jamur, daging sapi, Insidens defisiensi
dehydrogenase & tiamin pada HF :
hewan unggas, ikan,
susu, sayuran berdaun translocase
hijau, kacang-kacangan mediator substrat 13-93%.
dan biji-bijian metabolisme energi
 VITAMIN D
Berperan penting dalam homeostasis kalsium
Inhibitor produksi renin

Kadar vitamin D rendah ditemukan pada pasien gagal jantung

(Weber, 2008)

Vitamin D dan asam retinoat

Kontraksi miokard kembali mengurangi proses hipertrofi
menjadi normal setelah oleh endotelin yang meningkat
suplementasi vitamin D pada tikus HF
(Weishaar, 1987) (Wu, 1996 )
 Magnesium & Kalium

Def. Defisiensi Fonseca,

Mg & K Mg 1985
> 30% bersama-
sama dengan Koreksi kadar Mg
Aritmia pada HF dapat memperbaiki
defisiensi Mg
pada otot fungsi ventrikel kiri
pada HF

Berkontribusi
terhadap gejala
fatigue
 Zink
Antioksidan yang ditemukan kadarnya ↓ pada HF

Defisiensi Zn umumnya terjadi pada usia lanjut

Zn berkorelasi dengan obat-obat jantung dan

asupan protein ↓

Kadar Zn serum ↓dan kadar Zn urine ↑ ditemukan

pada pasien HF kemungkinan akibat penggunaan
diuretik
 Copper
Berperan dalam regulasi oksidatif radikal bebas

Defisiensi Cu meningkatkan kerentanan peroksidasi

lipoprotein

↓Cu  ↑ risiko kerusakan oksidatif miosit &

kolesterol plasma

↓Cu  aktivitas cytochrome C-oxidase  gangguan

mitokondria  disfungsi jantung
 Selenium
Komponen glutathione peroxidase, suatu enzim
antioksidan yang mencegah disfungsi endotel

Mencegah jaringan dari kerusakan oksidatif, membuat sel

mampu memproduksi ubiquinone dan mencegah
pemecahannya oleh degenerasi oksidatif.

Defisiensi Se jarang, tetapi gejala akan timbul bila

terdapat defisiensi vitamin E.

↓Se  perubahan ultrastruktural mitokondria seperti

hilangnya krista mitokondria
 DIET RENDAH GARAM
• Diet rendah garam I (200-400 mg Na)
 penderita dengan udem, Ascites dan atau
Hipertensi berat .
• Diet rendah garam II (600-800 mg Na)
 penderita dengan udem, Ascites dan atau
Hipertensi tidak terlalu berat.
• Diet rendah garam III (1000-1200 mg Na)
 penderita dengan udem dan atau Hipertensi
ringan.
 DIET JANTUNG

• Diet Jantung I :
- Penderita dengan infark miokard akut atau CHF berat.
- 1 - 1,5 liter cairan sehari selama 1 - 2 hari pertama
- Sangat rendah energi (835 kCal).
• Diet Jantung II :
- Diberikan berangsur dalam bentuk lunak, setelah
fase akut dapat di atasi.
- Menurut beratnya Hipertensi atau edema yang
menyertai penyakit
- Makanan diberikan sebagai Diit Jantung II rendah garam II
- Rendah energi (1325 kCal),Protein, Thiamin.
• Diet Jantung III :
- Makanan perpindahan dari diit Jantung II
atau kepada penderita penyakit jantung tidak terlalu berat.
- Makanan dalam bentuk mudah cerna
berbentuk lunak/biasa.
- Rendah energi (1756 kCal), tetapi cukup zat2 gizi lainnya ,
diet jantung III rendah garam.
• Diet Jantung IV :
- Makanan perpindahan dari Diet Jantung III atau kepada
penderita penyakit jantung ringan.
- Diberikan dalam bentuk biasa. Menurut beratnya Hipertensi
atau edema yang menyertai penyakit,.
- Makanan diberikan sebagai Diet Jantung IV Rendah Garam.
- Makanan ini cukup energi dan zat2 gizi (2023 kCal).