Coronary Artery Disease

• Dr. Sadewantoro, Sp.JP, FIHA

• Fakultas Kedokteran Universitas Hang Tuah
Coronary Artery
Disease
SERANGAN JANTUNG
• Kemajuan ekonomi dan teknologi kedokteran, usia harapan hidup meningkat.

• Pola penyakit bergeser : kelebihan gizi, penyakit metabolik & degeneratif.

• Penyakit kardiovaskuler, penyebab kematian urut 1, terutama PJK.

SKRT Depkes : mortalitas

1991 16,4%

1995 24,5%

2001 26, 4%

2010 53, 5%
 The broad spectrum of
cardiovascular disease

Thrombus formation Cerebral blood flow disorders

following vascular surgery
• Stroke
and interventions
• Transient ischaemic attack
• Haemodialysis
• CABG
• PTCA

Coronary heart disease

Peripheral vascular • Acute myocardial infarction
disorders • Myocardial infarction
• Venous thrombosis • Angina pectoris
• Arrhythmias
• Lung embolism
• Hypertension
• Peripheral artery disease
 Multiple Complex Coronary Plaques in
Patients With Acute MI
Multiple plaques
detected

Multiple plaques
detected
Culprit lesion

MI, myocardial infarction.

Goldstein JA, et al. N Eng J Med. 2000;343:915-922. (with permission)
Development of Atherosclerotic
Plaques
Fatty streak
Normal

Lipid-rich plaque

Foam cells

Fibrous cap

Lipid core
Thrombus

Ross R. Nature. 1993;362:801-809.

Secara klinis manifestasi pjk

• Asimtomatik  orang tua, DM

• Angina pectoris stabil
• Angina pectoris tidak Stabil
• Angina Variant/Prinzmetal
• Iskhemia myocard tenang
• Aritmia
• Gagal jantung
• Infark myocard Akut
• Mati Mendadak
 Angina Pectoris
(Nyeri dada jantung)
• Nyeri dada difus, retrosternal, precordial.
• Rasa tertindih, tertekan, tertusuk, dicengkram, terbakar.
• Menjalar ke bahu, punggung, leher, dagu, uluhati.

• Gejala tambahan : sesak, pucat, keringat dingin,

berdebar, pusing, gangguan pencernaan.
 PENYAKIT JANTUNG KORONER

• Terjadi penyempitan lebih 60 %

• Gejala Nyeri dada  Angina pectoris
Lokasi nyeri dada
 Atherosclerosis Timeline

Foam Fatty Intermediate Fibrous Complicated

Cells Streak Lesion Atheroma Plaque Lesion/Rupture

ti

Endothelial dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen haematoma

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

Atherogenesis and Atherothrombosis:
A Progressive Process to Cardiovascular Events
Plaque
Athero- Rupture/ Myocardial
Fatty Fibrous sclerotic Fissure & Infarction
Normal Streak Plaque Plaque Thrombosis

Ischemic
Stroke

Periferal
Ischemia

Clinically Silent Angina

TIA
PAD Cardiovascular Death

Increasing Age

3
Foam sel

Fatty streak

Plaque Atherom

Stenosis

Rupture

Infark myocard

Remodelling
 Infark miokard akut
• Diagnosa WHO :
2 dari 3 kriteria diagnostik

1. Nyeri dada khas, gelisah, keringat dingin, lebih 30 menit

2. ECG : segmen ST elevasi atau gel. Q patologis
3. Enzim : Troponin T, CK-MB, LDH, SGOT.
 ECG FEATURES OF ACS

T
NORMAL ECG
P wave

Q
ST-segment

ST-ELEVATION
STEMI

ST-ELEVATION PATHOLOGIC INVERTED

Q-WAVE T-WAVES
Faktor Resiko Penyakit Jantung Koroner

I. Tak dapat dirubah

a. Umur
b. Pria
c. Keturunan

II. Dapat dikendalikan

a. Merokok
b. Hipertensi
c. Kencing manis
d. Dislipidemia
e. Obesitas
f. Kurang olah raga
g. Kepribadian tipe A.
 Faktor resiko
PJK

Hypercoagulable states Life-style Hyperlipidemia

(smoking, diet,
lack of exercise) Hypertension
Homocysteinemia
Diabetes Infection
Obesity Age

Genetics
Atherosclerosis
Gender

Atherothrombotic Manifestations
(MI, Ischemic Stroke, Vascular Death)

American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement; Wolf. Stroke 1990;21(suppl 2):
II-4–II-6; Laurila et al. Arterioscler Thromb Vasc Biol 1997;17:2910-2913; Grau et al. Stroke 1997;28:1724-1729;
Graham et al. JAMA 1997;277:1775-1781; Brigden. Postgrad Med 1997;101(5):249-262.
9
 Faktor resiko Arterosklerosis

Bisa dimodifikasi : Tidak bisa di modifikasi :

Rokok, dislipidemia, Genetik.
hipertensi, diabetes mellitus, Usia.
obesitas, sedentary, stres. Gender.
Tradisional : Non tradisional :
Genetik, usia, Hiper-homosisteinemia.
gender, rokok, Lipoprotein-a.
dislipidemia, hipertensi, Hiperfibrinogenemia.
diabetes mellitus, obesitas, Hiperkoagulasi.
sedentary, stres. Infeksi/inflamasi.
Metabolik : Non metabolik :
Dislipidemia, hipertensi, Genetik, usia,
diabetes mellitus, obesitas, gender, rokok,
hiper-homosisteinemia, infeksi/inflamasi,
lipoprotein-a, hiperkoagulasi, sedentary, stres.
hiperfibrinogenemia.
 Prediktor kuat Aterosklerosis (Berenson,
Kolesterol Total, LDL, HDL, hs-CRP 1998)

Banyak digunakan peneliti lain (Sjodin,1990)

MDA Dapat dipakai sebagai pertanda biologis terjadinya stres oksidatif
(Pattelongi, 1999).
Marker stres oksidatif paling kuat(, Harjanto 2003)

Faktor risiko terhadap kejadian penyakit kardiovaskuler.

( Berenson, 1998. NEJM )
Merokok
Cholesterol
Hipertensi
Dominan pria.

Wanita dilindungi estrogen.

tetapi setelah menopause, sama banyak

• Makin berumur, makin banyak PJK.
• Biasanya mulai dekade 4 – 5

• Umur penderita PJK, makin muda saja

akibat perubahan pola hidup (modern).
 Merokok
• Asap rokok : mengandung gas & benda padat

• Nikotin & CO  merusak endotel, sehingga

kholesterol & Ca+ masuk.

• Tar  kanker paru, mulut, lambung,

ginjal, kandung kemih.

• 6 kali dari yang tidak merokok

• Tergantung lama, macam, banyaknya rokok
Hipertensi
 Blood Pressure Classification
JNC 7 ( 2003)

U.S. Department BP Classification SBP mmHg DBP mmHg

of
Health and
Human Services Normal <120 and <80

Pre hypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

National
Institutes Hypertension
of Health
Stage 2 >160 or >100
Hypertension

National Heart,
Lung, and Blood
Institute SCU 2003
 Faktor Risiko Hipertensi
• Tidak dapat dimodifikasi
– Usia lanjut
– Keturunan
• Dapat dimodifikasi
– Kegemukan
– Asupan garam berlebih
– Kurang bergerak
– Stres
– Merokok
 Otak

Jantung

Komplikasi Hipertensi
Ginjal
 10 kewajiban penderita hipertensi

1. Mengukur tekanan darah secara teratur

2. Jangan lupa mengkonsumsi obat sesuai aturan dokter
3. Mengontrol berat badan
4. Tidak mengkonsumsi garam berlebih
5. Makan makanan rendah lemak
6. Berhenti merokok
7. Berkonsultasi dengan dokter secara teratur
8. Latihan fisik sesuai anjuran dokter
9. Menjalani kehidupan secara normal dan sehat
10. Menganjurkan keluarga memeriksakan tekanan darah
secara teratur (risiko keturunan)
 Kholesterol
Kholesterol tinggi, disertai lemak tinggi,
mudah mengendap di dinding pembuluh darah.

Sumber kholesterol :
1. makanan
2. tubuh sendiri

Jerohan : hati, otak, limpa, paru, usus.

Udang, kepiting, kerang, cumi.
 KOLESTEROL
• BAGIAN / TURUNAN LEMAK
• ZAT BERWARNA KEKUNINGAN
SEPERTI LILIN
• DIBUAT : LIVER & SEL-SEL TUBUH
• ASAL : MAKANAN HEWANI, MINYAK
KELAPA
• DIBUTUKHAN TUBUH
• KADAR TINGGI  FAKTOR RISIKO PJK
 PROFIL LIPID
1. KOLESTEROL TOTAL
2. KOLESTEROL LDL
3. KOLESTEROL HDL
4. TRIGLISERIDA

• LDL : KOLESTEROL JAHAT

• HDL : KOLESTEROL BAIK
 9

Doubts about
cholesterol as
late as 1989
 MENGENDALIKAN
KOLESTEROL
• 1. DIIT

• 2. AKTIVITAS FISIK & OLAH RAGA

• OBAT-OBATAN
Sudden death is more common in those
who are naturally fat than in the slender
Hippocrates 410 B.C.

Messerli et al Arch Intern Med 1987; 147: 1725 - 1728

 Central obesity
= obesity
Abdominal
Visceral obesity
Android type obesity
Android obesity

Gynecoid obesity
Kurang olah raga
Visceral Obesity Risk Factors CHD

Hyper-
Dyslipidemia
tension

Type 2
Diabetes

Treating the cause by diet, Treating the complications ? Optimal management

exercise, pharmacology of CHD risk

Visceral obesity is an early and effective therapeutic target

for prevention of type 2 diabetes, hypertension, and CHD
 ATHEROSKLEROSIS
RISK FACTOR
1,6 x
Smoking

4,5 x
9x

16 x

3x
6x 4x
Hypertension
SBP > 195
Hyper
Cholesterol

Source : Framingham Heart Study, MRFIT

ATHEROSKLEROSIS
Glucose
RISK FACTOR
intolerance
1,8 x

3,5 x
2,3 x

4.5 x

1,9 x
2,6 x 1,3 x

Hypertension
SBP > 165 Cholesterol
> 210 m%

Kannel WB. In: Genest J, et al, eds. Hypertension: Physiopathology and

Treatment. New York, NY: McGraw Hill;1977:888-910.
 Metabolic syndrome may be constituted by conditioned by
many persons who have a constellation of major Risk Factors,
Life Habit Factors, and Emergency Risk Factors.

Factor characteristic :
Abdominal Obesity
Atherosgenic Dyslipidemia (TG, Small LDL-particles, HDL-C)
Raised Blood Pressure
Insulin Resistance (with or without IGT)
Prothombotic State
Proinflammatory State
Rimonabant (CB-1 blocker)
Pengobatan
(Therapy)

• Pola hidup sehat

• Obat.
• Tindakan invasif.
• Operasi Jantung.
 Multi-Slice CT for
Coronary Calcium Scoring
and Coronary Angiography

No Disclosures
The Examination
Curved Planar Image
 Coronary Angiography

Spine to
the
LAO view RIGHT
Cranial view

Catheter Catheter at
PA view Diaphrag
and spine the
RAO view CENTER
m
to the Caudal view shadow
LEFT Caudal
view
No diaphragm No
shadow diaphragm
shadow
The most important bleeding avoidance
strategy?

• Femoral • Radial
Arterial access
Radial artery

• Lower risk of significant

bleeding
• No bed rest required
 Normal Rt & Lt Coronary Arteries

63
 Standard Angiographic Views
Left Coronary Artery

LAD LAD
LM

Diagona
l

LCx

Septals
Dista
l
LAD

Distal LAD
fills by
collaterals

RAO 20 Caudal 20 RAO 20 Caudal 20

Best for visualization of
LM bifurcation and
proximal LAD and LCx
Knowledge of the orientation of the
artery for a given view can help identify
the probable path of the artery in the
setting of complete occlusion
 Percutaneous Transluminal Coronary Angioplasty (PTCA)

• Otherwise known as:

• Balloon Angioplasty
• Angioplasty
• PTCA

• Balloon Angioplasty is a technique used to dilate an area

of arterial blockage with the help of a balloon catheter.
• It is65 a way of opening a blocked blood vessel.
Drug Stents
Next Generation Stents

• Bioabsorbable /
dissolving stents
• In clinical trials at
Northwestern
Coronary Bypass
Coronary Artery Bypass Grafting (CABG)
 Coronary Artery Bypass Graft Surgery

• is a surgical procedure to treat severe coronary artery

disease (heart disease).
• Part of a vein or artery (called a graft) from another part
of the body is used to bypass a blockage in one or more
of the coronary arteries.
• The type of graft used,
• a vein* from the leg,
• or an artery from the chest,
• depends on the number
• and location of the blockage.

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