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PENYAKIT JANTUNG KORONER: PENCEGAHAN DAN DETEKSI DINI Dr. Emanoel Oepangat SpJP , FIHA, FAPSIC Tangerang, 10 February 2018 – inconjunction with PIT IDI TANGERANG 2018

PENYAKIT JANTUNG KORONER: PENCEGAHAN …. dr...Penyakit Jantung Penyakit Jantung Koroner Penyakit Jantung Rematik Infeksi Hipertensi Katup Jantung Irama Jantung Penyakit Jantung Bawaan

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PENYAKIT JANTUNG KORONER:

PENCEGAHAN DAN

DETEKSI DINI

Dr. Emanoel Oepangat SpJP, FIHA, FAPSIC

Tangerang, 10 February 2018 – inconjunction with PIT IDI TANGERANG 2018

Penyakit Jantung

Penyakit Jantung Koroner

Penyakit Jantung Rematik

Infeksi

Hipertensi

Katup Jantung

Irama Jantung

Penyakit Jantung Bawaan

Gagal Jantung

10 Penyakit Penyebab Kematianutama di Indonesia

Data KEMENKES 20141. Cerebrovaskular atau pembuluh darah di otak

seperti pada pasien stroke.2. Penyakit jantung iskemik.3. Diabetes Melitus dengan komplikasi.4. Tubercolusis pernapasan.5. Hipertensi atau tekanan darah tinggi dengan

komplikasi.6. Penyakit pernapasan khususnya Penyakit Paru

Obstruktif Kronis (PPOK).7. Penyakit liver atau hati.8. Akibat kecelakaan lalu lintas.9. Pneumonia atau radang paru-paru.10.Diare atau gastro-enteritis yang berasal dari

infeksi

PENYAKIT

JANTUNG

KORONER

Arteri Koroner

DEFINISI :

Athero : Lemak,

Sclerosis : Pengerasan /

Penebalan

Proses aterosklerosis dimulai dari metabolisme lipidabnormal dan terpaparnya dengan berbagai faktorrisiko al; Hipertensi, Diabetes mellitus, terutama biladisertai gangguan genetik

Aterosklerosis

NormalFattystreak

Fibrousplaque

Athero-scleroticplaque

Plaquerupture/fissure &

thrombosis MI

Ischemic

stroke/TIA

Critical leg

ischemia

Cardiovascular

death

Stable angina

Intermittent claudication

Unstable

angina

}ACS

ACS, acute coronary syndrome; TIA, transient ischemic

attack

Atherothrombosis: a Generalized and Progressive Process

ACUTE CORONARY SYNDROMES

No ST elevation ST elevation

Unstableangina

NSTEMI STEMIStableangina

Source (Photos): Davies MJ. Heart. 2000;83:361-366.

CAD = coronary artery disease; NSTEMI = non-ST-segment elevation myocardial infarction;

STEMI = ST-segment elevation myocardial infarction.

Spectrum of CAD/ACS

PENCEGAHAN PENYAKIT

JANTUNG KORONER

Non-Modifiable

Risk Factors

Increasing age

Male Gender

Family Hx

Ethnic Origin

Modifiable

Risk Factors

Smoking

Hypertension

Dyslipidemia

Diabetes Mellitus

Obesity

High Calorie Diet

Physical Activity

SCORE chart: 10-year risk of fatal CVD in populations at high and low CVD risk based on the following risk factors: age, sex, smoking, SBP, and

total cholesterol (TC). Note that the risk of total (fatal + non-fatal) CVD events will be approximately three times higher than the figures given.

Chapter: How to assess risk

From: The ESC Handbook of Preventive Cardiology: Putting Prevention into Practice

Editor(s): Catriona Jennings, Ian Graham and Stephan Gielen

Downloaded from Oxford Medicine Online.Reproduced from The ESC Textbook of Preventive Cardiology, Gielen et al. with permission of Oxford University Press.

Risk Stratification

Identifies risks

Important as IHD risks are SYNERGISTIC

Risk Stratification

Calculates ABSOLUTE risk of CVD event in 10 years

1) Age

2) Sex

3) Cholesterol

4) BP

5) Smoking

Multiple independent

risk factors (silo approach)Integrated identification and management of risk

factors contributing to CVD risk

(global approach)

HT

N

Hyp

erc

ho

lest

ero

lem

ia

Dia

bete

s

Traditional CVD perspective

New CVD risk perspective

Age

GenderDM

Hyper-

cholesterol-

emia

HTN

New targets andgoals for therapy

Reduction of

total CVD risk

is the primary

goal

Smoking

Organ

damage

New Paradigm: Multi-Risk Factor

Approach

CVD: Cardiovascular disease;

DM: Diabetes mellitus; HTN: Hypertension

Volpe M, et al. J Human Hypertens. 2008;22:154–157.

1. Kelebihan berat badan dan Obesitas

Kelebihan berat badan ( BMI > 25/23 kg/m2 ) atau

obesitas ( BMI > 30/27.5 kg/m2 ),

Obesitas sentral : risikolebih tinggi

Mengurangi berat badandengan diet yang benar danmeningkatkan aktivitas fisik

Penurunan berat badan menurunkan tekanan darah, kadarkolesterol, glukosa darah

Obesity, BMI, Waist circumference

Subcutaneous Fat

Abdominal Muscle

Layer

Intra-abdominal

Fat

Visceral Adiposity:

The Critical Adipose Depot

2. Tekanan darah

Target tekanan darah < 140/90

mmHg

Mengubah pola hidup

Olah raga teratur

Diet rendah garam

(<2 g/hari)

Menurunkan BB

Penurunan 2mmHg

TDS, risiko PJK 7%,

Stroke 10%

Terapi obat

ACC Guidelines ESC Guidelines

Figure 13.2 Initiation of lifestyle changes and antihypertensive drug treatment.

Chapter: Managing blood pressure

From: The ESC Handbook of Preventive Cardiology: Putting Prevention into Practice

Editor(s): Catriona Jennings, Ian Graham and Stephan Gielen

Downloaded from Oxford Medicine Online.G. Mancia, R. Fagard, K. Narkiewicz, 2013 ESH/ESC Guidelines for the management of arterial hypertension, European Heart Journal, 2013; 34(28):2159–219 by permission of Oxford University Press.

Partners in Healthcare Education, LLC 2009

Lifestyle Modifications to Manage

HypertensionModification Recommendation Systolic Diastolic Chgs

Weight Reduction BMI 18.5-24.9 5-20mm/10 kg wt loss

Adopt DASH eating Diet rich in fruits 8-14 mm Hg

vegetables and low

fat with reduced

saturated and total fat

Dietary Sodium 2.4g Na 2-8 mm Hg

Physical Inactivity Brisk exercise 30” day 4-9 mm Hg

most days of week

Moderation of

Alcohol intake 2 drinks day max 2-4 mm Hg

24 oz beer; 10 oz wine

2 oz 100 proof whiskey

JAMA. 2003:289:2560-2577.

Target kontrol glukosa darah pada diabetes tipe 2 yakni :

kadar glukosa darah puasa 110 mg/dL,

post prandial 140 mg/dL,

HbA1C < 6.5 % dan menghidari hipoglikemia (ADA)

Pada pasien diabetes tipe II target yang lebih rendah bisa dicapai

dengan aman

Terapi obat profilaksis

Skrining keluarga dekat (Check-Up)

Keluarga dekat pasien dengan PJK prematur

(pria < 45 tahun dan wanita < 55 tahun) harus diskrining

untuk risiko koroner karena tingginya risiko PJK

3. Glukosa darah

(mg/dL)

Diagnostic Criteria for Diabetes,

IFG, and IGT

3.5

4.5

5.5

6.5

7.5

8.5

2.5 4.5 6.5 8.5 10.5 12.5 14.5

Normal

glucoseIGT

IFG + IGTIFG

2-h Postload Glucose (mmol/L)

Fasti

ng

Glu

co

se (

mm

ol/

L)

(mg

/dL

)

140 200

126

110

Diabetes

IFG = impaired fasting glucose.

American Diabetes Association. Diabetes Care. 2003;26(suppl 1):S5-S20.

7.0 11.1

Figure 15.1 Scottish Intercollegiate Guidelines Network (SIGN) Guideline 116: Management of Diabetes.

Chapter: Managing blood glucose

From: The ESC Handbook of Preventive Cardiology: Putting Prevention into Practice

Editor(s): Catriona Jennings, Ian Graham and Stephan Gielen

Downloaded from Oxford Medicine Online.Scottish Intercollegiate Guidelines Network (SIGN). Management of Diabetes. Edinburgh: SIGN; 2010. (SIGN publication no. 116).

4. MENILAI ARTI KOLESTEROL

Total Cholesterol Level Category

Less than 200 mg/dL Desirable

200-239 mg/dL Borderline high

240 mg/dL and above High

LDL Cholesterol Level LDL Cholesterol Category

Less than 100 mg/dL Optimal

100-129 mg/dL Near optimal/above optimal

130-159 mg/dL and above Borderline high

160-189 mg/dL High

190 mg/dL and above Very high

NCEP-ATP III

HDL 40 mg/dL resiko tinggi PJK

HDL 40 mg/dL resiko rendah PJK

TG 150-199 mg/dL Borderline high

TG 200 mg/dL High

HDL dan Triglyserid

LDL Cholesterol

is

The Primary Target

in Dyslipidemia Treatment

NCEP ATP III 2003/ NCEP ATP III Update 2004

ADA/ACC Guideline Update for Secondary Prevention 2006

ESC/EAS Guidelines for the management of Dyslipidemias 20112013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce

Atherosclerotic Cardiovascular Risk in Adults

ADA Standards of Medical Care in Diabetes 2015

Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004; 9(2): 269-279

LDL-C achieved mg/dL (mmol/L)

WOSCOPS – Placebo

AFCAPS - Placebo

ASCOT - Placebo

AFCAPS - Rx WOSCOPS - Rx

ASCOT - Rx

4S - Rx

HPS - Placebo

LIPID - Rx

4S - Placebo

CARE - Rx

LIPID - Placebo

CARE - Placebo

HPS - Rx

0

5

10

15

20

25

30

40(1.0)

60(1.6)

80(2.1)

100(2.6)

120(3.1)

140(3.6)

160(4.1)

180(4.7)

6

Secondary Prevention

Primary Prevention

Rx - Statin therapyPRA – pravastatinATV - atorvastatin

200(5.2)

PROVE-IT - PRA

PROVE-IT – ATV

TNT – ATV10

TNT – ATV80

On-Treatment LDL-C is Closely Related to

CHD Events in Statin Trials – Lower is Better

CORONA - RxCORONA - Placebo

Recommendation for treatment target LDL-C

(ESC/EAS 2011)

Recommendation Class Level

VERY HIGH CV risk (established CVD, DM type 1

&2 with target organ damage, severe CKD or SCORE

level > 10%) the LDL-C goal is < 70 mg/dl and or

> 50% reduction when target level cannot be

reached

I A

HIGH CV risk (markedly elevated single risk factor, a

SCORE level > 5 to < 10%), an LDL-C goal < 100

mg/dl

II a A

MODERATE risk (SCORE level >1 to< 5), an

LDL-C goal < 115 mg/dl

II a C

European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J. 2012;33:1635–1701

Clinical ASCVD

• High-Intensity statin (age ≤75 years)

• Moderate-intensity statin if >75 years or not a candidate for high-intensity statin

LDL-C ≥190 mg/dL

•High-intensity statin

•Moderate-intensity statin if not a candidate

for high-intensity statin

Diabetes ; age 40-75 years*

• Moderate-intensity statin

• High-intensity statin if estimated 10 year ASCVD risk ≥7.5%

Estimated 10-yr ASCVD risk ≥7.5%†;

age 40-75 years*

• Moderate- to high-intensity statin

ASCVD Statin Benefit GroupsHeart healthy lifestyle habits are the foundation of ASCVD prevention

2013 ACC/AHA Guideline Recommendations

for Statin Therapy

ASCVD prevention benefit of statin therapy may be less clear in other groups . Consider additional factors

influencing ASCVD risk , potential ASCVD risk benefits and adverse effects, drug-drug interactions, and patient

preferences for statin treatment.* With LDL-C of 70-189 mg/dL† Estimated using the Pooled Cohort Risk Assessment Equations

Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the

American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(suppl 2):S1-S45

http://www.cvriskcalculator.com/

High-Intensity Statin

Therapy

Moderate-Intensity Stain

Therapy

Low-Intensity Statin

Therapy

LDL–C ↓ ≥50% LDL–C ↓ 30% to <50% LDL–C ↓ <30%

Atorvastatin (40†)–80 mg

Rosuvastatin 20 (40) mg

Atorvastatin 10 (20) mg Rosuvastatin (5) 10 mg Simvastatin 20–40 mg‡

Pravastatin 40 (80) mg Lovastatin 40 mg

Fluvastatin XL 80 mg

Fluvastatin 40 mg bid

Pitavastatin 2–4 mg

Simvastatin 10 mg

Pravastatin 10–20 mg

Lovastatin 20 mg

Fluvastatin 20–40 mg

Pitavastatin 1 mg

Lifestyle modification remains a critical component of ASCVD risk reduction, both prior to and in concert with the use of cholesterol

lowering drug therapies.

Statins/doses that were not tested in randomized controlled trials (RCTs) reviewed are listed in italics

†Evidence from 1 RCT only: down-titration if unable to tolerate atorvastatin 80 mg in IDEAL

‡Initiation of or titration to simvastatin 80 mg not recommended by the FDA due to the increased risk of myopathy, including rhabdomyolysis.

Intensity of Statin Therapy

Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the

American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(suppl 2):S1-S45

ContinuousRhytmicalIntervalProgressiveEndurance

30 minutes: 3 - 4 times / week

5. EXERCISE

Target nadi: 60-80% nadi max (220-umur)

6. SMOKING KILLS...

Diagnosis dan Tata laksana

Diagnosis :

Anamnesa dan Pemeriksaan Fisik

Elektrokardiogram (EKG)

Uji latih jantung (Treadmill test)

Ekokardiographi (resting and stress)

Szintigrafi Miokard / PET Scan (Kardiologi Nuklir)

CT Scan jantung

Angiografi Koroner (non operatif)

• Angina klasikRasa tidak enak di daerah substernal, sifatnya tumpul, seperti ditekan / diperas, menjalar ke lengan kiri / leher, dapat disertai kesulitan bernapas, berdebar-debar, keringat, mual atau muntah

• Angina EquivalentTidak ada nyeri / rasa tidak enakdi dada yang khas, namun pasien menunjukkangejala gagal jantung mendadak(sesak napas), atau gangguan irama jantung(palpitasi, presinkop, sinkop)

Gejala Penyakit Jantung Koroner

Chest pain

DefiniteACS

Possible ACS

Chronic Stable Angina

Non Cardiac Diagnosis

Assess 12 lead ECG Goal = 10 minInitial assesment

– Hx

– PE

– EKG and EKG monitoring

– CXR

0 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-

sensitivity cardiac troponin assays.

Authors/Task Force Members et al. Eur Heart J

2015;eurheartj.ehv320

© The European Society of Cardiology 2015. All rights reserved. For permissions please email:

[email protected].

Acute Coronary Syndromes

Non-ST elevation ACS

ST-elevation MI

Cardiac marker +ve

Cardiac marker +ve

Unstable angina

Cardiac marker - ve

Initial assessment of patients with suspected acute coronary syndromes.

Authors/Task Force Members et al. Eur Heart J

2015;eurheartj.ehv320

© The European Society of Cardiology 2015. All rights reserved. For permissions please email:

[email protected].

ECG Ischaemia

12-Lead ECG *During* acute event

Inducible Ischaemia

1) Exercise ECG

2) Stress ECG/Echo

3) Myocardial Perfusion Scanning

Treadmill Test (Uji Latih Beban)

Echocardiogram

Scintigrafi Koroner

(Thallium Scanning)

CT-Scan Angiography (DSCT)

Kateterisasi Jantung

Tatalaksana dan Pengobatan

Tata laksana:

Prevensi sekunder dan primer

Pengobatan konservatif (obat – obatan)

Pengobatan invasiv (non operatif) denganmetode kateter

Operasi “Bypass” Jantung

Early Hospital Care In ACS

Tatalaksana

PTCA + Stent CABG

Coronary Angiography

Angioplasty dan Stenting

Operasi By-Pass

A- antiplatelets, ACE-I

B- beta-blocker, blood pressure control

C- cholesterol lowering, cigarette

smoking cessation

D- diet, diabetes management

E- exercise

“ A B C D E ”

Terima Kasih