Pleno Skenario b Blok 15 30 Januari 15

Oleh

Dr. Liniyanti D. Oswari.MNS.MSc

Tanggal 30 Januari 2015

PLENO SKENARIO B BLOK 15

Skenario B Blok 15 Tahun 2015 Mr. Manaf, a-57 year-old man, an accountant,

comes to MH hospital because of shortness of breath since 3 hours ago. In the last 3 weeks he became easily tired in daily activities. He also had night cough, nausea, and lost of appetite. Seven months ago he was hospitalized due to chest discomfort.

Past medical history: treated hypertension, heavy smoker, rarely exercised

Family history: no history of premature coronary disease

Physical Exam: Orthopneu,height 167 cm, body weight 79

kg,;BMI=27.3 BP 180/110 mmHg, Hypertension HR 122 x/min irregular, PR 102 x/min,

irregular, unequal, RR 32 x/min.Pallor, JVP (5+0) cmH2O, rales (+),

wheezing (+), liver: palpable 2 fingers below the costal arch, and minimal ankle edema

Laboratory results:  Hemoglobin: 12,8 g/dl, WBC: 8.500/mm3, Diff count:

0/2/10/60/22/6, ESR 20 mm/jam, Platelet: 225.000/mm3. Total cholesterol 325 mg/dl, LDL 215 mg/dl, HDL 35

mg/dl, Triglyceride 210 mg/dl, blood glucose 110 mg/dl. Urinalysis: normal findings.SGOT 55 U/L, SGPT 45 U/L, CK NAC 92 U/L, CK MB

14 U/L, Troponin I 0,1 ng/ml

Additional examinations:ECG: atrial fibrillation, LAD, HR 120 x/min, QS pattern

V1-V4, LV strainChest X-ray: CTR > 50%, shoe-shaped cardiac, Kerley’s line (+), signs of cephalization

Questions

 What is the main problem of this

patient?What are the pathogenesis of those

problems?What are the management of those

problems?

Learning objectives1. Memahami anatomi dan fisiologi jantung dan pembuluh

darahnya.2. Memahami patogenesis penyakit jantung koroner dan

penyulitnya3. Memahami faktor risiko penyakit jantung koroner4. Memahami patogenesis gagal jantung5. Memahami hubungan anamnesis dan pemeriksaan fisik

dengan penegakan diagnosis kerja6. Memahami interpretasi hasil pemeriksaan penunjang 7. Memahami tatalaksana penyakit jantung koroner 8. Memahami tatalaksana gagal jantung 9. Mengetahui prognosis gagal jantung 

Synthesis:Hipertensidisfungsi diastolikLVHdispneu d’effortHipertensi, obesitas, dislipidemi, sedentaritas aterosklerosistekanan darah meningkat, insufisiensi koronerangina pektorisLVHpeningkatan tekanan atrium kiridilatasi atrium kiripeningkatan tekanan vena pulmonalisedema parudispneu, ralesInfark miokarddisfungsi sistolikkongesti paruedema parudispneu, ralesDisfungsi sistolik/diastolikpeningkatan tekanan vena pulmonalispeningkatan tekanan arteri pulmonalis (hipertensi pulmonal)peningkatan tekanan di ventrikel dan atrium kananJVP meningkat, hepatomegali, edema tungkai Hypotesis :Mr. Manaf, a-57 year-old man suffered from congestive heart failure due to hypertensive heart disease and coronary artery disease

Am J MEd. 1999;107;254-261 Myocardial Infarction in Young Patients

Cigarette SmokingSmoking produces endothelial

dysfunction and can precipitate coronary spasm.

Cigarette smoking appears to be the most common risk factor in young MI patients.

The extent of smoking appears to be inversely related to the age at which the first MI occurs.

Risk Factors for Atherosclerosis

Etiology - risk factors; additive effectFamily historyAge and sexObesityDyslipidemiaHypertensionPhysical inactivityAtherogenic dietDiabetes mellitusImpaired fasting glucose/ metabolic syndrome

Cigarette smoke

HatiHati

Sumber Kolesterol Endogenous & Exogenous

Faeces asam empedu & Sterol netral

Exogenous

Jaringan Ekstrahepatik

Endogenous

Kolesterol Kolesterol makananmakanan

(~300–700 (~300–700 mg/day)mg/day) Intestine

Adapted from Champe PC, Harvey RA. Biochemistry. 2nd ed. Philadelphia: Lippincott Raven, 1994; Glew RH. In Textbook of Biochemistry with Clinical Correlations. 5th ed. New York: Wiley-Liss, 2002:728-777; Ginsberg HN, Goldberg IJ. In Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998:2138-2149; Shepherd J Eur Heart J Suppl 2001;3(suppl E):E2-E5; Hopfer U. In Textbook of Biochemistry with Clinical Correlations. 5th ed. New York: Wiley-Liss, 2002:1082-1150.

Kolesterol empeduKolesterol empedu (~1000 mg/day)(~1000 mg/day)~700 mg/day

Sintesa(~800 mg/day)

© Continuing Medical Implementation ® …...bridging the care gap

Prevention Goals for CVD

VariableVariable GoalGoalSmoking Total Cessation

Total Dietary Fat / Saturated Fat < 30% calories / < 7% calories

Dietary Cholesterol < 200 mg/day

Physical Activity 30-45 min. moderate intensity 5X/week

Body Weight by Body Mass index Initial BMI Weight Loss Goal 25-27.5 BMI < 25 > 27.5 10% relative weight loss

LDL cholesterol (primary goal) 1.6 – 2.2 mmol/L (60-85 mg/dL )

HDL cholesterol (secondary goal) 1.0 mmol/L ( > 40 mg/dL )

Triglyceride (secondary goal) 1.7 mmol/L ( < 150 mg/dL )

Blood Pressure < 130/80 mmHg (< 120/80 for LVD)

Diabetes HbAlc < 7.0 %

Image courtesy of the Internet Stroke Center at Washington University - www.strokecenter.org

•Dapat dilihat agregasi Thrombosit untuk meresponse Sel busa kimiiawi dan kerusakan jaringan.•Thrombosit dapat mengaktivasi koagulasi yang berakibat produksi Fibrin yang akan menangkap Thrombosit, Sel darah merah dan Putih pada area itu membentuk thrombussumbatan•Pada pembuluh darah besar perlu waktu lebih lama thrombus menyumbat total pembuluh darah. Ini sebagai peringatan terjadi.(TIA,= Transient Ischemict attack) dar istroke bila tersumbat di Otak dan Myocardia Infarct bila tersumbat di pemb uluh darah jantung.•Proses ini dapat terjadi dimana saja termasuk otak dan jantung.

Image courtesy of the Internet Stroke Center at Washington University - www.strokecenter.org

Penyakit Jantung Koroner (PJK)

MVS 110: Lecture #11

Athrogenesis

Kadar Lemak yang dianjurkanTotal cholesterol: <200 mg/dLLDL cholesterol: <130 mg/dLHDL cholesterol: >35 mg/dLTriglycerides: <200 mg/dL

Kadar Kolesterol yang diinginkanNormal = < 200 mg/dl (5.2 mmol/L)Batas = 200-239 mg/dl or (5.2-6mmol/L)Hypercholesterolemia>240 mg/dl or > 6mmol/L)

Specific Dyslipidemias:Very High LDL Cholesterol (190 mg/dL)

Management :LDL- Total Cholesterol lowering drugs

Statins (higher doses)Statins + bile acid sequestrants(colestipol or Cholestyramine)

Statins + bile acid sequestrants + nicotinic acid(Niacin high dose)

Side Effect Statin: Myalgia or Myopathia

Specific Dyslipidemias: Elevated Triglycerides (150 mg/dL)

Causes of Elevated Triglycerides

Obesity and overweightPhysical inactivityCigarette smokingExcess alcohol intakeHigh carbohydrate diets (>60% of energy intake)Several diseases (type 2 diabetes, chronic renal

failure, nephrotic syndrome)Certain drugs (corticosteroids, estrogens, retinoids,

higher doses of beta-blockers)Various genetic dyslipidemias

Specific Dyslipidemias:Elevated Triglycerides

Management of Very High Triglycerides (500 mg/dL)

Goal of therapy: prevent acute pancreatitisVery low fat diets (15% of caloric intake)Triglyceride-lowering drug usually required (fenofibrate

or nicotinic acid)Reduce triglycerides before LDL lowering

Side effect of fenofibrate : skin rash, decrease of WBC and Hemotocrite, Increase liver Function (SGOT,SGPT, Alkaline Phospatase) , GIT & muscular symptoms

Specific Dyslipidemias:Low HDL Cholesterol

Management of Low HDL Cholesterol

LDL cholesterol is primary target of therapyWeight reduction and increased physical

activity (if the metabolic syndrome is present)Non-HDL cholesterol is secondary target of

therapy (if triglycerides 200 mg/dL)Consider nicotinic acid or fenofibrates

(for patients with CHD or CHD risk equivalents)

Side effect of Nicotinic acid(Niacine) : Vasodilatation, Unconfortable sensation of warmth

Lipoprotein pattern: atherogenic dyslipidemia (high TG, low HDL, small LDL particles)

LDL-cholesterol goal: <100 mg/dLBaseline LDL-cholesterol 130 mg/dL

Most patients require LDL-lowering drugsBaseline LDL-cholesterol 100–129 mg/dL

Consider therapeutic optionsBaseline triglycerides: 200 mg/dL

Non-HDL cholesterol: secondary target of therapy

Specific Dyslipidemias:Diabetic Dyslipidemia

TreatmentNutrition Therapy

Therapeutic Lifestyle Changes (TLC) developed as component of ATP-IIIModifications in fat, cholesterolRich in fruits, vegetables, grains, fiberLimit sodium to 2400 mgInclude stanol esters

Nutrition Therapy - Fat ModificationsTotal fat 25-35% of calories &Very-low-fat dietsSaturated fat < 7% of calories &Avoid trans fatsIncrease intake of monounsaturated fats &Polyunsaturated omega-6 fatty acidsIncrease intake of omega-3 essential fatty acidsLimit dietary cholesterol < 200 mg daily

Post Myocardial InfarctionReduction of potential arrhythmias

by elimination of caffeine and use of a liquid diet in the first 24 hours when nausea and choking are common

Reduction of cardiac workload with small, frequent feedings of soft or liquid foods (800-1200 kcal)

Individualization of sodium and fluids.

Management of CHFSodium restriction to reduce fluid

retention and cardiac workloadMay require sodium restriction as low as

500 mg but more moderate of 2-3 gm is more common

Weight control is essentialDiuretic and digoxin therapyFollow serum potassiumSmall frequent feedings

Makanan yang kaya akan kolesterol

1. Sebutir telur mengandung kolesterol sekitar: 200–300 mg2. Daging sapi, babi, kambing seberat 100 g : 84- 120 mg3. Hati Sapi seberat 100 g : 400-450 mg Hati ayam seberat 100 g : 600 mg4.Ayam tanpa Kulit seberat 100 g sekitar : 85 mg5. Udang seberat 100 g sekitar : 200 mg6.Cumi seberat 100g sekitar : 460 mg7. Otak seberat 100 g sekitar : 200 mg8.Ginjal 100 g sekitar : 380 mg.

Kebutuhan Cholesterol Orang Normal sekitar : 300 mg/hariKebutuhan Cholesterol Pasien Stroke & PJK: 150-200 mg/hari

Kolesterol hanya dijumpai pada Produk hewani.Bentuk cincin Struktur Kolesterol berbeda dengan lemak lainnya, tapi mirip dengan sterol lainnya.

Diet Supplements Fish Oil (source of omega-3 polyunsaturated fatty acids)

Salmon, flaxseed, canola oil, soybean oil and nutsAt high doses > 6 grams/day reduces TG by inhibition of VLDL-

TG synthesis and apolipoprotein B Possibly decreases small LDL (by inhibiting CETP)Several studies have shown lower risk of coronary events2 servings of fish/week recommended??Pharmacologic use restricted to refractory hypertriglyceridemia Number of undesirable side effects (mainly GI)

Soy Source of phytoestrogens inhibiting LDL oxidation25-50 grams/day reduce LDL by 4-8%Effectiveness in postmenopausal women is questionable

GarlicMixed results of clinical trials In combination with fish oil and large doses (900-7.2 grams/d),

decreases in LDL observed Cholesterol-lowering Margarines

Benecol and Take Control containing plant sterols and stanols Inhibit cholesterol absorption but also promote hepatic cholesterol synthesis 10-20% reduction in LDL and TC however no outcome studies AHA recommends use only in hypercholesterolemia pts or those with a cardiac

event requiring LDL treatment