Cardiac Prevention and Rehabilitation Dede Kusmana, MD, PhD, FACC Professor of Cardiology Head of Department of Cardiology and Vascular Medicine Faculty of Medicine University of Indonesia National Cardiovascular Center
Background
Incidence of Cardiovascular disease highly correlated with prevalence of risk factors (hyperlipidemia, hypertension, diabetes, smoking, obesity, sedentary lifestyle, Lp(a), fibrinogen, homocystein, Chlamydia, H-Pilory infection)*. *(Shibly UF. “Hubungan kadar homosistein plasma dengan asam folat dan vitamin B serum penderita penyakit jantung koroner di RS. Jantung Harapan Kita” (Tesis).FKUI;1987)). (Gotto A, Pownall H. “Manualof lipid 12
disorders”. Baltimore: William & Wilkins; 1999. p.60-335). (Berlinder JA, Navab M, Fogelman AM, Franks JS, Demer LL, Edwards PA, et al. “Atherosclerosis: Basic mechanism, oxidation, inflamantion and genetics”. Circulation 1995;91:2488-96)
Cardiovascular events in US decreased by management of risk factors : – 24% (Stop smoking) – 54% (plus exercise and lipid management)** **Goldman L, Cost Effectiveness
perspective in coronary heart disease, AMJ 1990,119(supll 3);733-40
Smoking prevalence on various studies Smoker percentage Author
Subject
Total Man
Woman
23.44
1.38
Ranti, ISF – West Java
General population
Maryono, J
Worker
Rasad, A
Doctor, employee
25.7 60.8
Kalim, H
Student 15 – 19 yo
53
2.2
25.25
Boedhi Darmajo et al, Monica 1988,Jakarta
General population
59.9
5.9
31.5
Boedhi Darmojo, et al Monica 1993,Jakarta
General population
56.9
6.2
30.6
46.62
3.92
33.97
Average
-
-
25.27 38,7 25.7 60.8
Background
Study in Jakarta revealed : Prevalence of hypertension was lower in heavy physical activity (12.0%) compare to moderate (44.8%) or low (43.2%) group (p<0.003), Hypercholesterolemia (13.2% : 50.8% : 36.0%) (p<0.0003).
ECG abnormality in regular exercise (19.0%),
non-regular exercise (22.7%), not exercise (58.3%) (p<0.05
Indonesia in Crisis situation How do we manage
?
Kusmana, D.(Medical Journal of Indonesia, vol. 10 No.1. Jan – Mar 2001)
Physical Activity , atherosclerotic process and blood pressure reduction.
Ornish D, Life-style modification regressed atherosclerosis process. (Circ 1998;80)
Niebauer; Risk factor intervention – moderate physical exercise – delayed atherosclerosis process. (JACC, 1996;28)
Hambrecht,R ; Endurance exercise improved ultra structure of skeletal muscle on heart failure patient.(JACC 1997;29) Spataro . Meta Analysis from 118 studies ( n = 3.331 subjects, n = 2.316 f cont), showed physical exercise blood pressure reduction on hypertension : SBP decreased -5 mmHg, and DBP -8 mmHg, in mild hypertension -13 mmHg and -8 mmHg respectively.(Med Sci Sport Exerc 1991)
Natural History of Cardiovascular Disease Coronary thrombosis
CV Death Stroke
Myocardial Ischemia
Myocardial infarction
Silent Angina Hibernation
Sudden death
Arrhythmia & Myocardial damage
Remodeling
CHD Ventricular dilatation
Atherosclerosis
LVH Congestive heart failure
Endothelial dysfunction RISK FACTOR hypercholesterolemia, blood pressure, Diabetes, smoking, thrombosis, fibrinogen
HEALTH
End stage Heart disease
Death
Figure: Risk factor, endothelial dysfunction and cerebro-cardiovascular death Kusmana, D. “Pengaruh tidak/stop merokok disertai olahraga teratur, dan/atau pengaruh kerja fisik terhadap daya survival penduduk di Jakarta : penelitian KOHORT selama 13 tahun” (Disertasi) 2002. p. 17
Pathophysiology Atherosclerosis Endothelial dysfunction :
Monocyte Lipid-Cluster
Endothelial barrier Monocyte
Subintima Endothelial permeability
Vesselwall
Monocyte migration
Endothelial adhesion
Monocyte adhesion
0.5 µm
Monocyte transmigration
Ross R, NEngl J Med340 (1999) &LusisAJ, Nature 407 (2000)
10.078x
Anatomy of the Atherosclerotic Plaque Fibrous cap Lumen
Lipid Core
Shoulde r
Intima Media
Elastic laminæ
Internal External
Matrix Metabolism and Integrity of the Plaque’s Fibrous Cap Brea kdow n
is s e h t Syn
IFN-γ
Collagen-degrading Fibrous cap Proteinases
– CD-40L +
+ + + + +
Lipid core Libby P. Circulation 1995;91:2844-2850.
IL-1 TNF-α MCP-1 M-CSF
Tissue Factor Procoagulant
Thrombosis of a Disrupted Atheroma, the Cause of Most Acute Coronary Syndromes, Results from: Weakening of
the fibrous cap Thrombogenicit
y of the lipid core
Illustration courtesy of Michael J. Davies, M.D.
Smoking, hyperlipidemia, hypertension, hyperglycemia Endothelial dysfunction Activation of NF-kB
+ Adhesion molecules
VCAM-1
P-selectin
+
TNF-a
+
ICAM-1
+
IL-1
CD40L
+ Interleukins
IL-6
+ IL-8
Matrix metalloproteinases Inflammation Plaque destabilization Acute phase proteins
Serum amyloid-A
CRP
Fibrinogen
Lipoprotein (a) Total Homocysteine Total Cholesterol (TC) Fibrinogen t-PA antigen TC/HDL ratio CRP CRP + TC/HDL ratio
0
1
2
3
4
Relative risk of future myocardial infarction
5
6
Cardiovascular Risk Profiles and follow up decisions** Low Risk: (Jakarta Score < 1 ) e.g, age 40 , normal weight, normal blood pressure, normal cholesterol, normal sugar, no smoking , good physical fitness ( > 8 Mets)
Moderate Risk: (Jakarta Score 2 - 4 ) e.g,normal weight, either one of Hypertension St 1, cholesterol > 239 mg/dl , sugar > 200 mg/dl, no smoking, age 50, average physical fitness (67 Mets)
Retest at intervals suggested in table 15
Counsel to lower the risk profile through risk factor modification , drugs Retest at one year
If low, follow the Table 15
If still moderate, reapeat every one year depend on Exercise ECG result (positive –high risk, negative –moderate risk High Risk: (Jakarta Score > 5) e.g, obese, Hypertension St 2 , cholesterol > 239 mg/dl, sugar > 200 mg/dl, smoking, age 50, low physical fitness ( < 5 Mets)
Counsel to lower the risk through modification risk factor. Drugs , depend on Exercise ECG result (positive –high risk, negative–moderate risk) Retest at one year
Positive Repeat to 6 weeks, if still positive perform Dobutamine stres test or Thalium or MSCT
Coronary arteriography
Kiat Menekan Proses Aterosklerosis Pengendalian faktor risiko konvensional Menekan laju kaskade inflamasi Hs CRP melalui olahraga Antibodi tnfα, CD40
Jakarta
Jakarta
AHA Guidelines
Smoking Cessation Lipid Management Physical activity Weight management Aspirin/other Antithrombotic agents ACE inhibitors Beta blockers Blood pressure control Diabetes Management Stroke Specific: Atrial Fibrillation Management, Drug and Alcohol Abuse Management
Adapted from Smith, Circulation 92:3, 1995
Tatalaksana Prevensi Primer Prioritas kardiologi preventif ialah : Pasien yang telah terbukti menderita PJK atau penyakit aterosklerotik lainnya Individu sehat yang memiliki risiko tinggi untuk menderita PJK atau penyakit aterosklerotik lainnya, oleh karena kombinasi berbagai faktor risiko, seperti merokok, hipertensi, dislipidemia (peningkatan kadar kolesterol total dan LDL, penurunan kadar HDL, dan peningkatan trigliserida), peningkatan kadar gula darah, terdapat riwayat keluarga yang mengalami PJK, premature/dini, atau yang memiliki hiperkolesterolemia berat, atau bentuk lain dari dislipidemia hipertensi dan diabetes melitus. Kerabat dekat penderita PJK dini atau penyakit aterosklerosis dan individu sehat dengan risiko tinggi. Individu-individu lain yang dijumpai berkaitan dengan praktekklinik sehari-hari.
Tabel Faktor Risiko Independen Utama Perokok Hipertensi Peningkatan kadar kolesterol serum total (dan LDL) Kadar kolesterol – HDL serum rendah Diabetes Mellitus Usia lanjut
