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 ndonesia !ational Cardiovascular Center

-ac#ground

ncidence of Cardiovascular disease highly correlated "ith prevalence of ris# factors $hyperlipidemia, hypertension, dia%etes, smo#ing, o%esity, sedentary lifestyle, &p$a', fi%rinogen, homocystein, Chlamydia, H(Pilory infection')* )$+hi%ly UF* ,Hu%ungan #adar homosistein plasma dengan asam folat dan vitamin - serum penderita penya#it 0antung #oroner di 1+* 2antung Harapan Kita3 $4esis'*FKU 5.678''* $9otto A, Po"nall H* ,Manualof lipid
./

disorders3* -altimore: ;illiam < ;il#ins5 .666* p*=>(??@'* $-erlinder 2A, !ava% M, Fogelman AM, Fran#s 2+, Demer &&, Ad"ards PA, et al* ,Atherosclerosis: -asic mechanism, oBidation, inflamantion and genetics3* Circulation .66@56.:/C77(6='

Cardiovascular events in U+ decreased %y management of ris# factors :

/CD $+top smo#ing' @CD $plus eBercise and lipid management'))
))9oldman &, Cost Affectiveness
perspective in coronary heart disease, AM2 .66>,..6$supll ?'58??(C>

+mo#ing prevalence on various studies

Smoker percentage Author Ranti, ISF West Java Mar)ono, J Rasa+, A /alim, 0
2oe+hi ,armajo et al, Monica %1&&,Jakarta 2oe+hi ,armojo, et al Monica %11",Jakarta

Subject Man eneral population Worker ,octor, emplo)ee Stu+ent %' %1 )o eneral population eneral population !"#$$ * !'#( -.#& '" '1#1 '-#1 Woman %#"& * * * !#! '#1 -#!

Total

!'#!( "&,( !'#( -.#& !'#!' "%#' ".#-

Average

$-#-!

"#1!

""#1(

-ac#ground

+tudy in 2a#arta revealed : Prevalence of hypertension "as lo"er in heavy physical activity $./*>D' compare to moderate $CC*7D' or lo" $C?*/D' group $pE>*>>?', Hypercholesterolemia $.?*/D : @>*7D : ?=*>D' $pE>*>>>?'*
non(regular eBercise $//*8D', not eBercise $@7*?D' $pE>*>@

AC9 a%normality in regular eBercise $.6*>D',

ndonesia in Crisis situation Ho" do "e manage

Kusmana, D.(Medical Journal of Indonesia, vol. 10 No.1. Jan Mar 2001)

Physical Activity , atherosclerotic process and %lood pressure reduction*

Ornish D, Life-style modification regressed atherosclerosis process. (Circ

!!"#"$%

&ieba'er# Ris( factor intervention moderate physical e)ercise delayed atherosclerosis process. (*+CC, !!,#-"% .ambrecht,R # /nd'rance e)ercise improved 'ltra str'ct're of s(eletal m'scle on heart fail're patient.(*+CC !!0#-!% 1pataro . 2eta +nalysis from " st'dies ( n 3 4.44 s'b5ects, n 3 -.4 , f cont%, sho6ed physical e)ercise blood press're red'ction on hypertension 7 18P decreased -9 mm.g, and D8P -" mm.g, in mild hypertension - 4 mm.g and -" mm.g respectively.(2ed 1ci 1port /)erc !! %

!atural History of Cardiovascular Disease

Coronary thrombosis Myocardial infarction Arrhythmia & Myocardial damage

Sudden death

CV Death Stro e

Myocardial Ischemia CHD

Silent Angina Hibernation

Remodeling

Atherosclerosis

Ventricular dilatation

!VH Endothelial dysfunction RIS" #AC$%R hy&ercholesterolemia' blood &ressure' Diabetes' smo ing' thrombosis' fibrinogen Congestive heart failure

HEA!$H

End stage Heart disease

Death

Figure3 Risk 4actor, en+othelial +)s4unction an+ cerebro*car+iovascular +eath

Kusmana, D. Pen aru! "ida#$s"o% mero#o# diser"ai ola!ra a "era"ur, dan$a"au %en aru! #er&a fisi# "er!ada% da'a survival %endudu# di Ja#ar"a ( %eneli"ian K)*)+, selama 1- "a!un. (Diser"asi) 2002. %. 1/

Pathophysiology Atherosclerosis
Endothelial dysfunction :

Monocyte &ipid*+luster

Endothelial barrier Monocyte

/ubintima Endothelial permeability Monocyte migration Endothelial adhesion Monocyte adhesion ,- .m

" , (01

Vesselwall
Ross R, NEngl J Med34 !"###$ %&usis 'J, Nature 4 ( !)

Monocyte transmigration
$

+natomy of the +therosclerotic Pla:'e

Fibrous cap Lumen Lipid Core Shoulde r

Intima
Media Elastic lamin Internal External

2atri) 2etabolism and ;ntegrity of the Pla:'e<s =ibro's Cap

is s e h t Syn
Brea kdow n
Colla#en-de#radin# Fibrous cap Proteinases C -!"L + + + + + +
IL-1 TNF- MCP-1 M-CSF

IFN-

Lipid core
Libby P. Circulation 1995;91:2 !!"2 5#.

Tiss$e%Factor Procoa#$lant

>hrombosis of a Disr'pted +theroma, the Ca'se of 2ost +c'te Coronary 1yndromes, Res'lts from7
$ea%enin& o'

the 'ibrous cap

(hrombo&enicit

y o' the lipid core

Illustration courtesy o' )ichael *. +a,ies- ).+.

Smoking, hyperlipidemia, hypertension, hyperglycemia Endothelial dysfunction Activation of NF-kB

(
Adhesion molecules TNF-a

(
I$-,

(
Interleukins

!"#$

(
I$-/

+ A%-,

'-selectin

I A%-,

I$-.

%atri& metalloproteinases Inflammation 'la(ue desta)ili*ation Acute phase proteins

Serum amyloid-A

-'

Fi)rinogen

!i&o&rotein )a* $otal Homocysteine $otal Cholesterol )$C* #ibrinogen t+,A antigen $C-HD! ratio CR, CR, ( $C-HD! ratio

"

Relative ris of future myocardial infarction

Cardiovascular Risk Profiles and follow up decisions**

$o3 -isk4 56akarta Score 7 , 8 e9g, age "# , normal 3eight, normal )lood pressure, normal cholesterol, normal sugar, no smoking , good physical fitness 5 : / %ets8

-etest at intervals suggested in ta)le ,2

%oderate -isk4 56akarta Score 0 - " 8 e9g,normal 3eight, either one of ;ypertension St ,, cholesterol : 01< mg=dl , sugar : 0## mg=dl, no smoking, age 2#, average physical fitness 5.> %ets8

ounsel to lo3er the risk profile through risk factor modification , drugs -etest at one year If still moderate, reapeat every one year depend on E&ercise E ? result 5&ositive .high ris , negative @moderate risk

If lo3, follo3 the Ta)le ,2

High Ris / )0a arta Score 1 2* e3g' obese, ;ypertension St 0 , cholesterol : 01< mg=dl, sugar : 0## mg=dl, smoking, age 2#, lo3 physical fitness 5 7 2 %ets8

ounsel to lo3er the risk through modification risk factor9 !rugs , depend on E&ercise E ? result 5positive @high risk, negative.moderate ris 8 -etest at one year

,ositive Re&eat to 4 5ee s' if still &ositive &erform Dobutamine stres test or $halium or MSC$

oronary arteriography

?iat 2ene(an Proses +teros(lerosis

Pengendalian fa(tor risi(o (onvensional 2ene(an la5' (as(ade inflamasi .s CRP melal'i olahraga +ntibodi tnf@, CDA$

*a(arta

*a(arta

'2' 3uidelines

1mo(ing Cessation Lipid 2anagement Physical activity Beight management +spirinCother +ntithrombotic agents +C/ inhibitors 8eta bloc(ers 8lood press're control Diabetes 2anagement 1tro(e 1pecific7 +trial =ibrillation 2anagement, Dr'g and +lcohol +b'se 2anagement

Adapted from Smith, irculation <041, ,<<2

>atala(sana Prevensi Primer

Prioritas #ardiologi preventif ialah : Pasien yang telah ter%u#ti menderita P2K atau penya#it ateros#leroti# lainnya ndividu sehat yang memili#i risi#o tinggi untu# menderita P2K atau penya#it ateros#leroti# lainnya, oleh #arena #om%inasi %er%agai fa#tor risi#o, seperti mero#o#, hipertensi, dislipidemia $pening#atan #adar #olesterol total dan &D&, penurunan #adar HD&, dan pening#atan trigliserida', pening#atan #adar gula darah, terdapat ri"ayat #eluarga yang mengalami P2K, prematureGdini, atau yang memili#i hiper#olesterolemia %erat, atau %entu# lain dari dislipidemia hipertensi dan dia%etes melitus* Kera%at de#at penderita P2K dini atau penya#it ateros#lerosis dan individu sehat dengan risi#o tinggi* ndividu(individu lain yang di0umpai %er#aitan dengan pra#te##lini# sehari(hari*

>abel =a(tor Risi(o ;ndependen Dtama Pero(o( .ipertensi Pening(atan (adar (olesterol ser'm total (dan LDL% ?adar (olesterol .DL ser'm rendah Diabetes 2ellit's Dsia lan5't