TOPIC 1

Afraid of the results of general medical check-up

CASE

Mr. Kasino, a 48-year-old office worker, comes to the doctor's office for a consultation on the results
of annual general medical check-ups that are routinely carried out by the company where he works.
At present, he has never felt any complaints. He is an active smoker. He has hypertension and
routinely takes ramipril 5mg daily. His father passed away because of a heart attack in 15 years
before. His brother suffered from coronary disease (CAD) and had already undergone coronary
artery bypass graft (CABG) surgery. Because of those conditions, he is so frightened that he wants to
consult a doctor.

The current physical examination reveals a bodyweight of 58 kg, a height of 168 cm, blood pressure
of 165/110 mmHg, strong radial artery pulsation, and apex pulsation was palpated in the fifth
intercostal space and left midclavicular line.

Laboratory examination reveals ureum of 23.5 mg/dl, creatinine of 1.05 mg/dl, fasting blood sugar of
101 mg/dl, 2-hour postprandial blood sugar of 143 mg/dl, HbA 1C 4.8%, total cholesterol of 205
mg/dl, LDL of 198 mg/dl, HDL of 35 mg/dl, and triglycerides of 208 mg/dl.

ECG:
REFERENCES

1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of
high blood pressure in adults: report from the panel members appointed to the Eighth Joint
National Committee (JNC 8). Jama, 2014; 311 (5), 507-520.
2. Lilly LS. Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and
Faculty 6th Edition, 2015.
3. Thaler M. The Only EKG Book You'll Ever Need 9th Edition, 2017.
4. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of
arterial hypertension. European heart journal, 2018; 39 (33), 3021-3104.
5. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald's Heart Disease: A
Textbook of Cardiovascular Medicine 11th Edition, 2018.
6. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of
dyslipidaemias: lipid modification to reduce cardiovascular risk: The Task Force for the
management of dyslipidaemias of the European Society of Cardiology (ESC) and European
Atherosclerosis Society (EAS). European heart journal, 2019; 41 (1), 111-188.
Kata2 sulit

Cue n Clue

 Mr kasino48 thn pekerja kantoran

 Perokok aktif
 Pykit hipertensi
 Pgbatan : ramipiril 5mg 1 kl sehari
 Riw keluarga : ayah meninggal krn srgan jantung kaka pykit jtg coroner sdh operasi cabg
 Fisik: bb 58kg tb 168 cm bp 165/110 mmhg nadiarteri kuat pulsasi apex ics 5 mcl kiri
 Lab : ureum 23,5 mg/dl kreatinin 1,05mg/dl gdp 101 mg/dl 2jam pp 143 mg/dl hba1c 4,8%
Total kolesterol205 mg/dl ldl 198 mg/dl hdl 35 mg/dl tg 208 mg/dl ekg sprit gambaran kasus
Interpretasi: ureum naik, kreatinin normal, gdp normal, 2jap pp normal, hba1c normal, total
kolesterol & LDL naik, HDL turun, TG naik
 EKG : lead II : tdpt p wave tdk jelas V1 smp V4 ada st elevasi Vi V2 V3 ada deep s V5 V6 left
ventricular strain dan st depresi downslope, QRS menyempit (hy 2 kotak)
Rate EKG: 60 bpm regular
 Gdp & 2 jam pp: prediabetes
 Pemfis: BMI 20,54 : normal BP hipertensi stage 2

Permasalahan

1. apa yg ditemukan EKG, pemeriksaan fisik, pemeriksaan lab? Diagnosis?

2. Penyebab hipertensi pd pasien? Factor resiko pykit cvs pada pasien?
3. Komplikasi yg akan terjadi
4. Pengobatan hipertensi sdh benar? Apa obat perlu dganti/ dtambahkan?
5. Tatalaksana pasien prediabetes
6. Pencegahan pd pasien

Brainstorming

1. EKG dan pemfis:

Menentukan irama: sinus krn p diikuti qrs frekuensi : 50 60/mnt axis: lead1 + avf + : normal
Ada kelainan left vent hypertrofi v1 deep s v5 v6 tall R
Sokolow lyon index : LVH krn s v1 + R V5 / V6 > 35 mm = memenuhi
Avl: R> 11mm = tdk memenuhi (ttp dx LVH)
Pemfis : pulsasi apex + perbesaran ventrikel kiri
LVH krn pressure overload stenosis aorta n hipertensi 2 hal : prolonged depolarisasi &
delayed repolarisasi (krn deep S wave di lead 3 AVR V1 smp V3)
V5 V6 depresi downslope Left ventricular strain. klo volum overload tidak ada
Inversi T & ST depresi di V5 V6 krn kelainan repolarisasi
ST elevasi di lead V1 smp V4 krn iskemi anteroseptal
Lihat posisi/ rotasi
Tdk ada transisonal zone di V3 = rotasi jantung clockwise ( k ventrikel)
 Lab: kolesterol total ldl naik hdl turun = dislipidemi. Ureum naik = ada congestive heart
failure
2. Fx resiko mayor: laki2, usia tua, perokok, dyslipidemia, tek sistol tinggi, diabetes, obesitas
Fx resiko hipertensi
Non modif: umur, laki2 2x > wanita, riw genetic
Modif: obesitas, merokok, krg akt fisik, konsumsi garam berlebih, alcohol berlebih,
dislipidemi, stress
Pybab hipertensi:
Primer: genetic, 90% tdk diidentifikasi bhbungan dgn keturunan , stress obesitas
Sekunder : multiple etiologi ex ; polycystic, chronic kidney disease, Urinary tract obstruction,
renin producing tumor, vaskuler ( coarcatio aorta, vaskulitis), hormonal, neurogenic,
obat2an
Pasien ada riwayat ayah srgan jantung kaka coronary disease hrs cek framingham score
(mntukan resiko coronary heart disease 10 thn kdepan)
Lk2 48 thn = 5 perokok=5 BP>160=8 48thn=3 HDL 35=2 total = 23 (resiko >30%)
ESC 2013 5 resiko= high risk
3. Komplikasi
 Aterosklerosis bs serangan jantung,, stroke, pykit arteri perifer, kehilangan
penglihatan krn pypitan pembuluh darah mata
 Aneurysma bs di otak
 Gagal ginjal krn pypitan pemdrh
 Gagal jantung krn kerja lebih keras mybabkan systolic dysfunction LV hipertrofi =>
diastolic dysfunction, o2 demand naik
 Demensia vaskuler (gang aliran darah ke otak)

Dyslipidemia komplikasi

 Aterosklerosis
 Peny jtg coroner
 Cerebrovascular= stoke

Hipertensi

 Angina/infark myocard
 Hipertrofi ventikel kiri
4. Hipertensi stage 2 perlu kombinasi 2 obat shg ramipril sj krng mbantu
Ramipril ACE inhibitor tepat unt pasien hipertensi
Kombinasi: CCB (bs dikombinasi kecuali dg thiazide)
Bradycardi: tdk boleh ca antagonis/ Beta blocker krn akan mprparah Bradycardi
5. Prediabetes: modifikasi gaya hidup = penurunan bb(0,5 smp 1 kg/week jk panjang 7% bb
tubuh), akt fisik (jalan cepat sebeda santai jogging berenang >= 130 mnt per minggu) makan
sehat
Lebih ke pola makan(3J jumlah jadwal jenis)
6. Pencegahan
 Resiko jantung: berhenti merokok, rutin periksa TD, kadar LDL, gula darah
 Kelola stress
 Mind map

penyakit
kardiovask
uler

pemeriksaa
faktor pemeriksaa
hipertensi n
resiko n fisik
penunjang

pressure
klasifikasi treatment laki laki merokok usia tua dislipidemi diabetes TTV EKG Lab
overload

Lo
1. Tatalaksana dyslipidemia farmako dan non
2. Algoritma tatalaksana hipertensi menurut stagenya farmako dan non
3. Pencegahan komplikasi hipertrofi jantung
4. Patofisiologi hipertensi & factor resiko