Penyakit Jantung Koroner

(Coronary Heart Disease)

Dr. Refli Hasan, SpPD, SpJP(K)

Dept. Cardiology and Vascular Medicine
Fac. Medicine USU / Adam Malik Hospital
 Penyakit Jantung Iskemia

 Iskemia miokardial : merupakan

ketidak seimbangan antara suplai oksigen
dan kebutuhan miokardial.
 Ketidaksembangan akibat :
– Reduksi aliran darah koroner
– Suplai oksigen
Sekunder akibat peningkatan tonus vaskuler,
agregasi platelet,atau trombus
ANGINA PEKTORIS

INFARK MIOKARD
Normal Arterial Wall
Tunica adventitia
Tunica media
Tunica intima
Endothelium

Subendothelial connective
tissue

Internal elastic membrane

Smooth muscle cell
Elastic/collagen fibres

External elastic membrane

Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18

 Pathogenesis of
Atherosclerotic Plaques
Endothelial damage

Protective response results in production of

cellular adhesion molecules

Monocytes and T lymphocytes attach to

‘sticky’ surface of endothelial cells

Migrate through arterial wall to subendothelial space

Macrophages take up oxidised LDL-cholesterol

Lipid-rich foam cells

Fatty streak and plaque

The ‘Activated’ Endothelium
activated endothelium

cytokines (e.g. IL-1, TNF-)

CELLULAR
chemokines (e.g.MCP-1, IL-8) ADHESION
MOLECULES
growth factors (e.g. PDGF, FGF)

attracts monocytes induces cell

and T lymphocytes proliferation and a
which adhere to prothrombic state
endothelial cells

Adapted from Koenig W. Eur Heart J 1999;1(Suppl T);T19–26

Atherogenesis and Atherothrombosis:
A Progressive Process
Plaque
Athero- Rupture/ Myocardial
Fatty Fibrous sclerotic Fissure &
Normal Streak Plaque Plaque Thrombosis Infarction

Ischemic
Stroke

Critical
Leg
Clinically Silent Angina
Ischemia
Transient Ischemic Attack
Claudication/PAD
Cardiovascular Death
Increasing Age

3
 Clinical Manifestations
of Atherosclerosis
 Coronary heart disease
– Angina pectoris, myocardial infarction,
sudden cardiac death
 Cerebrovascular disease
– Transient ischaemic attacks, stroke
 Peripheral vascular disease
– Intermittent claudication, gangrene
Indonesia :
Thn 2001
29,7% kematian di Jawa
Bali akibat peny.jantung
dan p.darah
 ATP III: Major CHD Risk Factors
Other Than LDL-C
 Cigarette smoking
 Hypertension: BP 140/90 mm Hg or on
antihypertensive medication
 Low HDL-C: 40 mg/dL*
 Family history of premature CHD (1st-degree
relative):
– male relative age 55 years
– female relative age 65 years
 Age
– male 45 years
– female 55 years *HDL-C 60 mg/dL is a negative risk factor
and negates one other risk factor.
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services®
www.lipidhealth.org
 ATP III: Additional CHD Risk
Factors (Minor)
• Life-habit risk factors: targets for intervention; not
used to set lower LDL-C goal
– obesity
– physical inactivity
– atherogenic diet
Emerging risk factors: can help guide intensity of
risk-reduction therapy; do not categorically alter
LDL-C goals
– lipoprotein(a) – homocysteine
– impaired fasting glucose – prothrombotic and
– subclinical atherosclerotic proinflammatory
factors
disease
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services®
www.lipidhealth.org
FAKTOR RISIKO PADA PENDERITA
Infark Miokard Akut
RS JANTUNG HARAPAN KITA
FAKTOR RISIKO PERSENTASE
usia 28-72 tahun

•MEROKOK 68.0%
•HIPERTENSI 50.5%
•DISLIPIDEMIA 31.4%
•RIWAYAT KELUARGA 21.4%
•STRES 63.1%
•TIDAK PERNAH atau
KURANG OLAHRAGA 62.1%
 Efek Faktor Risiko Multipel Terhadap
Kemungkinan Penyakit Jantung Koroner:
Studi Framingham
42 40
10-Year % Probability

36
30
of Event

24 21
18 14
12 10
4 6
6
0
SBP 150-160 + + + + + +
Cholesterol 240-262 - + + + + +
HDL-C 33-35 - - + + + +
Diabetes - - - + + +
Cigarettes - - - - + +
ECG-LVH - - - - - +

Kannel. Am J Hypertens. 2000;13:3S-10S.

 KELUHAN
Angina

 Merupakan rasa tidak nyaman di dada

atau daerah sekitarnya disebabkan oleh
iskemia miokardial
 Dicetuskan oleh aktivitas fisik/aktivitas
atau emosional dan berkurang atau hilang
dengan preparat nitrogliserin
Dimana Rasa Nyeri
Dirasakan??
Penyakit Jantung Koroner

Angina Stabil

Angina Tidak stabil

Infark Miokard Akut Gagal Jantung

Kematian
Alat bantu diagnosa
EKG
 ECG merupakan salah satu instrumen pengukuran
medik tertua dalam sejarah. Alat ini bermula dari
percobaan Waller di tahun 1889 yang merekam
sinyal jantung pada anjing peliharaan
menggunakan elektrometer kapiler [5].
 Secara total, pengukuran ECG terdiri atas
pengukuran gelombang depolarisasi dan
gelombang repolarisasi. Gelombang radio yang
digunakan memiliki intensitas atau energi yang
rendah sehingga tidak membahayakan.
 Tahap evolusi terbesarnya terjadi di saat sistem
ECG diintregasikan dengan micro processor yang
hasilnya adalah peningkatan efisiensi pengukuran
dan digitasi yang membuka cakrawala baru
terhadap peralatan analitik dan intrepetasi data
medik.
EKG
ST Segment
T Wave
Treadmill Test
 Digunakan untuk menegakkan diagnosa
pasien dengan penyakit jantung koroner
khususnya dan penyakit jantung pada
umumnya sehingga pencegahan dapat
dilakukan, kematian dapat dihindari dan
harapan kualitas hidup dapat ditingkatkan.
 Cara noninvasif untuk mengkaji berbagai
aspek fungsi jantung, dengan mengevaluasi
aksi jantung selama dilakukan stress fisik,
respon jantung terhadap peningkatan
kebutuhan oksigen dapat ditentukan.
Manfaat Treadmill Test
 Membantu mendiagnosa penyebab nyeri
dada,
 Menentukan kapasitas fungsional jantung
setelah miokard infak atau pembedahan
jantung,
 Mengkaji efektivitas terapi pengobatan
antiangina dan antidisritmia,
 Mengidentifikasi disritmia yang terjadi
selama latihan fisik, dan
 Membantu mengembangkan latihan fisik
selama rehabilitasi.
Coronary Angiography
Coronary Angiography
of Stenotic Coronary Artery

Arrow indicates atherosclerosis (stenosis) of the coronary artery

Grading of Angina of Effort
by the Canadian Cardiovascular
Society
I. “Ordinary physical activity does not cause … angina,” such as
walking and climbing stairs. Angina with strenuous or
rapid or prolonged exertion at work or recreation.
II. “Slight limitation of ordinary activity.” Walking or climbing
stairs rapidly, walking uphill, walking or stair climbing
after meals, or in cold, or in wind, or under emotional
stress, or only during the few hours after awakening.
Walking more than 2 blocks on the level and climbing
more than one flight of ordinary stairs at a normal pace
and in normal conditions.
III. “Marked limitation of ordinary physical activity.” Walking one
to two blocks on the level and climbing one flight of
stairs in normal conditions and at normal pace.
IV. “Inability to carry on any physical activity without discomfort --
anginal syndrome may be present at rest.”
Circulation 1976; 54:522-523
MANAJEMEN
ANGINA PEKTORIS STABIL
 Tujuan manajemen :
mengurangi simtom /gejala/keluhan
angina dan iskemia berulang
(kualitatif)
mencegah infark miokard akut dan
kematian (mengurangi morbiditas dan
mortalitas )
Manajemen farmakologis

 Antiplatelet (Aspirin, Klopidogrel,

Glikoprotein IIb/IIIa, Adenosine
Diphosphate Inhibitors)
 Antiangina (Beta bloker, Ca antagonis,
Nitrat)
 ACE Inhibitor
 Penurun Kolesterol (statin)
Antiplatelet Agents to Prevent MI and Death
aspirin - Class I

 Aspirin 75 to 325 mg daily should be used routinely in all

patients with acute and chronic ischemic heart disease with or
without manifest symptoms in the absence of
contraindications
– aspirin exerts an antithrombotic effect by inhibiting cyclo-
oxygenase and synthesis of platelet thromboxane A2
– in >3,000 patients with stable angina, aspirin reduced the
risk of adverse cardiovascular events by 33%
– in patients with unstable angina, aspirin decreases the
short and long-term risk of fatal and nonfatal MI
– in the Physicians' Health Study, aspirin (325 mg), given on
alternate days to asymptomatic persons, was associated
with a decreased incidence of MI

ACC/AHA Guideline of Chronic Stable Angina 2001

Clopidogrel

 Diberikan bila ada riwayat

intoleransi terhadap aspirin
 Clopidogrel Blocks the
ADP Receptor

Platelet ADP

Fibrinogen Binding Site

Fibrinogen

Fibrinogen Binding Reduced

 Acts by selective inhibition of ADP binding to its platelet
receptor and prevents subsequent platelet aggregation
Herbert. Exp Opin Invest Drugs 1994;3:449-455.
Glycoprotein IIb/IIIa
Inhibitors
 50,000 receptors per platelet
 Aggregation final common pathway
 “Passivation”; stops deposition
 Abciximab (Reopro); tirofiban
(Aggrastat); eptifibatide (Integrilin)
and lamifiban (Canada)
 Pre-PCI/ Procedural Coronary
Intervention
BETA-BLOCKERS

 Mechanism of Action
– reduction in inotropic state and sinus rate
– slowing of AV conduction
– decreased myocardial oxygen demand, increased diastolic
perfusion time

 Clinical Effectiveness
– improve the survival rate of patients with recent MI
– improve the survival rate and prevent stroke and CHF in
patients with hypertension
– adjust the dose of -blockers to reduce heart rate at rest to
55 to 60 bpm
– increase in heart rate during exercise should not exceed
75% of the heart rate response associated with onset of
ischemia
ACC/AHA Guideline of Chronic Stable Angina 2001
Calcium Antagonists
Mechanisms of Action
 reduce the transmembrane calcium transport (L-,
T-, or N-type channels)
 alter myocardial oxygen supply and demand
– dilate epicardial coronary arteries
– reduce cardiac contractility
 nifedipine >> amlodipine and felodipine
– decrease heart rate
 verapamil and diltiazem (heart rate-modulating
calcium antagonists) can slow the sinus node and
reduce AV conduction
– reduce systemic vascular resistance and arterial
pressure
ACC/AHA Guideline of Chronic Stable Angina 2001
PREPARAT NITRAT

 Nitrat sublingual atau spray diberikan untuk

mengurangi keluhan angina dengan cepat
 Nitrat jangka panjang dan Ca antagonis
diberikan sbg terapi awal apabila terdapat
kontraindikasi Beta bloker
 Nitrat jangka panjang dan Ca antagonis
diberikan bila terapi dng Beta bloker tidak
berhasil
 Nitrat jangka panjang dan Ca antagonis bila
Beta bloker memberikan efek samping yang
tidak diinginkan
ACC/AHA Guideline of Chronic Stable Angina 2001
ACE INHIBITOR

 Kelas I :
pasien CAD yang juga menderita DM dan
atau penurunan fungsi ventrikel kiri

ACC/AHA Guideline of Chronic Stable Angina 2001

MANAJEMEN FAKTOR
RISIKO
 Tangani Hipertensi
 Stop merokok
 Atasi diabetes
 Program rehabilitasi yang komprehensif
 Penurunan kadar LDL pada suspect CAD
atau penderita CAD dengan kadar LDL >
130 mg/dl ,dng target <100mg/dl
 Penurunan berat badan pada penderita
obesitas
Intervensi Non Bedah
Indication for Cardiac
Catheterization
 Acute Myocardial infarction
– Primary PCI, refractory post infarct symptom, treatment
complication (VSD ruptured).
 ACS
– refractory symptom, high risk clinical features
 Stable angina
– high risk clinical symptoms
 Severe Asymptomatic ischemia
 Valvular heart diseases
 Congenital heart diseases
 Unexplained heart failure, Malignant Arhythmias or
resuscitated cardiac arrest
 Cardiomyopathy
 Risk Cardiac
Cathetherization
SCAI Registry
(%)
Mortality .11
Myocardial Infarction .05
Cerebrovascular accident .07
Arrhythmias .38
Vasclar complication .43
Contrast reaction .37
Hemodynamic complication .26
Perforation of heart chamber .03
Other complication .28
Equipment
Percutaneous Coronary
Intervention
 Percutaneous Coronary Intervention

Pre-Dilatation Dilatation Post-Dilatation Post- Stenting

Early indications Advance in Techical, equipment &

Angina Pectoris, myocardial ischemia
In :
Relatively stable Patients
Good LV function
Simple Stenotic Lesion
1 VD, proximal
Dicrete, Concentric,
nonCalsified
medications : enable to performed PCI in
more complicated setting
APTS
Acute Coronary Syndrome
Poor LV function
Elderly
Post CABG
Complicated Lesion ; bifurcatio, calcified
 Lower Rate of Restenosis with Stenting
(6 month follow-up)
Treatment Restenosis
External elastic External elastic lamina
lamina

Tunica media Internal

elastic
Internal elastic PTCA lamina
lamina
Intimal area

Treatment
Coronary
stenting
Intimal Stent
area
Lumen
Angioplasti /PCI

 Keberhasilan Primer : 85 - 95 %
 Kematian : 0.3 - 1.3 %
 Infark Miokard : 1.6 - 6.3 %
 Operasi By-pass darurat :1 - 7 %
 Stenosis lebih lanjut
sblm era stent: 30 - 40 %
era stent : 15-20%
Drug eluting stent : almost 0%
PTCA

 Benefits: ICH 0%,

 Complications: experience counts
>100 cases/yr/ea provider;
>600/yr/hospital
 Mortality: reinfarction 5 vs 12% for
TPA; 30 day same as TPA; but in
AWMI; age>70 pulse >100 rates 2%
vs 10% for TPA
 Trials: RITA, PAMI (93); MITI (96)
 Evolution of PCI for STEMI
AngioJet

Platelet

GP IIb/IIIa inhibitor Embolization

Protection Device

Thrombus
Balloon Antiplatelet Stent DES Removal and
Rx Distal
Embolization
Protection
Antman. Circulation 2001;103:2310.
Devices
Thank you