Navigating Your Acute Heart Failure Patient in Emergency and Pre-Discharge Phase

Heart failure (HF) leads to frequent hospitalizations. The presence of re-hospitalization risk among patientshospitalized for heart failure is important, especially hemodynamic instability and neurohormonal over activation. ARNI is needed to restore the balance of neurohormonal system in HF. PARADIGM-HF study provide insight on long term benefit of ARNI (i.e. sacubitril/valsartan) in ambulatory setting. How is the evidence of ARNI use for in hospitalization phase of HF? PIONEER and TRANSITION showed that initiation of sacubitril/valsartan shortly after an ADHF event is feasible and well tolerated. In-hospital initiation of sacubitril/valsartan is associated with early and sustained improvements in biomarkers of cardiac wall stress and myocardial injury, indicating pathophysiological benefits in a wide range of HFrEF patients

Increasing Age, Diabetes Mellitus and Beta Blocker Influence Heart Rate Recovery Values in Patients Undergoing Exercise Treadmill Test

Background: Heart disease is the number one cause of death globally. This disease is initiation affected by autonomic dysfunction which will cause disruption of the sympathetic-parasympathetic system. Heart Rate Recovery (HRR) is used to determineautonomic dysfunction.Objective: To determine the relationship of risk factors and cardiovascular treatment to HRR values of 1 minute and 2 minutes.Methods: Cross sectional study to measure HRR 1 and 2 minute undergoing exercise treadmill test for the screening of coronary heart disease in Saiful Anwar hospital in May 2016 until September 2017. Univariate analysis was performed to determine the frequency and proportion of HRR values classified into normal groups (HRR 1 minute > 12x / minute or HRR 2 minutes > 22x / minute) and abnormal groups (HRR 2 minutes ≤ 12x / minute or HRR 2 minutes ≤ 22x / minute).We also performed bivariate analysis using comparative test (Generalized Linear Model) and correlation test (Pearson, Spearman and Eta) and multivariate linear regression analysis.Results: This study found that age, hypertension and beta blocker were significantly associated with HRR abnormalities (p<0.05). HRR 1 and HRR 2 were significantly associated with diabetes mellitus (DM) (p=0.004 and p=0.039) and beta blocker (p=0.042 and p=0.039). Then looking at the relationship of multivariate correlations found a significant correlation between age (β=-0.133, p=0.000) and DM (β=-2.617, p=0.032) at 1 minute HRR and significant correlation with age (β=-0.165, p=0.004) and beta blockers (β=-2,947, p=0.017).Conclusion: increasing of age, diabetes mellitus and beta blockers correlate with decreasing of HRR. The most influential risk factors for HRR values of 1 minute were increasing age and DM, while for HRR values of 2 minutes were increasing age and beta blockers

Dealing with Sudden Cardiac Death: Who Deserves Device Implantation

Sudden cardiac death is one of the leading causes of death in the western industrial nations. Most people are affected by coronary heart disease (coronary heart disease, CHD) or heart muscle (cardiomyopathy). These can lead to life-threatening cardiac arrhythmias. If the heartbeat is too slow due to impulse or conduction disturbances, cardiac pacemakers will be implanted. High-frequency and life-threatening arrhythmias of the ventricles (ventricular tachycardia, flutter or fibrillation) cannot be treated with a pacemaker. In such cases, an implantable cardioverter-defibrillator (ICD) is used, which additionally also provides all functions of a pacemaker. The implantation of a defibrillator is appropriate if a high risk of malignant arrhythmias has been established (primary prevention). If these life-threatening cardiac arrhythmias have occurred before and are not caused by a treatable (reversible) cause, ICD implantation will be used for secondary prevention. The device can stop these life-threatening cardiac arrhythmias by delivering a shock or rapid impulse delivery (antitachycardic pacing) to prevent sudden cardiac death. Another area of application for ICD therapy is advanced heart failure (heart failure), in which both main chambers and / or different wall sections of the left ventricle no longer work synchronously. This form of cardiac insufficiency can be treated by electrical stimulation (cardiac resynchronization therapy, CRT). Since the affected patients are also at increased risk for sudden cardiac death, combination devices are usually implanted, which combine heart failure treatment by resynchronization therapy and the prevention of sudden cardiac death by life-threatening arrhythmia of the heart chambers (CRT-D device). An ICD is implanted subcutaneously or under the pectoral muscle in the area of the left collarbone. Like pacemaker implantation, ICD implantation is a routine, low-complication procedure today

Applicability of Recent Dyslipidemia Guidelines in Clinical Practice

Atherosclerotic plaque rupture is closely related to acute coronary syndromes.Stabilization of atherosclerotic plaque which slashes plaque rupture is as importantas regression ofplaque size for reducing cardiovascular events. Dyslipidemia therapy targeting to decrease LDL cholesterol reduces cardiovascular events such as acute myocard infarct, stroke, and death which are suggested to be the result of plaque stabilization. Dyslipidemia therapy also regress atherosclerotic plaque into a smaller volume. Plaque regression improves coronary flow responsible for the reduction of myocardial infarction incidence in patients with coronary heart disease (CHD).This paper consists of two parts. The first part discusses the evidence of cardiovascular event reduction with statin. The second part describes dyslipidemia management based on the 2017 Indonesian Heart Association (PERKI) Guideline on the Management of Dyslipidemi

Significance of Mitral M-Mode Vp (Velocity Propagation) for Estimating Mitral Valve Area and Severity in Mitral Stenosis

Background: Confirming mitral valve area (MVA) by planimetry is one of the standard procedures for assessing mitral stenosis but MVA were frequently need to be confirmed by other echocardiography parameters that only available in sophisticated centers. Our aim was to evaluate the significance of a simple mitral inflow color M-mode velocity propagation (Vp) for estimating MVA and MS severity.Methods: The best color view of MS jet were taken from apical 4 chamber, the nyquist limit were adjusted for aliasing the central highest velocity, then M-mode were applied to MV to calculate Vp by measuring the slope of the blue jet with the first aliasing velocity. MVA,PHT and mean transmitral gradient were analyzed with Pearson correlation and linear regression. Predictive discrimination value of Vp were analyzed by ROC.Results: Thirty one MS patients had mean MVA planimetry 0.99 ± 0.35 cm2 and mean Vp 64.49 ± 21.63 cm/s. Vp that were found to have a strong negative correlation with MVA (Spearman rho -0.865, p < 0.01). Vp had a good predictive discrimination value as from AUC 0.931. Vp were found to have a moderate correlation with MVA by PHT ( Spearman rho -0.621, p <0.01). Vp more than 55 cm/s had 93.8% sensitivity and 86.7% specificity to distinguish severe MS.Conclusions: By making use of the high temporal resolution of M-mode, a simple color Mitral M-Mode Vp were found statistically significant for estimating MVA severity in MS. Interventional decision for MS could also consider Vp for its strong correlation with MVA on MS, especially for helping on targeting moderate to severe MS in rural and limited centers

Correlation between Leptin with Diastolic Function in Young Adult Obesity

Background: Obesity is one of the global health problems with increasing prevalence, and the complication is related to the alteration of the left ventricle. An obese person without symptoms has impaired diastolic function compares to a normal population, but the mechanism is still unclear. One of the evolving theories is caused by chronic inflammation, characterized by the increase of proinflammatory adipocytokines in an obese person. Leptin is a chronic inflammatory marker which is synthesized by all adipose tissues and has a positive correlation with the body mass index. Leptin level are influenced by age except young adult group. The aim of this study is to investigate the correlation between leptin level and diastolic function of the left ventricle in youngadult obese.Method: This study was conducted in a single centre with cross-sectional design. The subject of this study consists of all young adult obese, worked in Dr. Hasan Sadikin General Hospital, between June-August 2018. The diastolic function of the left ventricle was measured by examining the ventricle relaxation (E/mean e’) by tissue doppler imaging method. The examination of leptin level was done by sandwich-ELISA testmethod. Pearson correlation test was done to assess the correlation between those two.Result: This study consisted of 38 patients with the mean of age 30.75±7.25 years old, 68% were males. The mean score of E/mean e’ was 6.49±3.02 ng/mL and the median of leptin was 13.95 (9.1–25.4) mg/L. After data log transformation of leptin was done, there was a significant positive correlation (r= 0.5892, p<0.001) between leptin level and E/mean e’.Conclusion: There was a significant correlation between the level of leptin and diastolic function of the left ventricle in young adult obese

Committee The 3rd JINCARTOS 2019

Committee The 3rd JINCARTOS 201

Two Cases of Acute Myocardial Infarction in Patients with Severe Aortic Stenosis and Normal Coronary Arteries

In patients with aortic stenosis (AS), the development of left ventricular systolic dysfunction and heart failure predicts poor prognosis. Myocardial ischemia, particularly of the circumferential sub endocardial region, commonly occurs in patients with severe AS duringhemodynamic stress, even in the setting of angiographically documented normal coronary arteries. We report two case patients who experienced of ischemic chest pain with ST-changes and undergoing a coronary angiography but we found normo coronary arteries and echocardiography with nomokinetic. These cases highlight the importance of the correlating between history taking, physical examination and other supporting examination, especially focused on bedside investigation like echocardiography in the management of patients presenting with chest pain

Moderated Case Reports

Moderated Case Reports Presentatio

Significance of Electrocardiographic QTc Interval on Assessment of Left Ventricular Diastolic Dysfunction in Hypertensive Patient: A Simple Screening Tool

Background: Diastolic dysfunction as part of heart failure with preserved ejection fraction (HFpEF) has gain interests, due to the increasing prevalence rate and poor prognosis. Besides the mechanism is not fully understood, there are some difficulties in detecting the presence of diastolic dysfunction. Previous studies have shown correlation between some electrocardiographic parameters and diastolic function. Furthermore, the aim of this study is to assess the diagnostic value of the QTc interval in detecting left ventricular diastolic dysfunction.Methods: A cross sectional study was conducted on patients with clinical suspicion of heart failure. Electrocardiographic examination was performed to obtain QTc interval (msec) using the Bazett formula. Left ventricular diastolic function was assessed using Tissue Doppler Imaging by echocardiography. Using correlation test and ROC method, the relationships between QTc interval and LV diastolic function were investigated.Results: Of 82 patients analyzed, there were 62 patients (75.9%) known to have diastolic dysfunction. The QTc interval was found to be longer in the group with diastolic dysfunction compared to the normal group (442.9±27 vs. 402.1±18.2, p <0.001). There was a strong negative correlation between the QTc interval and diastolic function (r = -0.619; p <0.001). Using ROC analysis, the cut off point for QTc interval was 410 ms with 91% sensitivity, 70% specificity, and 90% positive predictive value.Conclusion: The QTc interval is an accurate, simple and highly feasible electrocardiographic parameter as a screening tool to determine the presence of left ventricular diastolic dysfunction