Hemoglobin Variability as Risk Factor of Left Ventricle Dilation in Chronic Kidney Disease Patient on Routine Hemodialysis

Background: Several patients with chronic kidney disease (CKD) undergoing routine hemodialysis (HD) have abnormalities of left ventricle (LV) morphology with feature LV dilation due to volume overload and chronic ischemia, which has high risk of mayor adverse cardiovascular event. Anemia causes LV dilation through high output state mechanism. Anemia management in CKD patients causes hemoglobin (Hb) fluctuations or hemoglobin variability (Hb-Var) which is thought to cause LV dilation through relative repetitive ischemia mechanisms. Research linking Hb-Var as risk factor for LV dilation has never been done.Method: Matched case-control study was carried out by taking echocardiographic data of CKD patients undergoing routine HD in HD Unit Dr. Sardjito hospital. The LV diameter is divided into samples with LV (+) dilated profile as a case group, and LV (-) dilated as a control group. Matching was done on variables of age, gender and HD frequency. The HbVar parameter was calculated by the residual SD method based on the Hb value in the last 6 months. Fisher-Exact hypothesis test was used to assess the relationship between Hb-Var and LV dilation, while the logistic regression test was used for multivariate testing.Result: Total of 79 subjects entered in this study, there were 23 subjects of case groups and 28 subjects of control group after matching and adjusting the control formula. The proportion of high Hb-Var in the group with dilated LV (+) and dilated LV (-) were 21.7% and 17.9%, respectively. The Fisher-Exact test shows that there is no relationship between HbVar and LV dilation, with OR 1.28 (95% CI 0.32-5.10). Logistic regression test shows that there are no variables that affect independently of LV dilation.Summary: CKD patients undergoing routine HD with high Hb-Var profiles do not have a higher risk of LV dilation than patients with low Hb-Var profiles

Diagnostic Performance Addition of Abnormal P Wave Dispersion on Moderate Risk Duke Treadmill Score Criteria in Detecting Severe Stenosis of Coronary Arteries in Stable Angina Pectoris Patients

Background: Moderate risk Duke treadmill score (DTS) in threadmill test (TMT), needs additional diagnostic tool to increase its sensitivity of detecting severe coronary artery stenosis in patients with stable angina pectoris. A P wave dispersion (PWD) during TMT currently has a significant relationship with DTS value and can increase the sensitivity in identifying an ischemia. This studyaimed to investigate whether the addition of PWD in moderate risk DTS can improve the prediction of the severity of coronary artery stenosis in patients with stable angina pectoris. Methods: This study is a diagnostic test with cross-sectional design. The subjects were patients who had undergone TMT and coronary angiography at the Dr. Sardjito General Hospital Yogyakarta. The outcomes were sensitivity and specifi city of abnormal PWD in moderate risk DTS patients for predicting the severe stenosis in those with stable angina pectoris as compared with moderate risk DTS and normal PWD.Results: The additional of PWD at moderate risk DTS on 64 subjects had a sensitivity of 86.7%, a specifi city of 44.1%, a positive predictive value of 57.8%, a negative predictive value of 79.0%, a positive likelihood ratio of 1.6, a negative likelihood ratio of 0.3 and a prevalence of 46.9%, witha prediction accuracy of 64.1%. Conclusion: The additional of abnormal PWD in moderate risk DTS had a sensitivity of 86.7% and a specificity of 44.1% for severe coronary artery stenosis in patients with angina pectoris.Keywords: P wave dispersion, moderate risk Duke treadmill score, severe coronary stenosis

Common Atrium in Ellis Van-Creveld Syndrome

Single atrium is a complete absence of atrial septum.1 It is often found in Ellis-van Creveld Syndrome. Ellis-van Creveld Syndrome is a chondral and ectodermal dysplasia that is characterized by short ribs, polydactyly, growth retardation and also ectodermal and heart defects. We report a male, 18 years old who came with worsening of dyspnea. At physical examination we found short stature, polydactyly, cardiomegaly, severe scoliosis, genu valgum and nail hypoplasia. Transthoracic echocardiography showed the complete absence of atrial septum with signs of pulmonary hypertension.Keywords: common atrium, Ellis-van Creveld Syndrome, polydactyl

Association Between Coronary Artery Lesion Severity and Erectile Dysfunction in Stable Coronary Heart Disease Patients

Background: Atherosclerosis is the underlying process of coronary heart disease. Atherosclerosis is preceded by endothelial dysfunction caused by systemic mechanical and chemical stressors that may occur throughout the blood vessels. Recent studies have found the link incidence of atherosclerosis in the coronary arteries and other arteries as well. Erectile dysfunction (ED) is a clinical manifestation might be caused by atherosclerosis in iliac or pudendal artery. Previous studies have established the relationship between coronary artery involvement and the incidence of ED, but the odds of risk has not been well established. Methods: This was an age matched-paired case-control study. Erectile dysfunction in CHD patients who had undergone coronary angiography was checked by IIEF - 5 questionnaire. The severity of coronary artery lesion was assessed with a Syntax score from coronary angiography results. Moreover these results were assessed by a single experienced observer, blind method and were shown consistency test. Then, the risk of coronary artery lesion severity of the ED was analyzed by chi square test using SPSS version 20. Result: There were 86 subjects consist of 57 subjects in the case group and 29 subjects in thecontrol group. Stable CHD patients with high Syntax scores had 2.75 times risk for development of ED compare with low Syntax scores patients (OR : 2.75, 95 % CI : 1.08 to 6.95, p = 0.03). The severity of coronary artery lesions assessed with Syntax scores were not statistically signifi cant as an independent factor as the incidence of ED. Conclusion: Stable CHD patients with higher severity of lesions in coronary artery have a higher risk of erectile dysfunction than patients with lower severity of the lesion but was not statistically significant as an independent factor on the incidence of ED.Keywords: Severity of coronary artery lesions, erectile dysfunction, stable coronary heart diseas

Low Plasma Atherogenic Index Associated with Poor Prognosis in Hospitalized Patients with Acute Myocardial Infarction

Aim: the impact of atherogenic index of plasma (AIP), calculated as logarithmic of triglyceride:HDL ratio (log10.[TG:HDL]), on major adverse cardiovascular events (MACE) during acute myocardial infarction (AMI) has not been fully accepted. This study aims to investigate the role of AIP in predicting major adverse cardiovascular events following AMI during intensive care in the hospital. Methods: this was a prospective cohort study. We enrolled subjects with AMI hospitalized in intensive coronary care unit at Dr. Sardjito General Hospital, Yogyakarta. The AIP was measured in fasting blood within 24 hours of hospital admission. The total cholesterol, LDL, HDL, and triglyceride (TG), were measured and AIP value was determined as log10.[TG:HDL]). Based on AIP value, subjects were allocated into low AIP (<0.24) and high AIP (≥0.24). The outcome of the study was major adverse cardiovascular events during hospitalization, i.e. multipart of all cause mortality, acute heart failure, cardiogenic shock, reinfarction, and rescucitated VT/VF. Results: among 277 subjects, the high AIP group comprised 213 subjects (77%) and low AIP group comprised 64 subjects (33%). During intensive hospitalisation, 66 subjects (24%) developed MACE and 20 subjects (7%) developed fatal outcome (all cause mortality). The incidence of MACE tended to be higher in low AIP group, however its difference was not significant. The incidence of all cause mortality was significantly higher in low AIP group (14%) than in high AIP group (5%). Multivariable analysis showed that low AIP predicted all cause mortality independently with a risk ratio 3.71 (95% CI 1.26 – 10.97, p=0.02). Conclusion: low AIP value (<0.24) is an independent predictor for all cause mortality in patients with acute myocardial infarction undergoing intensive hospitalisation

Role of Traditional Cardiovascular Risk Factors for the Occurrence of Erectile Dysfunction in Patients with Coronary Artery Disease

Background: Erectile Dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient to permit satisfactory sexual intercourse. Erectile dysfunction affects more than 150 million men worldwide and impairs psychological well-being and personal relationships, hence quality of life. Recent studies have shown that ED is present in 42% to 76% of men with coronary artery disease (CAD). Epidemiological study showed clearly role of traditional cardiovascular risk factors such as diabetes, hypertension, dyslipidemia and smoking in CAD. Erectile dysfunction and vascular diseases share a similar risk factors and pathogenic involvement of nitric oxide (NO)-pathway leading to impairment of endothelium-dependent vasodilatation (early phase) and structural vascular abnormalities (late phase). This study was conducted to determine whether the stable CAD patients who have traditional cardiovascular risk factors has a higher risk for ED compared with stable CAD patients without traditional cardiovascular risk factors. Methods: We performed an age matched-paired case control study. Men with CAD documented by angiography were evaluated for ED. Erectile function was assessed by a 5-item version of the International Index of Erectile Function (IIEF-5). Traditional cardiovascular risk factors such as diabetes, hypertension, dyslipidemia and cigarette smoking were assesed. Depression and anxiety were screened using Indonesian version of Hospital Anxiety and Depression Scale (HADS). Basic demographic and other variables were also collected. Results: This study evaluated 127 men, 96.8% of them had traditional cardiovascular risk factors, 25.2% had diabetes mellitus, 77.2% had dyslipidemia, 55.9% had hypertension and 64.6% were smoker. Traditional cardiovascular risk factors was strongly associated with ED (OR=10.67 [1.25-232.83]). ED was independently associated with diabetes mellitus (OR=4.17 [1.14-15.24]), hypertension (OR=2.64 [1.07-6.49]) and cigarette smoking (OR=2.26 [1.01-5.75]). Conclusion: CAD patients with traditional cardiovascular risk factor had more risk for developing ED than those with no traditional cardiovascular risk factor

Nilai Diagnostik Duke Treadmill Score untuk Mendeteksi Keparahan Lesi Koroner pada Pasien yang Terduga Penyakit Jantung Koroner Stabil

Background: Duke Treadmill Score (DTS) is a well known score to stratify prognosis with good diagnostic value in predicting number of diseased coronary arteries in ischemic heart disease patient. DTS has also been shown to have a strong correlation with the severity of coronary lesion based on the Syntax score. However, the diagnostic value of DTS in predicting the coronary lesions severity based on Syntax score has not been well established.Methods: Cross-sectional study was performed in Dr. Sardjito General Hospital based on data from 1st January 2012. Patients with positive exercise test results and already had coronary angiography were included in the study. DTS was calculated based on the assessment of the exercise test result and Syntax score I was measured from the coronary angiography result.Results: There were 76 patients with average age of 56.64±7.41 year old consisting of 53 male subjects (70%) and 23 female subjects (30%). Hypertension was found to be the most common risk factors in 57 subjects (75%), dyslipidaemia in 33 subjects (43.3%), Diabetes Mellitus in 27 subjects (35.5%), smoking in 24 subjects (31.6%) and family history in 1 subject (1.3%). Subjects with high Syntax score and the low Syntax score were found in 30 subjects (39.5%) and 46 subjects (60.5%) respectively. In this study, the DTS diagnostic value in predicting high Syntax score was determined by the value of area under the curve based on the the Receiver Operating Characteristic (ROC) curve analysis was 92% (95% CI: 86%-97%, p&lt;0.0001). Moreover, DTS with value -8.5had 83% sensitivity, 82% specificity, 75% positive predictive value, 88% negative predictive value, and 83% accuracy to predict high Syntax score.Conclusion: DTS has a good diagnostic value in predicting coronary lesions severity, particularly in patients with suspected stable coronary artery diseases. DTS value of -8.5 has shown to have the best cut point in this study.Latar Belakang: Duke Treadmill Score (DTS) diketahui dapat menunjukan stratifikasi prognosis dan memiliki nilai diagnostik yang baik dalam memprediksi jumlah arteri koroner yang terlibat pada populasi pasien dengan penyakit jantung iskemik. Selain itu, DTS juga terbukti memiliki korelasi yang kuat dengan keparahan lesi koroner yang dinilai berdasarkan nilai Syntax. Walaupun demikian, belum ada data mengenai nilai diagnostik DTS dalam memprediksi keparahan lesi koroner berdasarkan nilai Syntax.Metode: Penelitian ini merupakan studi potong lintang di RSUP Dr. Sardjito dengan menggunakan data sejak 1 Januari 2012. Pasien dengan Uji Latih Treadmill (ULT) positif, telah dilakukan angiografi koroner, dan memenuhi kriteria inklusi dan eksklusi dimasukan ke dalam penelitian. Penilaian DTS dilakukan berdasarkan hasil ULT dan nilai Syntax I berdasarkan hasil angiografi koroner. Dilakukan analisis statistik untuk mengetahui nilai diagnostik DTS guna mendeteksi keparahan lesi koroner berdasarkan nilai Syntax.Hasil: Didapatkan 76 pasien dengan rata-rata usia 56,64±7,41 tahun yang terdiri atas laki-laki sebanyak 53 subjek (70%) dan perempuan sebanyak 23 subjek (30%) dengan faktor risiko terbanyak adalah hipertensi yaitu 57 subjek (75%), diikuti dislipidemia sebanyak 33 subjek (43,3%), DM sebanyak 27 subjek (35,5%), merokok sebanyak 24 subjek (31,6%), dan riwayat keluarga menderita PJK sebanyak 1 subjek (1,3%). Total subjek yang memiliki nilai Syntax tinggi sebanyak 30 subjek (39,5%), dan nilai Syntax rendah sebanyak 46 subjek (60,5%). Pada penelitian ini didapatkan nilai diagnostik DTS untuk memprediksi nilai Syntax tinggi berdasarkan nilai area bawah kurva berdasarkan analisis dengan kurva Receiver Operating Characteristic (ROC) adalah sebesar 92% (95% IK: 86%-97%; p=0,000). Duke Treadmill Score -8,5 memiliki nilai sensitivitas sebesar 83%, spesifisitas sebesar 82%, nilai duga positif sebesar 75%, nilai duga negatif sebesar 88%, dan akurasi 83% untuk mendeteksi lesi koroner dengan nilai Syntax tinggi.Kesimpulan: Duke Treadmill Score memiliki nilai diagnostik yang baik untuk mendeteksi derajat keparahan lesi koroner pada pasien yang terduga penyakit jantung koroner stabil. Nilai batas prediksi yang dapat digunakan untuk mendeteksi derajat keparahan lesi koroner adalah DTS -8,5

Rehabilitation Program in a Patient Undergoing Mitral and Aortic Valve Replacement Surgery

Heart disease due to valvular anomaly has increased prevalence along with increasing age. The operative management including reparation or substitution with prosthetic valve is the main therapy. Still becoming question mark either rehabilitation program is benefcience for patient undergoing valvular surgery. We report a patient with heart failure due to valvular heart disease and underwent double valve replacement surgery. Cardiac rehabilitation phase 1 and phase 2 was done. Patient feel physical condition is much better than before. 

The Effects of Aerobic Exercise on Functional Capacity of Geriatric Chronic Heart Failure Patients

Background: Chronic heart failure, a condition predominantly affecting the elderly, is a major clinical burden and cause death in admission patients especially the elderly population.  The focus of cardiac rehabilitation recently is exercise used as one of the modality of therapy designed for stable heart failure patients.  Exercise is recommended as one of modality in management of heart failure to improve prognosis, increase physical activity tolerance and quality of life of heart failure patients. Aim: The objective of this study is to understand is aerobic exercise program can improve functional capacity in geriatric heart failure patients. Methods: The design of this study is randomized controlled trial.  Twenty subjects were cardiology outpatient clinic at Dr Sardjito hospital men and women with chronic heart failure functional class I-II of NYHA age > 60 years and agreed to be included to the study.  Subjects were divided into two group randomly, which were the exercise group (10 subjects) and the control group (10 subjects).  To compare the functional capacity of both groups, t-test independent is used with condition of normal data range and Mann Whitney test is used if abnormal data range is found. The level of significance was set at p<0,05 with confidence interval 95% Result : Comparison of the mean increase in the six minute walk test distance between aerobic exercise group 107.9 ± 22.153 meters compared with the control group 21.3 ± 16.166 was significantly better in the aerobic exercise group (p <0.001) Conclusion : Aerobic exercise can improve the functional capacity of patients with chronic heart failure in the elderly. Keyword: chronic heart failure, elderly, aerobic exercise, functional capacity.

Functional Capacity Improvement on Patent Ductus Arteriosus with Pulmonary Arterial Hypertension: A Case Report and Literature Review

Pulmonary artery hypertension (PAH) is a pathophysiological disorder involving a wide range of clinical conditions. This can be a condition of complications from heart disease and respiratory system. Pulmonary arterial hypertension is defined as an increase in mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg at rest assessed by right heart catheterization. The cardiovascular rehabilitation program is a set of efforts to improve the underlying cause of cardiovascular disease such that it can maintain or restore the best conditions and secondary prevention. Cardiac rehabilitation and physical exercise programs have the benefit of improving pulmonary vascular endothelial function, physical activity capacity and quality of life parameters for PAH patients. A 6-minute walk test can be used to assess the functional capacity of PAH patients