Era Jaminan Kesejahteraan Nasional: Tantangan dan Kesempatan untuk Standarisasi Pelayanan Kardiovaskular

Cerita dimulai dengan terbitnya Sistem Jaminan Sosial Nasional (SJSN) yang merupakan salah satu bentuk perlindungan sosial untuk menjamin seluruh rakyat agar dapat memenuhi kebutuhan dasar hidup yang layak.1 Sistem ini tentu saja ditunggu oleh berbagai pihak yang mengharapkan peningkatan kesejahteraan masyarakat dengan jaminan sosial dari negara

Disfungsi Autonom pada Pasien Penyakit Jantung Hipertensi Asimptomatik: Hasil evaluasi pemulihan laju jantung

Background.Imbalance of the autonomic nervous system has been known to have an important role in the pathophysiology of chronic heart failure (CHF). How early this imbalance occurs in CHF patients has not much been studied. We hypothesized that imbalance of the autonomic function evaluated with heart rate recovery (HRR) already occur in asymptomatic hypertensive patients with left ventricular hypertrophy (LVH) as subset of an early stage of CHF patients . Methods.Sixty two hypertensive patients (31 with LVH by echocardio-graphic criteria and 31 patients without LVH ) underwent treadmill exercise testing using the Bruce protocol and immediate supine on the recovery phase. Heart rate recovery was evaluated on minute 1 and 2 of the recov-ery phase and considered abnormal if = 18x/min in minute-1(HRR1) and = 42x/min in minute-2 (HRR2).Results.The mean HRR was significantly lower in hypertensive patients with LVH then the ones without LVH (19,48 ± 7,21 vs 26,45 ± 8,03) in minute-1, and (38,35 ± 11,19 vs 45,35 ± 9,97) in minute-2. An abnormal-ity in HRR1 percentage was found in 48.4% in patients with HHD and in 12.9% in patients without HHD. An inverse weak correlation (r = 0.329, p = 0.009) was found between LV mass index and HRR1.Conclusions.Abnormality of the HRR has already been found in hyper-tensive patients with LVH without signs or symptom of CHF suggesting an early occurrence of imbalance of the autonomic nervous system in early stage of CHF.Latar belakang. Gangguan keseimbangan dari sistem saraf autonom telah diketahui memiliki peran penting dalam patofisiologi gagal jantung kronik (GJK). Seberapa dini gangguan keseimbangan ini timbul pada pasien GJK belum terlalu banyak diteliti. Kami memiliki hipotesa bahwa gangguan dari keseimbangan sistem saraf autonom yang dinilai berdasarkan evaluasi pemulihan laju jantung (PLJ) sudah timbul pada pasien-pasien hipertensi dengan hipertrofi ventrikel kiri (HVK) yang asimptomatik sebagai subset pasien GJK tahap awal.Metode.Enampuluh dua pasien hipertensi (31 pasien dengan HVK berdasarkan kriteria ekokardiografi dan 31 pasien tanpa HVK) menjalani uji latih jantung dengan menggunakan protokol Bruce dan segera dibaringkan pada awal fase pemulihan. Pemulihan laju jantung dinilai pada menit 1 dan 2 dari fase pemulihan, dan dikatakan abnomal apabila =18 x/menit pada menit-1(PLJ1) dan =42 x/menit pada menit-2 (PLJ2).Hasil.Rata-rata PLJ secara signifikan didapatkan lebih rendah pada pasien-pasien hipertensi dengan HVK dibandingkan pasien-pasien hipertensi tanpa HVK (19,48 ± 7,21 vs 26,45 ± 8,03) pada menit-1, and (38,35 ± 11,19 vs 45,35 ± 9,97) pada menit-2. Didapatkan persentase PLJ1 yang abnormal pada 48.4% pasien dengan HVK dan pada 12.9% pasien tanpa HVK. Korelasi lemah didapatkan antara LV mass indexdan PLJ1(r = 0.329, p = 0.009).Kesimpulan. Abnormalitas PLJ sudah didapatkan pada pasien-pasien hipertensi dengan HVK tanpa tanda dan gejala gagal jantung. Hal ini menunjukan keberadaan gangguan keseimbangan dari sistem saraf autonom pada tahap awal dari GJK

Quality of Life Evaluation After Coronary Artery Bypass Graft Surgery in Patient who Underwent Phase III Rehabilitation Program

Background. Coronary artery bypass graft surgery (CABG) is one of the management for coronary artery disease. Cardiovascular rehabilitation usually conducted for recovery and improved quality of life. Questionnaire was used to evaluate quality of life. One of the quality of life instrument most commonly used is Questionnaire SF-36. So far there isnt any study to evaluate quality of life in patients post CABG who wish to follow rehabilitation program phase III in Indonesia. Methods and results.This is a cross sectional study conducted in the National Cardiovascular Centre (NCC) - Rehabilitation Division to patients post CABG in phase III rehabilitation program during 2004-2005. Subject was taken in consecutive sampling manner. Questionnaire SF-36 was handed directly or via mail. Validity and reliability test was done for the questionnaire form in Indonesia language. There were 112 patients, 34 patients did rehabilitation program in hospital and 78 were home-based. The characteristics between two groups were similar. Validity test using r product moment from Pearson to every questions in SF-36 showed r = 0,53-0.83 > 0,51 (r table) and Cronbach a= 0,855. SF-36 scoring was not significantly different among the two groups (in hospital rehab vs home-based rehab) and also control group (healthy). Conclusions. There were no difference in quality of life and aerobic ca-pacity in patients who performed rehabilitation program phase III in hospi-tal and home-based

Pharmacotherapy in Effort to Quit Smoking

Nicotine dependence is a main role in tobacco dependence. Its physiological and psychological effect make smoker difficult to quit, making low success rate in smoking cessation. Combination of different method and continuity will increase smoking cessation success rate. Evidence shown that pharmacotherapy will increase success rate. Guidelines for smoking cessation endorse physician to use first line pharmacotherapy, but its clinical application still limited. Physician should be aware about possibility for side effect. Some randomized controlled trial report major cardiovascular event in first line pharmacotherapy. Recent systematic review report no correlation between first line pharmacotherapy in smoking cessation and major cardiovascular event

Exercise-based cardiac rehabilitation adaptation protocol during Covid-19 pandemic achieved similar results as compared to non-pandemic usual practice: a single center experience

During the Covid-19 pandemic, exercise-based cardiac rehabilitation (EBCR)faced challenges. Adaptation protocols were implemented to circumvent thesechallenges. The study aimed to investigate whether the adaptation protocols ofEBCR during Covid-19 period influenced the result of cardiac rehabilitation. Thiswas a retrospective cohort study. The subjects were patients who underwentan EBCR program in Dr. Sardjito General Hospital. Yogyakarta, Indonesia. Theregistry of cardiac rehabilitation was obtained and divided into two periods:non-Covid-19 period and Covid-19 period. During the non-Covid-19 period,3 EBCR sessions per wk (10-12 total sessions) were performed. During theCovid-19 period, EBCR was reduced to 2 sessions per wk (10-12 total sessions).The functional capacities were evaluated as metabolic equivalents (METs) andexercise test time (min) by treadmill test. A total of 122 subjects completedthe EBCR. There were no significant differences in METs and exercise minuteachieved between two time periods. Among subjects with different sessionsper wk, namely 2, 3, and 4-5 sessions per wk, there were no significantdifferences in METs (7.01±1.89; 7.23±1.74; and 7.33±2.13, p=0.813) and minutesachieved (6.72±1.94; 6.96±1.96; and 6.81±1.84, p=0.848) in the end sessions. Inconclusion, the adaptation of EBCR protocols during the Covid-19 period byreducing the number of sessions per wk has similar results as compared to theusual regular EBCR practice

Factors Affect Heart Rate Recovery After Symptom-limited Exercise Stress Testing

Background. Heart rate recovery (HRR) has been recognized as an inde-pendent predictor of mortality. Objective.To identify factors that may affect HRR in patient with un-known coronary artery disease (CAD). Methods. This cross sectional study was performed in National Cardiac Center Harapan Kita. We reviewed the chart of patients with unknown CAD who underwent symptom-limited exercise stress testing for medical check up between January December 2006. Factors that may influence HRR were recorded including current medications, peak exercise heart rate (HR), HR after 3-minute recovery, and the ischemic response to exer-cise. HRR was defined as the change in HR from peak exercise to 3-minute recovery. We further categorized patients to normal or abnormal HRR by using mean HRR as cut off value. All factors related to HRR and normal/abnormal categories were analyzed. Results. There were 188 patients aged 48 + 11 years. HRR significantly influenced by male sex (p=0.003), hypertension (p=0.028), -blocker (p=0.03), calcium channel blocker (p=0.008), aspirin (p<0.001), and pro-voked ischemia (p=0.005). Using mean HRR (57x) as cut off, patients were classified as having normal (HRR <57x) or abnormal (HRR ? 57x). On fur-ther analysis, there was significant association between age (p=0.003), male sex (p=0.02), hypertension (p=0.02), use of -blocker (p=0.026) and aspirin (p<0.005). Conclusion. In patients with unknown CAD who underwent symptom-limited exercise stress testing, HRR was influenced by age, male sex, hy-pertension, the presence of provoked ischemia, use of -blocker, calcium channel blocker, and aspirin

Pengaruh Latihan Fisik Dan Respon Molekuler Pembuluh Darah Arteri

Regular physical activity (exercise training, ET) has a strong positive link with cardiovascular health. The beneficial effects of ET on the endothelium arteries are believed to result from increased vascular shear stress during ET bouts. A number of mechanosensory mechanisms have been elucidated that may contribute to the effects of ET on vascular function. Exercise training also consistently improves the nitric oxide bioavailability, and the number of endothelial progenitor cells, and diminishes the level of inflammatory markers, namely pro inflammatory cytokines and C-reactive protein. This review summarizes current understanding of control of vascular adaptation by exercise and how these processes lead to improved cardiovascular health.Aktivitas fisik yang dilakukan secara teratur mempunyai hubungan yang positif dengan kesehatan kardiovaskular. Efek latihan fisik yang menguntungkan pada endotel pembuluh darah arteri dipercaya akibat dari peningkatan shear stresspembuluh darah selama melakukan latihan fisik. Beberapa mekanisme mekanosensori yang terjadi karena efek latihan fisik ikut berperan pada fungsi pembuluh darah. Latihan fisik yang dilakukan secara terus menerus juga memperbaiki bioavailibilitas nitrik oksida, jumlah sel­sel progenitor endotel, dan menurunkan kadar petanda inflamasi, yaitu sitokin proinflamasi dan C­reactive protein. Tinjauan pustaka ini merangkum pengertian terkini tentang adaptasi pembuluh darah terhadap latihan fisik dan bagaimana hal tersebut dapat memperbaiki kesehatan kardiovaskular

Improvement of exercise capacity after early phase II cardiac rehabilitation in patients who undergo rheumatic mitral valve surgery

Background: Rheumatic heart disease still become a major concern in developing countries. Recent studies showed the benefits of early phase II cardiac rehabilitation (CR) on improving the exercise capacity but the evidence in patients after rheumatic mitral valve surgery due to rheumatic heart disease is limited. This study aims to investigate the effects of early phase II CR program on increasing exercise capacity in the rheumatic mitral valve surgery patients. Methods: This is a cohort retrospective study. A review of medical records identified 254 patients who underwent early phase II CR after rheumatic mitral valve &nbsp;surgery between July 2009 – June 2019. Effects of CR was assessed by 6 Minutes Walking Distance (6MWD) pre and post early phase II CR and peak oxygen uptake (VO2 peak) calculated by Cahallin formula. In this study, we observed and analyzed the increasing of 6MWD and VO2 peak. Results: Our findings showed that 6MWD and VO2 peak increased significantly in these patients after early phase II CR program (p = 0.001). Mean of 6MWD increased from 316.3 ± 71.7 meters to 378.6 ± 60.3 meters and VO2 peak increased from 7.7 ±2.4 mL/kg/min to 8.9 ± 2.2 mL/kg/min. The mean difference of 6MWD was 62.3 meters and VO2 peak was 1.2 mL/kg/min. There was a strong correlation between VO2 peak and 6MWD (r = 71%; R2 = 51%; p = 0.001). Conclusion: Early phase II CR in patients with Rheumatic Mitral Stenosis after mitral valve surgery improved the exercise capacity. Based on 6MWD, we can predict the value of VO2 peak patients with rheumatic mitral stenosis surgery patients. &nbsp; Keywords: Cardiac rehabilitation, rheumatic mitral stenosis, 6MWD, VO2 pea

Retrospective Study of the Association Between Platelet-to-Lymphocyte Ratio in Patients with Acute Coronary Syndrome on Admission to a Rural Referral Center in East Java, Indonesia, and the Incidence of New Symptomatic Heart Failure at 6 Months

BACKGROUND: This was a retrospective study conducted at a rural referral center in East Java, Indonesia, to evaluate the association between the platelet-to-lymphocyte ratio (PLR) on hospital admission and the incidence of new symptomatic heart failure (HF) within 6 months in patients with acute coronary syndrome (ACS). MATERIAL/METHODS: The study population consisted of all ACS patients who were hospitalized between 1 January and 31 December 2018 at a non-percutaneous coronary intervention-capable secondary referral hospital and came for a routine follow-up until 6 months afterwards. The diagnosis of new symptomatic HF was based on International Classification of Diseases 10(th) revision code I50.9. RESULTS: From 126 hospitalized patients, 92 patients were included in the analysis. The incidence rate of new symptomatic HF at 6 months was 70.65%. High PLR upon initial admission was significantly associated with new symptomatic HF incidence (odds ratio=1.70, P<0.001). PLR was also able to discriminate new symptomatic HF incidence at 6 months with area under the curve of 0.83 (P=0.001). Multivariate Cox regression analysis showed that PLR was an independent predictor for new symptomatic HF incidence (hazard ratio=4.5, P=0.001). CONCLUSIONS: In a rural center in Indonesia, the PLR was independently correlated with the onset of new symptomatic HF in patients with ACS 6 months after hospital admission. The PLR may be a supplementary biomarker for clinical outcomes in patients with ACS for use in resource-limited regions

Return to Sexual Activity After Coronary Artery Bypass Surgery

Surgical coronary revascularization can affect the quality of life and psychosocial functions, including the return of sexual activity. A 43-year-old male patient underwent four graft coronary artery bypass (CABG) surgery at National Cardiovascular Center Harapan Kita. The second phase of rehabilitation results showed patients functional capacity is 9.75 METs and ischemic negative response. Before surgery, patient often experienced chest pain during intercourse. The patient must consume sublingual isosorbide dinitrate (ISDN). Currently the patient is no longer feel chest pain during intercourse, but he was still afraid to do intercourse and reduce the activity frequency. Return to sexual activity after undergoing CABG surgery is a common concern. Cardiac rehabilitation program and sexual counseling can help patients to return to their sexual function and activity