Of All Antioxidants, Would One Finally Be Used Clinically For Atherosclerotic Disease?

Oxidation of LDL by oxygen free radicals results in unregulated uptake of modified LDL by macrophages in arterial wall. This is considered a key initiating factor for development and progression of atherosclerotic process. It is then logical to hypothesize that anti-oxidants, which can directly scavenge free radicals, can be useful in preventing atherosclerotic process. Initial support for this hypothesis accumulated rapidly from numerous in-vitro studies

Stratifikasi Risiko, Cost-Analysis dan Jaminan Kesehatan Nasional di Bidang Kardiovaskular

Mulai berlakunya sistem kesehatan nasional di Indonesia menandai era baru di bidang pembiayaan kesehatan nasional, dimana pembiayaan kesehatan yang sebelumnya didominasi oleh pembayaran tunai secara pribadi kini secara perlahan tapi pasti telah bergeser pada sistem asuransi, dimana keikutsertaan seluruh warga negara merupakan salah kunci sukses terselenggaranya sistem pembiayaan ini dengan baik. Berkaca pada pendapat para ahli di bidang pembiayaan kesehatan dan pengalaman negara-negara maju, tidak disangsikan lagi, ketika telah berjalan dengan sempurna sistem ini merupakan sistem pembiayaan terbaik. Tentu saja pada tahap awal pelaksanaan sistem jaminan ini masih terdapat beberapa kekurangan mendasar yang perlu mendapat perhatian serius untuk dapat segera diperbaiki.Seperti mengkonfirmasi data statistik yang telah ada tentang mortalitas dan morbiditas, BPJS kesehatan baru-baru ini me release data penyakit dengan pembiayaan kesehatan tertinggi dimana penyakit jantung dan pembuluh darah, keganasan (kanker) dan penyakit ginjal kronik merupakan 3 penyakit yang memuncaki tabel pengeluaran keuangan BPJS kesehatan.1 Penyakit jantung dan pembuluh darah berada di urutan pertama dengan jumlah pengeluara

Catheter Directed Thrombolysis pada Trombosis Vena Dalam Iliofemoral

Background Iliofemoral deep vein thrombosis (IFDVT) is associated with more severe outflow obstruction which results in more severe DVT symptoms and late clinical sequelae. Despite anticoagulation therapy, IFDVT patients is still at risk to develop postthrombotic syndrome (PTS). Recent studies found that additional catheter-directed thrombolytic therapy may offer advantages in reducing PTS and maintaining venous patency. Several ongoing multi-center randomized controlled trials are expected to evaluate safety and efficacy of CDT in IFDVT patients, and define who will benefit most.Case Illustration A 59-year-old male was presented with numbness, pain, and movement limitation in the left leg that were preceded by left leg swelling. Peripheral edema was found in both patient’s leg but more prominent on the left side. Dupplex sonography revealed extensive soft thrombus from left iliac vein to left tibialis vein. Initial anticoagulation therapy took no effect to the thrombus. Catheter-directed thrombolysis was performed and provided satisfactory symptoms resolution as well as thrombus dissolution.Summary A case of iliofemoral DVT has been reported. The present therapeutic strategy of anticoagulation therapy has not been proven to prevent PTS. CDT is an effective way in achieving clot lysis in acute thrombosis, and this may help to prevent PTS and subsequent ulceration. The potential benefits of therapy must be weighed carefully against the risk of bleeding. There are several ongoing RCTs that are awaited to help provide evidence on functional outcome after CDT and define who will benefit most.Latar Belakang : Trombosis vena dalam iliofemoral berhubungan dengan obstruksi aliran vena berat yang mengakibatkan gejala dan sekuele yang lebih berat. Pasien dengan kondisi ini memiliki risiko tinggi terjadinya sindrom pasca trombosis walaupun sudah mendapat terapi antikoagulan. Studi terkini menunjukkan bahwa terapi trombolisis dengan bantuan kateter memberikan manfaat dalam mengurangi sindrom pasca trombosis dan menjaga patensi vena. Beberapa randomized controlled trials besar sedang berjalan dan diharapkan dapat mengevaluasi keamanan dan efikasi tatalaksana ini pada pasien dengan trombosis vena dalam iliofemoral, dan juga menjelaskan siapa saja yang paling mendapat manfaat.Ilustrasi Kasus : Seorang laki-laki 59 tahun datang dengan keluhan baal, nyeri, dan sulit menggerakan tungkai kiri yang didahului dengan kaki bengkak. Edema perifer ditemukan pada kedua tungkai pasien namun lebih berat pada tungkai kiri. Duplex sonografi menunjukkan trombus yang ekstensif dari vena iliaka hingga tibialis kiri. Terapi antikoagulan saja tidak memberi efek terhadap trombus. Trombolisis dengan bantuan kateter dilakukan dan memberikan perbaikan gejala dan pengurangan trombus yang bermakna.Kesimpulan : Dilaporkan sebuah kasus trombosis vena dalam iliofemoral. Strategi tatalaksana terkini dengan antikoagulan tidak terbukti dalam hal mencegah sindrom pasca trombosis. Trombolisis dengan bantuan kateter adalah cara yang efektif dalam mencapai lisis bekuan darah pada trombosis akut, dan dapat membantu mencegah kejadian sindrom pasca trombosis. Potensi keuntungan dari terapi ini harus ditimbang baik-baik mengingat risiko perdarahan yang dapat terjadi. Saat ini terdapat beberapa randomized controlled trials besar yang sedang berjalan dan diharapkan dapat menyediakan basis bukti atas tatalaksana ini

Rokok, Perokok pasif, Kematian Kardiovaskular dan Jaminan Kesehatan

Peran rokok dalam menyebabkan kematian prematur akibat berbagai sebab/penyakit telah lama di-dokumentasi kan. Namun demikian, angka konsumsi rokok secara agregat masih terus meningkat.  Peto dan Lopez memproyeksikan, dengan pola konsumsi rokok saat ini, angka kematian akibat rokok di seluruh dunia pada tahun 2000-2050 akan mencapai 520 juta. Data dari berbagai penelitian epidemiologi menunjukkan sebagian besar kematian ini disebabkan oleh penyakit kardiovaskular dan secara demografis proporsi kematian dini akibat penyakit kardiovaskular ini  terjadi di Negara-negara berkembang di kawasan Afrika dan Asia Tenggara. Akibat yang sangat logis, mengingat data pada penelitian yang lain memperlihatkan bahwa lebih dari 80% prevalensi perokok di dunia berada di Negara dengan pendapatan perkapita rendah. Penelitian lain menunjukkan, di kawasan Eropa Timur, Asia Tengah dan Asia tenggara, sekitar 50% dari  seluruh penduduk berusia dewasa adalah perokok

Sel Punca Pada Penyakit Kardiovaskular: Kembali ke Bench

Ungkapan from bench to bedside sesungguhnya merupakan dambaan setiap peneliti yang bergerak dalam ilmu-ilmu dasar kardiovaskular, dimana penemuan yang mereka hasilkan dari laboratorium pada tingkat kultur sel sampai uji efektitivitasnya pada hewan coba dengan model penyakit kardiovaskular dapat men-emukan aplikasi klinik yang bermanfaat. Tidak semua temuan yang secara teoritis menjanjikan pada tingkat laboratorium maupun hewan coba dapat menunjukan efektivitas yang diharapkan pada uji klinik. Bahkan, ketika suatu modalitas yang secara meyakinkan menunjukkan potensi terapetik yang baik pada pe-nelitian laboratorium atau hewan coba, namun gagal pada tingkat uji klinik seringkali diuji kembali pada penelitian laboratorium untuk mencari pemecahan dari kegagalan pada uji klinik tersebut

Biomarker pada Infark Miokard Akut: Diperlukan yang lebih Dini

Paling tidak dalam 4 dekade terakhir, Infark Miokard Akut (IMA) masih menempati urutan pertama dalam daftar penyakit penyebab kematian di seluruh dunia. Secara historis, terdapat kemajuan yang sangat pesat dalam penatalaksanaan penyakit ini, baik dalam segi diagnostik, terapi medikamentosa, maupun tindakan revaskularisasi. Khususnya di bidang diagnostik, penggunaan 3 kriteria WHO yang meliputi nyeri dada tipikal, perubahan EKG dan meningkatnya biomarker (enzim) yang spesifik sangat membantu meningkatkan akurasi diagnostik IMA secara signifikan. Bandingkan, pada tahun 19401950 hanya sekitar 15 persen penderita yang dirawat di ICCU dengan dugaan ternyata benarbenar mengalami IMA. Kemajuan di bidang diagnostik juga diikuti oleh kemajuan yang sangat pesat dalam penata laksanaan IMA, dimana fokus utama tatalaksana IMA telah bergeser dari limitasi luasnya infark dengan cara menurunkan kebutuhan oksigen miokard menjadi terapi reperfusi, baik dengan cara farmakologi (fibrinolitik) maupun secara mekanik (Primary PCI

Elabela: novel perspectives on vascular physiology and disease

Recently, a novel endogenous ligand of APJ called elabela has been identified to play an important role in cardiovascular development. Elabela and its G-protein-coupled receptor APJ are widely expressed throughout the human body. These have been identified to play a significant role in diverse biological processes, especially in the normal and pathological cardiovascular system. In addition, increasing evidences indicate that elabela is also intimately associated with a large number of vascular physiological processes in adulthood, such as angiogenesis, vascular tone and atherosclerosis. However, a comprehensive summary of elabela in the vascular system has not been reported to date. In this review, we provide an overview of elabela in vascular physiology and diseases. Collectively, elabela, a potential biomarker and therapeutic peptide, exerts diverse biological vascular effects in adult.

The Protective Effect of Vitamin E for Reducing Intra-Hospital Mortality in Acute Limb Ischemia Patients

Background Management of acute limb ischemia (ALI) is still a huge challenge. Current advances of endovascular therapeutic approach in management of ALI have decreased the overall amputation rate, nevertheless, mortality rate remains high which may be caused by metabolic consequences of reperfusion injury. Aim To understand the role of vitamin E to intra-hospital and 30-day mortality among acute limb ischemia patients. Methods This retrospective cohort study included all patients with ALI between 2015 to 2018. Vitamin E 2x400 mg orally for seven days was given based on physician preference after ALI diagnosis was confirmed. Data were collected from Vascular Registries of National Cardiovascular Center Harapan Kita (NCCHK), Jakarta, Indonesia. Univariate analysis and logistic regression models were used to explore factors that contribute to intra-hospital and 30-day mortality. Results                                        A total of 160 patients with ALI involving 192 limbs were admitted to our hospital. Mostly were male (63.1%) and mean age were 56±13 years old. Majority of the patients had unilateral lesion (80%), and were diagnosed with Rutherford stage IIA (36.3%), followed by stage IIB (33.8%), stage I (20%), and stage III (10%) respectively. Intra-hospital and 30-day mortality were 28.1% and 36.9%, respectively. Low treatment of vitamin E increased intra-hospital mortality (HR 5,6 95%CI 1.7-18.3), however, it did not affect 30-day mortality. Other factors including IABP insertion, arrhythmia, bleeding requiring transfusion and acute renal failure were associated with higher intra-hospital and 30-day mortality. In addition, menopause (HR 3.2; CI 1.16-8.85) was also a predictor of 30-day mortality. Conclusion Vitamin E administration reduced intra-hospital mortality but not on 30-day mortality in acute limb ischemia patients. Keywords: Acute Limb Ischemia, vitamin E, mortality, reperfusion injur

Understanding Arteriosclerotic Heart Disease Patients Using Electronic Health Records: A Machine Learning and Shapley Additive exPlanations Approach

Objectives The number of deaths from cardiovascular disease is projected to reach 23.3 million by 2030. As a contribution to preventing this phenomenon, this paper proposed a machine learning (ML) model to predict patients with arteriosclerotic heart disease (AHD). We also interpreted the prediction model results based on the ML approach and deployed modelagnostic ML methods to identify informative features and their interpretations. Methods We used a hematology Electronic Health Record (EHR) with information on erythrocytes, hematocrit, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, leukocytes, thrombocytes, age, and sex. To detect and predict AHD, we explored random forest (RF), XGBoost, and AdaBoost models. We examined the prediction model results based on the confusion matrix and accuracy measures. We used the Shapley Additive exPlanations (SHAP) framework to interpret the ML model and quantify the contribution of features to predictions. Results Our study included data from 6,837 patients, with 4,702 records from patients diagnosed with AHD and 2,135 records from patients without an AHD diagnosis. AdaBoost outperformed RF and XGBoost, achieving an accuracy of 0.78, precision of 0.82, F1-score of 0.85, and recall of 0.88. According to the SHAP summary bar plot method, hemoglobin was the most important attribute for detecting and predicting AHD patients. The SHAP local interpretability bar plot revealed that hemoglobin and mean corpuscular hemoglobin concentration had positive impacts on AHD prediction based on a single observation. Conclusions ML models based on real clinical data can be used to predict AHD

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series [version 2; peer review: 2 approved]

Background Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion MSW technique is a simple and effective technique to modify aortic neck/iliac artery angulation in TEVAR or EVAR procedure