Indonesian Journal of Cardiology
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Clinical Profile of Acute Coronary Syndrome Patients in Kupang: a Result from 1-Year iSTEMI Registry
No full textBackground: Cardiovascular diseases (CVDs) have been the leading cause of global deaths over the years. In Indonesia, coronary heart disease (CHD) is the most common CVDs, responsible for 29% of all deaths in 2017. East Nusa Tenggara is one of the provinces in Indonesia with the highest prevalence of CHD, which corresponded with growing cases of acute coronary syndromes (ACS). Therefore, we develop a registry to obtain patients' profiles as a basis for strategy development in ACS management.
Methods: A retrospectively observational study was conducted on all patients who presented with ACS between January 2019 and September 2020 at a general hospital in Kupang, East Nusa Tenggara. Data collected include demography, patient awareness and transfer history, risk factors, physical findings, diagnosis, workup, treatment, and mortality.
Results: A total of 282 patients with ACS (STEMI, 41,2%; NSTEACS, 58,8%) were included in this study. Most patients were male with a mean age of 58,2 ± 12,2 years and normal BMI (32.6%). Nearly 50% of all ACS patients have one or more comorbidities, followed by relatively low adherence to therapy. Half of the patients were referred, but only 16,9% of patients arrived at the first medical facility less than 1 hour after onset. Patients with NTSEACS had more risk factors than patients with STEMI. The median LOS was five days (range, 1-17 days) with 2,8% in-hospital death. The presence of patient and system delay might contribute to the low number of STEMI patients who received reperfusion therapy.
Conclusions: This research serves as the primary data for the improvement of acute coronary syndrome management in Kupang and East Nusa Tenggara
Pengaruh Tricuspid Annular Plane Systolic Excursion (TAPSE) Pasca Pembedahan Katup Mitral Terhadap Mortalitas Jangka Panjang
No full textBackground: Heart valve disease is still a significant health burden in the world, including Indonesia. The postoperative outcome of mitral valve surgery is influenced by many things, including decreased right ventricular (RV) function, which is the most common complication. Several studies have shown that decreased RV function after mitral valve surgery is associated with long-term outcomes. TAPSE is a routine and easy measurement of RV systolic function. A decrease in TAPSE after cardiac surgery is common because of the effects of pericardiotomy, and does not necessarily reflect a decrease in RV ejection fraction (RVEF). Regardless of whether postoperative TAPSE values indicate right ventricular systolic function or only due to the effects of pericardiotomy, it is still not clear whether postoperative TAPSE values have a prognostic value to long-term mortality after mitral valve surgery. Therefore, the objective of this study is to obtain information regarding the relationship of TAPSE echocardiographic parameters after mitral valve surgery with long-term mortality.
Methods: This is a retrospective cohort study, looking at the effect of TAPSE on outcome after mitral valve surgery. The analysis starts from the starting point of the study when the patient was discharged alive from the hospital after mitral valve surgery (operation period January 2016 – February 2017) to the end point of the study, which was June 30th, 2021 and the observed outcome was mortality from any cause.
Results: Of the 266 study subjects, 11 subjects died within 4-5 years after mitral valve surgery, the mortality is 4%. Bivariate analysis was performed on several factors and no relationship was found between the analyzed variables and mortality.
Conclusion: There is no relationship between mortality and TAPSE after mitral valve surgery.
This article has a related Erratum.Latar belakang: Penyakit jantung katup masih merupakan beban kesehatan yang bermakna di dunia, termasuk Indonesia. Luaran pasca pembedahan katup mitral dipengaruhi banyak hal, antara lain penurunan fungsi ventrikel kanan (Vka) yang merupakan komplikasi yang paling sering terjadi. Pada beberapa penelitian menyebutkan bahwa penurunan fungsi VKa pasca pembedahan berhubungan dengan luaran jangka panjang. TAPSE merupakan pengukuran fungsi sistolik RV yang rutin dan mudah dilakukan. Penurunan TAPSE pasca pembedahan jantung merupakan hal yang sering terjadi karena efek dari perikardiotomi, dan belum tentu menggambarkan penurunan pada pemeriksaan RVEF. Terlepas dari apakah nilai TAPSE pasca pembedahan menunjukkan fungsi sistolik ventrikel kanan atau hanya akibat efek perikardiotomi, belum diketahui secara pasti apakah nilai TAPSE pasca pembedahan tersebut memiliki nilai prognostik terhadap mortalitas jangka panjang pasca pembedahan katup mitral.
Tujuan: Memperoleh informasi mengenai hubungan parameter ekokardiografi TAPSE pasca pembedahan katup mitral terhadap mortalitas jangka panjang.
Metode: Penelitian ini merupakan kohort retrospektif melihat pengaruh TAPSE terhadap luaran pasca pembedahan katup mitral. Analisis dimulai dari titik awal penelitian yaitu saat pasien keluar hidup dari rumah sakit pasca pembedahan katup mitral (periode operasi Januari 2016 – Februari 2017) hingga titik akhir penelitian yaitu 30 Juni 2021 lalu diobservasi luaran yang terjadi ialah mortalitas oleh sebab apapun.
Hasil: Dari 266 subjek penelitian, terdapat 11 subjek meninggal dalam 4-5 tahun pasca pembedahan katup mitral, sehingga mortalitas didapatkan 4%. Dilakukan analisis bivariat terhadap beberapa faktor dan tidak ditemukan hubungan antara variabel yang dianalisis dengan mortalitas.
Kesimpulan: Pemeriksaan TAPSE pasca pembedahan katup mitral tidak berpengaruh terhadap mortalitas jangka panjang
Kata Kunci: TAPSE, operasi katup mitral, mortalitas
 
Does Chronic Inflammation Play a Role in Rheumatic Mitral Valve Restenosis after Percutaneous Transvenous Mitral Commissurotomy?
Get PDFBackground: Mitral valve restenosis is defined as decreased mitral valve area (MVA) <1.5 cm2 or decreased MVA >50% after PTMC. It is time-dependent and associated with major adverse cardiovascular events (MACE), such as congestive heart failure, cardiac death, mitral valve replacement, and redo PTMC. The mechanism is not yet known; however, chronic inflammation may have a role. This research aims to determine the association between chronic inflammation and mitral valve restenosis after PTMC. Methods: A total of 40 patients with mitral valve stenosis who underwent successful PTMC were matched and classified into restenosis/case group (n=20) and no restenosis/control group (n=20). Secondary data was taken from electronic medical records such as patient characteristics (gender, age & 2nd prophylaxis), echocardiography data before PTMC (Wilkins’ score and MVA before PTMC), and echocardiography data after PTMC (MVA after PTMC). Follow-up echocardiography examination (follow-up MVA) and laboratory assessment of chronic inflammation marker (IL-6) were done on all patients. Statistical analyses were done to look for an association between the level of chronic inflammation marker & other independent variables with mitral valve restenosis. Results: Median IL-6 concentration was 2.39 (0.03 – 11.4) pg/mL. There was no statistically significant difference in IL-6 levels between both groups (p-value >0.05). MVA decrement was 0.13 (0 – 0.62) cm2/year with rate of MVA decrement ≥0.155 cm2/year was predictor of mitral valve restenosis (p-value <0.001, OR = 46.72, 95% CI 6.69 – 326.19). Conclusion: Chronic inflammation assessed by IL-6 was not associated with mitral valve restenosis.This article has a related Erratum
When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT
Get PDFBackground:Particular ischemic process that portrayed in Electrocardiogram (ECG) changes bear similar depiction to different conditions, one of them is hypokalemia. On the other hand, Treadmill Test (TMT) has been used for decades for risk stratifying and diagnosing coronary artery disease as a non-invasive, safe and affordable screening test. However, using ECG changes as interpretation, TMT could have incidence of false positive results reported in various conditions, one of which is hypokalemia. The aim is to report a case of positive ischemic response resemblance in TMT of patient with severe hypokalemia.
Case Illustration:A-43-years-old female with history of unstable angina pectoris with risk factors of diabetes mellitus and hypertension underwent several examinations. Computed Tomography Coronary Angiography (CTCA) showed a 60% stenosis lesion in Left Anterior Descending (LAD) coronary artery. Within 3 minutes of TMT the ECG showed ST-segment depression in lead II, III, aVF, V1-V6 and prominent elevation in lead aVR. Fear of left main coronary artery occlusion, the test was terminated and the patient was immediately planned for urgent Percutaneous Coronary Intervention (PCI). The result indicated non-significant coronary lesion. Potassium concentration of 1.87 mmol per liter and troponin levels were normal. Unbeknownst before, the patient had multiple episodes of vomiting for a whole day and felt dehydrated prior to the TMT. Patient then treated for potassium implementation and discharged uneventfully.
Conclusion:Hypokalemia could induce widespread ST-Segment depression or ST-Segment elevation in right limb lead. Peculiarly in context of stress testing or accompanied with chest pain, it is difficult to differentiate ECG changes in hypokalemia with true myocardial ischemia. Hypokalemia should be considered when TMT result is not concordance with true myocardial ischemia.
This article has a related Erratum
Cryptogenic Stroke: A Challenge in Diagnosis and Management
No full textIschemic stroke is responsible for 85% of all stroke globally. However, the etiology of around a quarter of ischemic stroke are undetermined, this is called cryptogenic stroke. This kind of stroke affects younger population. Several mechanism are associated with the incidence of cryptogenic stroke such as paroxysmal atrial fibrillation, patent foramen ovale, atherosclerosis, and atrial cardiopathy. Despite many advanced knowledge on stroke generally, cryptogenic stroke is still a challenge in clinical settings. To understand more about cryptogenic stroke, a new term of embolic strokes of undetermined source (ESUS) is proposed and may need a specific workup. Specific workup aims to detect any silent risk factors and also to evaluate the cardiac structure. The term of ESUS also leads to the understanding that cryptogenic stroke is highly related to embolic mechanism and anticoagulation administration might benefit the patients. However, the result of several recent studies showed that anticoagulant was not superior to antiplatelet, and antiplatelet is still the preferred treatment. Studies on PFO closure also shows different result, but the majority of the trials showed benefit of PFO closure in reducing the risk of stroke recurrence
Emerging Role of Coronary CT in Non-ST Elevation Acute Coronary Syndrome
No full textNSTEACS is subset of ACS that may present with a wide degree of stenosis from normal vessels to severe obstruction. Identification of which population of NSTEACS that has normal vessels has attracted a great attention. Several trials on non-invasive imaging such as coronary CT have been largely investigated. Current available trials have showed that coronary CT is accurately identify significant stenosis in patients with NSTEACS thus can be used to rule out the disease and reduce the need and duration of unneeded antithrombotic. However, several limitations of the studies has to be taken into account when translating into clinical practice. Nevertheless, current evidence are showing promising results on the role of coronary CT in management of NSTEACS
Patent Foramen Ovale Implying Paradoxical Embolism as a New Insight in Cryptogenic Stroke
No full textCerebrovascular thromboembolism is responsible annually for 510.000 ischaemic stroke in the united states alone. PFO mechanism as a paradoxical embolism transit from right to left-sided chambers to intracranial vessels has a tremendous impact in neurological deficits. The aggressive treatment started since 2016 when the US Food and Drug Administration (FDA) approved the Amplatzer PFO occluder for recurrent stroke prevention of cryptogenic stroke with PFO. The trials show positive results since 2017 and the collaboration and partnership between neurologist and cardiologist are more needed to build a holistic and comprehensive treatment for cryptogenic stroke patient with PFO. 
Case Series Coexistence of PFO with Other Conditions - Who’s the Culprit?
No full textBackground: Patent foramen ovale (PFO) is a major cause of cryptogenic stroke (CS). However, it is still possible that PFO comes with those other conditions during evaluation. This paper presents a series of CS cases highly suspected due to PFO origin with each of its special presentations.
Case illustration/summary of a review article: We present three cases of CS with PFO as a possible contributing factor. Case 1 showed a patient with repeated ischemic strokes that was investigated to be cryptogenic in origin. Case 2 showed CS with PFO and occult atrial fibrillation. Case 3 showed CS at a young age caused by a PFO with protein C/S deficiency.
Conclusion: The role of PFO as a culprit, risk factor, or a coincidental finding in CS is still debatable and is a controversial issue. Determining PFO as a cause of CS requires a thorough consideration of clinical and PFO anatomical/morphological factors
Complete Heart Block In Pregnancy: A Case Report
Get PDFBackground: Complete heart block occurs due to various pathological conditions that cause an infiltration, fibrosis, or lose the connection from a part of the cardiac conduction system. Complete heart block in pregnancy is often caused by congenital anomalies. Around 30% cases, complete heart block remain asymptomatic and not detected until adulthood and may present in pregnancy state and puerperium. When the reversible cause of the AV Block cannot be found, the permanent pacemaker or temporary pacemaker may be indicated when the patients show the symptoms.
Case Illusration: A-21 year old female, G2P0A1 preterm pregnancy (27-28 weeks) with bradycardia. From electrocardiograph examination revealed Total AV Block with junctional escape rhytym. Transthoracic echocardiogram shows massive tricuspid regurgitation, early phase of peripartum cardiomyopathy and ejection fraction 36-40%. Caesarean section was peformed due to PPROM. A male baby was born with birth weight of 1100 grams, 32 centimeters of body length and APGAR score of 7/9. The baby was died in NICU on day care 4th, with suspected respiratory problem.
Conclusion: Complete heart block in pregnancy is a rare condition. This condition could remain asymptomatic and not detected until pregnancy. Multidisciplinary approach, close monitoring of the symptoms and cardiac functions are needed for patients with CHB.Latar Belakang : AV Blok diakibatkan dari berbagai keadaan patologis yang menyebabkan infiltrasi, fibrosis, atau kehilangan koneksi dari suatu bagian sistem konduksi. AV Blok dalam kehamilan sering disebabkan oleh kelainan kongenital. Sekitar 30% kasus, AV Blok kongenital dapat asimptomatik dan tidak terdeteksi sampai masa dewasa dan dapat muncul pada kehamilan dan masa nifas. Apabila penyebab reversibel dari AV Blok tidak ditemukan, maka pacu jantung permanen atau penggunaan pacu jantung temporer dapat diindikasikan apabila pasien memiliki gejala.
Ilustrasi Kasus : Wanita 21 tahun, G2P0A1 gravid preterm (27-28 minggu) dengan bradikardi. Pada pemeriksaan elektrokardiografi dijumpai Total AV Blok dengan irama junctional escape. Pada pemeriksaan echokardiografi menunjukan regurgitasi tricuspid masif, peripartum kardiomiopati, dan fraksi ejeksi 36-40%. Dilakukan seksio sesarea atas indikasi KPD. Lahir bayi laki-laki, BBL 1100 gram, panjang badan 32 sentimeter, Apgar Skor 7/9. Bayi meninggal pada hari keempat rawatan di NICU dengan dugaan permasalahan pernafasan.
Kesimpulan: Blok jantung dalam kehamilan merupakan kondisi yang langka. Kondisi ini dapat asimptomatik dan tidak terdeteksi hingga mengalami kehamilan. Pendekatan multidisiplin, pemantauan ketat gejala dan fungsi jantung diperlukan untuk pasien dengan Blok Jantung
Cryptogenic Stroke: Cardiac Rhythm Monitoring as An Indispensable Screening Modality
No full textThe prevalence of stroke in Indonesia increased overtime. CS ranges from 15 to 40% from all ischemic strokes. Finding the etiology of ischemic stroke is important to prevent recurrence. AF is predicted as the etiology behind CS. The current recommendation only supports short period of ECG monitoring. However, studies have shown that a higher detection rate can be achieved with longer duration of monitoring. ICM, a diagnostic tool with the highest detection rate, is still considered cost-effective when the calculation takes into account the QALY gained. Digital health tools such as handheld devices and smartwatch ECG have revolutionized the screening of AF however it is still considered as pre-diagnostic and verification is needed to confirm the rhythm generated