185385091 Atherosclerosis Trombosis Dr Faturochman
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Transcript of 185385091 Atherosclerosis Trombosis Dr Faturochman
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Atherosclerosis & Atherotrombosis
OLEH
dr.Fatchurochman,SpJP
RS.TNI AU DR.M.SALAMUN
B A N D U N G
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Atherosclerosis ( Aterosklerosis ) • Atherosclerosis = pengerasan arteri
• Adalah suatu proses inflamasi o.k gangguan metab.
Karbohidrat & Lemak pada pembuluh darah
ateroma ( deposit KH,L,darah , jar.ikat ,kalsium,) yg
menyebabkan lapisan pembuluh darah berubah
menyempit
• Kapan dimulainya proses Aterosklerosis ? Yaitu
sejak masa anak dan merupakan proses satu pro
• ses yg progresif dg terbentuk nya plaque pada
dinding arteri & menyebabkan sirkulasi koroner
terganggu
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Atherothrombosis
Thrombus adalah bekuan darah
Atherothrombosis
Adalah suatu proses terjadinya bekuan darah yang menyumbat aliran pembuluh darah
Atherosclerosis Atherothrombosis oklusi mendadak
serangan mendadak
Arteri coronaria di jantung arteri di otak
↓ ↓
Acute Infark Miokard Cerebro Vasc.Accident
( PJK ) ( Stroke )
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24.7% 29.9%
Coronary
disease 7.4%
Atherothrombosis is commonly found in more
than one arterial bed in an individual patient*
Cerebrovascular
disease
Peripheral arterial disease
3.8% 11.8%
19.2%
* Data from CAPRIE study (n=19,185)
Coccheri S. Eur Heart J 1998; 19(suppl): P1268.
3.3%
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Major clinical manifestations
of atherothrombosis
Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.
Transient ischemic attack
Angina: • Stable • Unstable
Ischemic stroke
Myocardial infarction
Peripheral arterial disease: • Intermittent claudication • Rest Pain • Gangrene • Necrosis
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Manifestations of Atherothrombosis
1. CAPRIE Steering Committee. Lancet 1996; 348: 1329–1339
2. The CURE Trial Investigators. N Engl J Med 2001; 345: 494–502
3. Bertrand ME et al. Circulation 2000; 102: 624–629
4. Steinhubl SR et al. JAMA 2002; 288: 2411–2420
Stroke
TIA
Acute MI
Unstable angina
Prior MI
PCI/stenting
Atrial fibrillation
Intermittent
claudication
Peripheral
vascular
intervention
CHARISMA
CAPRIE1
ACTIVE
COMMIT
CLARITY
CURE2
CLASSICS3
CREDO4
CHARISMA
CAPRIE1
CAMPER
CHARISMA
CAPRIE1
MATCH
ACTIVE
CARESS
TIA = Transient ischemic attack
MI = Myocardial infarction
PCI = Percutaneous coronary intervention
© Teri J McDermott CMI 2003
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Identifying those at risk of atherothrombosis
Yusuf S et al. Circulation 2001; 104: 2746–53. 2. Drouet L. Cerebrovasc Dis 2002;13(suppl 1):1–6.
Lifestyle
• Smoking
• Diet
• Lack of exercise
Genetic
• Genetic traits
• Gender
• Age
Generalized
disorders
• Obesity
• Diabetes
Systemic
conditions
• History of vascular
events
• Hypertension
• Hyperlipidemia
• Hypercoagulable
states
• Homocystinemia
Local factors
• Elevated prothrombotic factors: fibrinogen, CRP, PAI-1
• Blood flow patterns, vessel diameter, arterial wall structure
Atherothrombosis
manifestations
(myocardial infarction,
stroke, vascular death)
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Angka Kejadian PKV:
Laporan WHO :
2004 : 7 juta orang meninggal/ tahun
2010 : 11juta orang meninggal/ tahun
( perkiraan )
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Penyakit jantung koroner (PJK)
• Ialah : Penyakit jantung akibat perubahan
obstruktif (penyumbatan)pada pembuluh
darah koroner yang menyebabkan fungsi
jantung terganggu.
• Sebab utama PJK : proses aterosklerosis
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Patofisiologi / Perjalanan penyakit pjk/ska :
• Lihat gambar berikut
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Atherothrombosis: A Generalized and
Progressive Disease
Unstable angina
MI
Ischemic stroke/TIA
Critical leg ischemia
Intermittent claudication
CV death
ACS
Atherosclerosis
Stable angina/Intermittent claudication
Atherothrombosis
MI = Myocardial infarction
ACS = Acute coronary syndromes
CV = Cardiovascular
Adapted from Libby P. Circulation 2001; 104: 365–372
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Dekade proses pembentukan trombus
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Ross (1999)
Endothelial
permeability
Leucocyte
migration
Leucocyte
adhesion
Endothelial
adhesion
The normal artery wall
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Endothelial cells
Contractile VSMCs
The normal artery wall
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Early atherosclerosis (I)
– Endothelial
dysfunction
Lipi
d
Lipid accumulates
in the intimal space
and is associated
with abnormal
endothelial cell
function
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Platelet thrombus
Platelets adhering to subendothelial space Platelets
Endothelial cells
Subendothelial space
Aggregation
of platelets into a
thrombus
Normal platelets
in flowing blood
Platelets adhering to
damaged endothelium
and undergoing activation
Platelet adhesion and activation
Adapted from: Ferguson JJ. The Physiology of Normal Platelet Function. In: Ferguson JJ, Chronos N,
Harrington RA (Eds). Antiplatelet Therapy in Clinical Practice. London: Martin Dunitz; 2000: pp.15–35.
A B C
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Characteristics of the
stable atherosclerotic
plaque Fibrous cap
(VSMCs and matrix)
Lipid core
Adventitia
Endothelial
cells
Intimal VSMCs
(repair
phenotype)
Medial VSMCs
(contractile
phenotype)
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Lipid core
Resolving
thrombus
Adventitia
Site of previous
plaque rupture
Recruitment
of new
VSMCs
Plaque growth
Weissberg, 1999
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Plaque disruption leading to
atherothrombosis formation
Adapted from: Falk E et al. Circulation 1995; 92: 657–71.
Macrophage Tissue factor
Fibrin
Aggregated platelets
BLOOD
FLOW
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Lipid core
Adventitia
Thrombus
Unstable
coronary
artery disease
(II)
Thrombus forms
and extends into the
lumen
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Atherothrombosis: a Life-threatening
Disease
• Atherothrombosis is a chronic, progressive, generalized and unpredictable disease
characterized by the formation of blood clots on top of established atherosclerosis
1. Falk E et al. Circulation 1995; 92: 657–671
2. Arbustini E et al. Heart 1999; 82: 269–272
3. Aronow WS, Ahn C. Am J Cardiol 1994; 74(1): 64–65
Plaque rupture1 Plaque erosion2
• An atherothrombotic manifestation (like myocardial infarction, stroke, transient
ischemic attack, unstable angina, or peripheral arterial disease) in one vascular
territory means increased risk in all vascular beds3
• Atherothrombosis (cardiovascular and cerebrovascular disease) is one of the world’s
biggest killers4
4. World Health Organization. Cardiovascular diseases site.
www5.who.int/cardiovascular-diseases/main.cfm?p=0000000424
(last accessed 24 January 2003)
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The ruptured atherosclerotic plaque
following fibrinolysis
Davies and Ho,
1998
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Penyakit jantung koroner
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Clinical classification of ACS
Acute Coronary Syndrome
(ACS)
No ST Elevation ST Elevation
Unstable
Angina
Pectoris
MI (NSTEMI) MI (STEMI)
No Q-wave Q-wave
National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand.
Med J Aust 2000;173 (suppl):S65–S88
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Tindakan Kateterisasi / Angiografi koroner
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Tindakan Kateterisasi / Angiografi koroner
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‘Significant’ (>70%)
stenosis
‘Insignificant’ (<70%)
stenosis
Coronary angiography and the
significance of stenosis
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Angiography of Unstable Angina
Davies. Atlas of Coronary Artery Disease. Lippincott-Raven, Philadelphia, Pennsylvania: 1998:79
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STENT
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.
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Pyridoxin Hydrochloride (Vit B6) ------- 25 mg
Cyanocobalamin (Vit B12) -------- 25 g
Folic Acid (Vit B9) ------------ 500 g
Natural Vitamin E (d- Tocopherol) ---- 400 IU
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.
• .
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Faktor –faktor risiko tradisional penting dan faktor –faktor
risiko non tradisional yang baru muncul dapat dilihat pada
tabel berikut ini
Faktor Risiko Tradisional Faktor Risiko Non Tradisional
. .
Merokok Homosisitein (HCy)
LDL –Kolesterol Lipoprotein (a)
Diet Lemak /Kolesterol tinggi Partikel small-dense LDL
Hipertensi Stres oksidatif
DM Inflamasi
Inaktivitas fisik Penanda-penanda hemostatik
Obesitas Disfungsi Endotel
Status post menopause Penginfeksi
Riwayat PJK pada keluarga Trigliserida
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Homocystein
• Homocystein ( Hcy):
Adalah *Asam amino sulfhidril
*Merupakan senyawa antara
*Terbentuk pada metab. Methionin
*Terdapat dlm beberapa btk didlm
plasma.
*Kadar Hcy plasma
tgt pd : -kadar enzim esential yg diatur scr genetik
-dan asupan as.folat, vit B6, B12
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Thrombin
Viral infectin
Oxidized lipids/ Free radicals
Leucocyte
Adhesion
Vasoactive
Substances
Procoagulant Activity
Altered
Permiability
Growth Factor
Response
Hypoxia
Shear stress Cytokines
Homocystein
Activation
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Gangguan/ Kekurangan
Asupan as.folat, vit B6, B12
Hyperhomocysteinemia
Risiko
Peny. Vaskular perifer Peny. Artyeri koroner
Cerebral
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B6
B6
B12
Transulfuration
Pathway
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vitamin
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Vitamin
vit
vit
vit
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PERAN VIT. E
• Berfungsi :
* Sebagai Anti oksidan yg efektif
(memberi manfaat jangka panjang dalam
perlindungan sel tubuh akibat zat oksidatif )
* Mengurangi bahaya inflamasi
* Sebagai nutrisi essential yang dibutuhkan untuk
menjaga kesehatan
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.
.