PENCEGAHAN DAN

REHABILITASI PENYAKIT
KARDIOVASKULAR
Cardiovascular disease is a major and
increasing cause of death Worldwide

CV deaths every year 23 million

17 million

2002 2030
Mathers CD & Loncar D. PLoS Med 2006; 3(11): e442
Global Cardiometabolic Risk

High
High
High TG
LDL-
BP
C
Insulin
Intra
Abdominal
Low
Resis- adiposity HDL-
tence
c
Elevated Inflam-
Bood matory
glucose marker

Gelfand EV et al, 2006; Vasudevan AR et al, 2005

WHO Perspective: Diabetes in Indonesia

World’s 4th
2030 Largest
Prevalence

2000 21.3 millions people

with DM (2.8%)
8.4 millions people
with DM (1.9%)
Wild, et al. 2004
 WHAT
?

WHERE WHY
?
?

HOW WHO
? ?
1. What is CVD
prevention & Rehabilitaion?
2. Why is prevention & Rehabilitaion of
CVD is needed?

3. Who should benefit from it?

4. How can CVD prevention &

rehabilitaion be used?

5. Where should programmes be

offered?
 Definisi
• Rehabilitasi jantung merupakan
suatu proses pada pasien
penderita penyakit jantung,
bersama-sama dengan tim
multidisiplin, dengan tujuan
mencapai dan memelihara
kondisi optimal dari kesehatan
fisik dan psikososial
Rehabilitasi jantung
mencakup langkah-langkah
untuk mengoptimalkan kondisi
fisik, psikis, dan sosial 
pasien dapat mencapai
kembali kapasitas maksimal
di masyarakat
Candidates
for Cardiac Rehabilitation
Traditionally most candidates for
cardiac rehabilitation services were:

Patients following
myocardial infarction
Coronary artery bypass graft
(CABG) surgery,
 Who should be Involved?
Exercise instructor
Physiotherapy Social Services

District Nurses
Consultant
GP
Secondary care
Psychologist
Patient Dietician
Practice nurses Smoking cessation advisor

Nurse
Pharmacist
Health Visitor
• Unit perawatan intensif jantung
(ICCU) dibentuk tahun 1961
• Menurunkan mortalitas

30% 1961 18% 1980 10% 1997

 Beberapa tahun terakhir,
kebutuhan pasien untuk
kembali ke kondisi semula
menjadi meningkat
 Dikembangkan rehabilitasi
jantung
• Rehabilitasi jantung
saat ini telah diterima
sebagai bagian dari
penatalaksanaan yang
komprehensif
 Its application is
a class I
recommendation in
most contemporary
cardiovascular clinical
practice guidelines.
 Cardiac rehabilitation is
increasingly recognized
as an integral component
of the continuum of care
for patients with
cardiovascular disease.
To optimize cardiovascular risk
reduction,
Foster healthy behaviors and
compliance with those
behaviors,
Reduce cardiovascular disability,
Promote an active lifestyles.
 Components of CR.
 Lifestyle:
– Diet and weight management
– Smoking cessation
– Physical activity and exercise
– Secondary prevention
– Education
 Psychosocial care
 Long-term management strategy
Komponen-komponen Rehabilitasi Jantung
 Kontraindikasi (1)
 Angina tidak stabil
 TD sistolik > 200 mmHg atau
TD diastolik > 110 mmHg
 Penurunan TD > 20 mmHg
dengan keluhan
 Stenosis katup aorta yang
berat
 Kontraindikasi (2)
Peradangan sistemik akut atau demam
Aritmia atrial atau ventricular yang tidak
terkontrol
Takikardia yang tidak terkontrol
Gagal jantung kongestif yang tidak
terkompensasi
Blok AV derajat 3
 Kontraindikasi (3)
 Perikarditis atau miokarditis
 Riwayat embolism
 Thrombophlebitis
 Perubahan segmen ST saat
istirahat >2 mm
 Diabetes yang belum terkontrol
 Kelainan ortopedi yang
menyulitkan latihan
 Fase-Fase
Rehabilitasi Jantung

Fase Fase Fase Fase

I II III IV
 Fase I
Selama pasien di rumah sakit
Edukasi pasien tentang perjalanan
penyakitnya
Evaluasi awal faktor-faktor risiko
Saran yang diberikan: sederhana,
diulang-ulang
 Fase I

 Setelah pasien stabil, dimulai

mobilisasi bertahap
 Tetap edukasi dan konseling:
pengobatan, kapan kembali
bekerja, program latihan
 Fase II
 Setelah pasien keluar dari rumah
sakit
 Modifikasi gaya hidup: berhenti
merokok, pola makan,
perencanaan untuk fase III
 Ahli gizi atau ahli psikologi dapat
memberikan saran ke pasien
 Fase III

 Rehabilitasi dengan
pengawasan selama
8 sampai 12 minggu

 Saran jenis latihan di rumah

 Tetap edukasi faktor risiko

 Fase IV

 Mempertahankan latihan
dan mengurangi faktor
risiko

 Seumur hidup
 Prevention for CHD

Prevention COR LOE

Lipid management with lifestyle modification and
lipid-lowering pharmacotherapy
 Lifestyle modification I B
 Statin therapy: I A
 Statin therapy which lowers LDL cholesterol to
100 mg/dL and achieves at least a 30% lowering
of LDL cholesterol I C
 Statin therapy which lowers LDL cholesterol
to 70 mg/dL in very high-risk* patients IIa C

Circulation 2011, 124:2584

 Prevention for CHD
Blood pressure control (with a blood pressure goal
of 140/90 mm Hg)
Lifestyle modification I B
Pharmacotherapy I A
Diabetes management (eg, lifestyle
modification and pharmacotherapy)
coordinated with the patient’s
primary care physician and/or
endocrinologist I C
Complete smoking cessation I A
Circulation 2011, 124:2584
PELAYANAN TREADMILL
 Berhenti Merokok
• Mencatat status merokok

• Efek merokok: radikal bebas

mengoksidasi LDL dan
menyebabkan kerusakan endotel

• Target berhenti merokok

 Manajemen Kadar Lipid

• Mengevaluasi dan modifikasi diet

• Terapi medikamentosa

• Target utama: LDL < 100 mg/dL

 Manajemen Hipertensi

• Mengukur tekanan darah pada

dua waktu yang berbeda

• Target <140/90 mmHg, atau

bila diabetes target < 130/85
 Mengurangi Berat Badan
• Dilakukan pada pasien dengan
IMT >25, atau lingkar perut >
100 cm pada laki-laki, atau >
90 cm pada perempuan
• Menyediakan konsultasi gizi
• Target IMT 20-25
Fat Topography In Type 2 Diabetic Subjects

Intramuscular
Subcutaneous

FFA*
Intrahepatic TNF-alpha*
Leptin*
Intra- IL-6 (CRP)*
abdominal Tissue Factor*
PAI-1*
Angiotensinogen*
 Manajemen Psikososial
• Identifikasi denial, depresi, cemas,
melalui anamnesis

• Menyediakan konsultasi individu atau

grup

• Dapat menggunakan instrumen

tervalidasi, contoh: Hospital Anxiety
and Depression Scale
Konsultasi Aktivitas Fisik dan Olahraga

• Mengevaluasi aktivitas fisik dan

toleransi latihan dengan exercise
stress test

• Mengidentifikasi hambatan dalam

melakukan aktivitas fisik

• Target peningkatan aktivitas fisik

 Latihan Fisik: Fase I

• Mengevaluasi kondisi pasien,

motivasi pasien, mobilisasi
• Dimulai pada hari kedua
• Intensitas latihan maksimal
4 METS, atau
perceived exertion < 13
 Latihan Fisik: Fase I

• Durasi 3-5 menit

• Hari ke-empat: berjalan

di koridor, 5-10 menit
 Latihan Fisik: Fase II
• Kontak dengan pasien
(telepon/kunjungan rumah)

• Pasien mendapat instruksi yang jelas

tentang aktivitas fisik yang
diperbolehkan

• Intensitas 4 METS, nadi maks = nadi

istirahat + 20
 Latihan Fisik: Fase III
• Olahraga dengan aman pada
lingkungan yang terstruktur

• Umumnya pasien menjalani exercise

stress test terlebih dahulu

• Intensitas latihan 60-70% dari HR

maksimal
 Latihan Fisik: Fase III
• Durasi program bervariasi:
• 8-12 minggu, 2-3 sesi
perminggu

• Pemanasan 15 menit, latihan

30-35 menit, pendinginan 10
menit
 Latihan Fisik: Fase IV

 Olahraga mandiri

 Menjaga gaya hidup

sehat
 Nutrisi: Fase I

• Dievaluasi oleh ahli gizi

• Dicatat pola makan

• Preskripsi individual pasien

 Nutrisi: Fase II

• Diberikan motivasi

• Diberikan food diaries

untuk dilengkapi selama
5 hari
 Nutrisi: Fase III

• Food diaries dikumpulkan

dan dianalisis

• 1 jam diskusi tentang nutrisi

 Nutrisi: Fase IV

•Menjaga gaya
hidup sehat
 Treatment of Risk Factors
Stop
smoking

Insulin
Oral
hypoglycaemics
Diet, Aspirin
Exercise,
Lifestyle
change
Statins
Anti-
& hypertensives
Fibrates
 Drug therapy – for all
All patients who have had an acute MI should be
offered treatment with the following drugs:

 ACE (angiotensin-converting enzyme)

inhibitor

 aspirin

 beta-blocker

 statin
 Treatment With Statins
Prior to PCI Improves Clinical
Outcomes
100
Clinical event-free survival
Clinical event-free† survival

90
statins
(%)

80

70 no statins

log rank P=.015

60

0 1 2 3 4 5 6
Time (months)

Study of 119 patients undergoing nonprimary PCI who received (n=63) or did not receive (n=56) statins prior to procedure.
*Myonecrosis defined as elevations in creatine kinase-myocardial band (CKMB) or CK >3 times the upper limit of normal within 24 hours of PCI in patients
without recent MI, or 25% increase from trough value in patients with an MI <72 hours before procedure.
†Events defined as death, nonfatal MI unrelated to PCI, target vessel revascularization, and UA requiring hospitalization.

Chang SM et al. Catheter Cardiovasc Interv. 2004;62:193-197.

 LUNAR
Secondary Endpoint

Mean Change
in LDL-C from
Baseline (%)

**
*

Pitt B et al. Am J Cardiol 2012; doi:10.1016/j.amjcard.2011.12.015 *p 0.05; **p 0.01 versus atorvastatin 80 mg
 Relationship Between LDL-C and CV Incidence in Statin Trials
30 Lower is Better How Low Should We Go?
4S - Placebo

25 Rx - Statin therapy Secondary Prevention

Event rate (%)

PRA – pravastatin
ATV - atorvastatin
4S - Rx
20

LIPID - Placebo
15
CARE - Placebo
LIPID - Rx
CARE - Rx
HPS - Placebo Primary Prevention
HPS - Rx TNT – ATV10
10 PROVE-IT - PRA
TNT – ATV80 WOSCOPS – Placebo
PROVE-IT – ATV AFCAPS - Placebo
6
5 AFCAPS - Rx WOSCOPS - Rx
ASCOT - Placebo
JUPITER - Placebo
ASCOT - Rx
0 JUPITER - Rx

40 60 80 100 120 140 160 180 200

(1.0) (1.6) (2.1) (2.6) (3.1) (3.6) (4.1) (4.7) (5.2)

LDL-C achieved mg/dL (mmol/L)

Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279 LaRosa JC et al. N Engl J Med 2005;352:1425-1435
Lifestyle:
Psycho-
social stress

Physical
inac-
tivity, Unhealthy
diet
Tobacco
habits
 INDONESIA
(> 60%)
CHINA
(= 60%)
Smoking: 
These Three  More common
Almost HALF In the developing
Of world’s users
world
(Braunwald’s Heart Disease, 9nd Ed, 2011)
 70 % perokok ingin berhenti
merokok tetapi….
HANYA
5%-10%
yang dapat
melakukannya
tanpa bantuan

1. Hughes JR. New treatments for smoking cessation. CA Cancer J Clin. 2000;50:143-151
2. FoulisJ, Burke M, Steinberg M, William JM, Ziedonis DM. Advances in pharmacotherapy for tobacco dependence. Expert Opin Emerg Drugs.
2004;9:39-53
3. Department of Health. Smoking kills: a White Paper on Tobacco. London, England: Stationery Office; 1998
 Cardiac Rehabilitation after MI
Olmsted County, MN Experience
This study was undertaken to:

Examine the utilization of rehabilitation after MI

in the community and test the hypothesis that
women and the elderly were less likely to
participate

Examine the impact of participation on survival

Witt B et al. JACC 2004;44:988-996

 Death within 3 Years
No Participation
Participation
%

Quartiles of Propensity Score

 Adjusted Survival Benefit
Associated with Participation

participation

RR = 0.43 after
Adjustment for non-participation
propensity score
 Medication Adherence

Statins: 75% at discharge, 44% 3 years

BB: 84% at discharge, 48% at 3 years

Am J Med. 2009
Oct;122(10):961.e7
ACE: 62% at discharge, 43% at 3 years -13.
Medication Adherence with
Cardiac Rehabilitation
All patients, not just post-MI

Squires et al, JCRP 2008;28:180-186

 Incidence
of death

Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among
elderly Medicare beneficiaries. Circulation. 2010 Jan 5;121(1):63-70
Rehabilitasi jantung
merupakan suatu proses
multidisiplin, dengan tujuan
mencapai dan memelihara
kondisi optimal fisik dan
psikososial
 Prevensi sekunder
merupakan bagian integral
rehabilitasi
Terdapat 4 fase rehabilitasi
jantung: di dalam dan
diluar rumah sakit
Rehabilitasi jantung dapat
mengurangi risiko `
kejadian infark miokard
berulang dan mortalitas