2. CARDIOVASCULAR DISEASE (Overview) Toni Mustahsani Aprami, dr., Sp.PD, Sp.JP Department of Cardiology and Vascular Medicine Cardiovascular Subdivision, Department of Internal Medicine Hasan Sadikin Hospital/Medical School, Padjadjaran University

3. Understanding the Cardiovascular System The Heart: A Mighty Machine –Four chambers Two upper chambers are called atria Two lower chambers are called ventricles –Valves regulate the flow of blood.

6. Conduction System of the Heart 5

7. The Heartbeat Is Controlled Each heartbeat is referred to as a cardiac cycle. Takes a total of 0.85 seconds / cycle on the average when at rest..... That’s ~70 X/minute, range 60-80 beats/ minute. – Systole - Contraction of heart muscle. – Diastole - Relaxation of heart muscle.

11. Blood Flow within the Heart

12. Blood Vessels 11

13. Capillary Bed Anatomy 12

14. Capillary Exchange

15. Functions of the Cardiovascular System 1.Contractions of the heart generates blood pressure, which moves blood through blood vessels. 2.Blood vessels transport blood, which moves from the heart into arteries, capillaries, and veins, before returning to the heart. 3.Exchanges at the capillaries (smallest vessels) refreshes blood and then tissue fluid (interstitial fluid). 4.The heart and blood vessels regulate blood flow, according to the needs of the body.

16. CARDIOVASCULAR DISEASE Congenital Heart Disease (ASD, VSD, PDA, TOF) Rheumatic Heart Disease (MS/MR, AS/AR) Hypertensive Heart Disease Coronary Artery Disease Cardiomyopathies Pericarditis Peripheral Artery Disease Aneurysm and Disectie Aortae Deep Vein Thrombosis Cardiac Tumor

17. Coronary Artery Disease 90% Atherosclerosis Process

18. Atherosclerosis can, and does, occur in almost any artery in the body. But in the heart it’s effects can be crucial. “The body depends on a strong pumping heart to circulate life-giving blood, and this includes to the heart muscle itself. If the coronary arteries become blocked, the cardiac muscle begins to fail, and so the blood circulation decreases, which includes the circulation to the heart muscle itself.” (Thibodeau, 494)

19. Atherosclerosis is a disease of large (elastic) and medium sized (muscular) arteries characterized pathologically by smooth muscle proliferation, lipid accumulation, cell necrosis, fibrosis, and calcification. Most commonly involved : Aorta CoronaryCarotidIliacMesentric CoronaryCarotidIliacMesentric

21. Uncontrollable Sex Hereditary Race Age Controllable High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Stress and anger Predict Risk Diagnostic/Screening test : EST, CRP, Echocardiography, CACS

22. Atherogenesis

23. Normal Artery Endothelium Internal elastic lamina External elastic lamina Media Intima Adventitia

24. Response to Injury

25. Endothelial Dysfunction

26. Initiation of Fatty Streak

27. Fatty Streak

28. Fibro-fatty Atheroma

29. FIBROUS CAP NECROTIC CENTER MEDIA (smooth muscle cells, macrophages, foam cells, lymphocytes, collagen, elastin, proteoglycans, revascularization) (cells debris, cholesterol crystals, foam cells, calcium)

30. Endothelial Dysfunction Foam Cells Fatty Streak Intermediate LesionAtheroma Fibrous Plaque Complicated Lesion/Rupture Endothelial injury nitric oxide endothelin-1 vasodilation Lipid accumulation adhesion molecules (ICAM, VCAM) monocyte adhesion macrophage LDL uptake Inflammation continued macrophage/lipid accumulation leukocyte accumulation cytokines (IL-6,TNFa, IFNg) MMP's CRP (hepatic) oxidized LDL homocysteine smoking aging hyperglycemia hypertension 35-45 yrs45-55 yrs 55-65 yrs >65 yrs The Evolution of Atherosclerosis

31. Common Consequences of Atherosclerosis in Vessels

32. Altered Vessel Function Vessel change –Plaque narrows lumen –Wall weakened –Thrombosis –Breaking loose of plaque –Loss of elasticity Consequence –Ischemia, turbulence –Aneurysms, vessel rupture –Narrowing, ischemia, embolization –Athero-embolization –Increase systolic blood pressure

33. Burden and causes of cardiovascular diseases: with an emphasis on Asia

34. Chronic diseases and injuries Infectious, maternal, perinatal and nutritional conditions Changing patterns of death Worldwide: 1990-2020 Global Burden of Disease Project, 1996 Millions of deaths

35. Leading causes of death Worldwide: 1990-2020 RankCause % RankCause % 1Coronary Artery disease 12.41Coronary Rtery disease 16.3 2Cerebrovascular disease 8.72Cerebrovascular disease 11.2 3Lower respiratory infections 8.53COPD 6.9 4Diarrhoeal diseases 5.84Lower respiratory infections 3.7 5Perinatal conditions 4.45Respiratory tract cancers 3.5 6COPD 3.9 6Road traffic accidents 3.4 7Tuberculosis 2.17Tuberculosis 3.4 8Measles 2.18Stomach cancer 2.3 9Road traffic accidents 1.99HIV 1.8 10Respiratory tract cancers 1.910 Self inflicted injuries 1.8 19902020 Global Burden of Disease Study, 1996

36. Reported in 1990  14 million deaths worldwide  5 million in developed countries  9 million in developing countries Predicted for 2020  25 million deaths worldwide  6 million in developed countries  19 million in developing countries Deaths from cardiovascular disease Worldwide: 1990-2020 Global Burden of Disease Study, 1996

37. World population change 0 2 4 6 8 10 17001800190020002100 World population (billions) United Nations 1999

38. Regional population change Population (billions) 2000 2050 Change Developing world 4.9 7.9 3.0 Developed world 1.0 1.0 0.0 Total 5.9 8.9 3.0 United Nations 1999

39. 0 500 1000 1500 2000 2500 3000 3500 Trends in per capita cigarette consumption: 1971-1991 1971 1981 1991 Per capita cigarette consumption High income countries Low & middle income countries China The World Health Report, 1999: Making a Difference

40. Tobacco-related death and disability 19902020 Deaths (millions) 3.0 8.4 India 0.1 1.5 China 0.8 2.2 DALYS (%) 2.6 9.0 Global Burden of Disease Project, Lancet 1997

41. Trends in overweight/obesity (BMI 25+ kg/m 2)

42. 0 50 100 150 200 250 300 350 DevelopedDevelopingWorld Millions 1995 2025 Projected King et al. Diabetes Care 1998; 21:1414-31 0 50 100 150 200 250 300 350 Asia-Pacific Global distribution of diabetes

43. Prevalence of smoking in the Asia Pacific APCSC, 2006 Indonesia

44. Prevalence of hypertension 140/90mmHg + Indonesia 27 11

45. Prevalence of obesity and overweight

46. Prevalence of, and predictions for, diabetes

47. Summary I  Global epidemic of CVD; the leading cause of death and disability  About 11 million new cardiovascular deaths each year by 2020  By 2020, 80% of cardiovascular deaths will occur in low and middle income countries  About half of these deaths will occur in the Asia-Pacific region

48. Summary II  Classic CVD risk factors act similarly in different populations  These risk factors are already common in many low/middle-income countries, and are often increasing (e.g. Asia)