Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease Ismail MT1, Hariawan H1, Wardhani Y2, Puspitasari M2, Artayasa IPA1, Ramadhan G1, Tarigan T1, Triatmaja R1 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, 55284, Indonesia 2Department of Internal Medicine Faculty of Medicine Universitas Gadjah Mada-RSUP Dr. Sardjito Yogyakarta Indonesia ABSTRACT Aim: AV fistula obstruction has become one of the main vascular access complications in patients undergoing haemodialysis. This complications have significant impacts on the morbidity and mortality of dialysis patients while also leading to higher medical costs. Clinical monitoring has been routinely used for early detection of AV fistula stenosis and obstruction, however screening with Doppler ultrasound is still not a routine recommendation. This study aims to know prevalence and risk factors of AV Fistula obstruction detected by Duplex ultrasound examination. Methods: This study was a hospital-based descriptive analytic study with cross sectional design conducted at the haemodialysis center of National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. Patient demographic and clinical risk factor were recorded using direct interview. AV fistula obstruction were assessed using Duplex ultrasound by professional sonographer. Results: Seventy four (74) patients are using AV fistula as entry access for hemodialysis in RSUP dr. Sardjito. It is consist of 39 male (53%) and 35 Female (47%). The mean age of patients is 50 years old. Surveillance using Doppler ultrasound found 20 patients (27%) have stenotic AV Fistula. Smoking habits (OR 5.37, 95% CI, 1.760 - 16.431, p=0.002) and diabetes mellitus (OR 5.00, 95% CI, 1.631 – 15.503, p=0.004) increase risk for having stenotic AV fistula. Only 4 patient (20 %) of all 20 patient with stenotic AV fistula were symptomatic, and needed for further vascular intervention Conclusion: Prevalence of AV fistula obstruction detected by Doppler ultrasound was 27% of all AV fistula patient with only 5% had symptomatic AV fistula failure. Smoking habits and diabetes mellitus are important risk factor for AV fistula obstruction. Asymptomatic AV fistula obstruction often goes undetected by clinical monitoring that can increase of risk of symptomatic AV fistula obstruction in the future. The further study is needed to determine level recommendation of routine AV fistula surveillance with Doppler Ultrasound. Key words: AV Fistula obstruction, CKD, Doppler ultrasound surveillance, Risk factors, Prevalence

Systemic Lupus Erythematosus-associated Pulmonary Arterial Hypertension: Serial Case Report

One of the causes of pulmonary arterial hypertension (PAH) is connective tissue disease, including systemic lupus erythematosus (SLE). The prevalence of PAH in patients with SLE according to cohort studies varies widely between 0.5% and 43%. In some cases, PAH is the initial manifestation leading to the diagnosis of SLE. However, PAH can develop as a complication in patients who are initially diagnosed with SLE. We report two cases with a different approach to the diagnosis of pulmonary hypertension in SLE patients. These cases emphasize the importance of investigating examination results according to the guidelines to establish the diagnosis of PAH in SLE.

RELATIONSHIP BETWEEN FRONTAL QRS-T ANGLE AND MYOCARDIAL PERFUSION DEFECT (MPD) FROM SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) IN PATIENTS WITH PRIOR MYOCARDIAL INFARCTION

Background: The frontal QRS-T angle is the angle between ventricular depolarization and repolarization. The QRS-T angle abnormalities will mirror the electrical instability, placing the patient in high risk of cardiac arrhythmia and sudden cardiac death. This study was conducted to analyzed as if the QRS-T angle will predict the myocardial perfusion defect in acute ST elevation myocardial infarction (STEMI). Methods: This is a cross sectional study which conducted in patients with previous history of STEMI in H. Adam Malik General Hospital Medan from June 2018 until March 2020. The patients will then be undergoing electrocardiography (ECG) and myocardial perfusion scintigraphy (SPECT) to acquire the frontal QRS-T angle and myocardial perfusion defect score. Results: Over 40 patients with prior STEMI we found the frontal QRS-T angle has a positive moderate correlation (r = 0,543; p < 0,001) with myocardial perfusion defect. The best cut-off value for frontal QRS-T angle to predict myocardial perfusion defect is > 70o with sensitivity and specificity of 70.6% and 82.6%, respectively. Conclusions: The frontal QRS-T angle is an independent predictor for myocardial perfusion defect in patient with previous history of STEMI. Keywords: STEMI; frontal QRS-T angle; myocardial perfusion defect.

The The COmprehensive Registry and rEsearch on Heart Failure (CORE-HF) : 2 years report from single-center Indonesian heart failure clinic registry

Introduction: Heart failure (HF) remains a rising global epidemic which lacking population-based data, especially in Indonesia. The COmprehensive Registry and rEsearch on Heart Failure (CORE-HF) is a single-center registry of Sebelas Maret HF Clinic as part of the ongoing national HF registry under InaHF. This paper designed to give an overview of HF epidemiological data, thus improves HF service quality, especially at Surakarta region. Methods: The CORE-HF is a cohort, prospective, single-center registry which enrolls all patients with chronic HF. Subjects were recruited consecutively from the outpatient clinic of Sebelas Maret HF Clinic at UNS Academic Hospital. Both enrollment and follow-up have been performed since January 2018 until present. Variables recorded consist of basic characteristics, baseline risk factors, subjective indicators, objective diagnostic assessments, pharmacological therapy, and outcome indicators. Results: HFrEF has a significant association towards a higher number of rehospitalization and all-cause mortality at any time (p<0.001). The 12 and 24-months cardiac related rehospitalization occurred significantly more in HFrEF group compared to other groups (p<0.001), whereas rehospitalization in HFpEF dominated by non-cardiac cause (p=0.381). Cumulative all cause mortality is significantly highest in HFrEF group for any period of time (p<0.001). Conclusion: As a part of InaHF National HF registry, the CORE-HF registry focuses in chronic HF and designed to give an overview of HF epidemiological data, especially at Surakarta region. Together with HF Clinic system, we assure not only the optimal GDMT for all indicative patients, but also patient’s compliance.

Hemostatic Factors and Its Correlation with Outcomes of COVID-19 Confirmed Patients in Ulin Regional Hospital Banjarmasin

Background: Corona Virus Disease (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) has become a Global Pandemic and has spread to more than 200 countries including Indonesia. Previous studies show that poor prognosis has a correlation with coagulopathy conditions. Objectives: To identify coagulopathy condition and its correlation with the outcomes of COVID-19 confirmed patients at Ulin Regional Hospital Banjarmasin in the period March-August 2020. Methods: A retrospective study by extracting laboratory data from medical record of 309 patients confirmed with COVID-19 at Ulin Regional Hospital Banjarmasin in the period March-August 2020. Results: This study showed that mean values of D-Dimer level in the COVID-19 cases were increased both in survivor and non survivor cases. The mean values of PT, APTT, INR and D-Dimer were higher in non survivor cases (PT 12.31 seconds; APTT 31.78 seconds; INR 1.15; D-Dimer 4.6 mg/L) than survivor case (PT 11.63 seconds; APTT 28.43 seconds; INR 1.12; D-Dimer 2.31 mg/L) while the platelet count was the opposite (288.28 in survivor cases; 281.89 in non survivor cases). The difference was statistically significant (P <0.005) in PT, APTT and D-Dimer variables between survivor and non survivor cases. However, the relationship between hemostasis factors and outcome of patient with COVID-19 was found to be very weak on the platelets, PT, APTT and INR variables (ρ = 0-0.25; P <0.005) and weak on the D-Dimer variable (ρ = 0.26-0.50; P <0.005). Conclusions: Most COVID-19 cases cause coagulopathy conditions. However, considering the risk of poor outcomes, further studies should investigate the prognostic role of hemostatic parameters in COVID-19 patients.

Prevalence and Risk Factors of Peripheral Arterial Disease in type 2 Diabets Mellitus in Yogyakarta, Indonesia

Aim: Diabetes mellitus increases the risk of peripheral artery disease (PAD) 2 times. PAD is diagnosed by ABI (Ankle Brachial Index). PAD increases mortality and morbidity of patient with Diabetes Mellitus (DM) Type 2. This study aims to determine the prevalence and risk factors of PAD in the population of type 2 diabetes mellitus (DM) in Yogyakarta, Indonesia. Methods: This study was a community-based descriptive and analytic observational study that examines the prevalence and risk factors of PAD in type 2 diabetes mellitus. Diagnosis of PAD was detected by ABI examination using VaSera VS-1500N. All patients with type 2 diabetes mellitus in Yogyakarta who meet the inclusion criteria will be enrolled in this study. The research subjects were taken in multi-stage, cluster-random sampling in Yogyakarta. The patient will undergo an interview of demographic data which were assessed by one assessor. Data from interviews and ABI examinations were analysed statistically. Results: Two hundred and fifty-six (256) patients with type 2 DM consisted of 188 patients (73.4%) women and 68 patients (26.6%) men. Prevalence of PAD diagnosed by abnormal ABI was found in 41 (16%) of 256 patients. Subjects with age more than 67 years old was significantly associated with PAD occurrence (P=0,001) in type 2 DM population. Conclusion: The prevalence of PAD was 16% of 256 type 2 DM patients. Age more than 67 years old was the strong risk factor of PAD in type 2 DM. Key words: Ankle Brachial Index, Peripheral Arterial Disease, Diabetes mellitus, Prevalence, Risk Factor

Polyphenol in reducing cardiovascular outcomes in adult: A Rapid Review and Meta Analysis

Objectives This review has an objective to determine the effectiveness of polyphenol intervention for the primary prevention of cardiovascular disease events and others surrogate endpoint which may correlate with cardiovascular disease events Data Sources These electronic databases were used to search the appropriate trials: MEDLINE (OvidSP, 1946 to March week 2 2020); The Cochrane Central Register of Controlled Trials (CENTRAL,week 2 March 2020). We only used English language trials that were available on these two databases. Review Methods We chose randomized controlled trials both in healthy or having high risk of cardiovascular diseases. Polyphenol as intervention was described as any food or drink that has polyphenol or its derived substance as main content. Placebo or no intervention is the comparison group. Cardiovascular clinical events and surrogate endpoints or cardiovascular disease risk factors are included in the outcome. Revman 5.5 software was used to analyze all the trials and to assess the risk of bias each trial. We selected random or fixed effects depend on the heterogeneity between trials in the meta analysis. Results Seven trials were included with 49200 participants randomized. Heterogeneity was shown between trials regarding the characteristic of participants, types of polyphenol intervention, and follow up periods. Cardiovascular event outcomes are only available in one trial (Howard et al 2006), with the intervention not clearly defined as polyphenol but increasing fruit and grain consumption. This trial shows no evidence was shown on fatal and non-fatal cardiovascular outcome by consuming more fruit and grain with 8 years mean of follow up. By analyzing remaining trials, which provide surrogate endpoints or cardiovascular risk factors, there is no evidence that polyphenol intervention reduce systolic and diastolic blood pressure, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol level, and triglyceride level. However, reduction total cholesterol level was shown from the baseline (MD -5.41 mg/dl, 95% CI -8.21 to -2.62, P=0.0001). Subgroup analyses were done with dividing the trials that involve women only and both men and women. This analysis shows the reduction of both systolic (MD -2.78 mmHg, 95% CI -5.47 to -0.08, P=0.04) and diastolic blood pressure (MD -2.59 mmHg, 95% CI -4.84 to -0.34, P=0.02) in trials involving both men and women. A sensitivity analysis was done by excluding the trials with risk of bias with no different results effect. Moreover, not any trials reported adverse events of polyphenol. Author’s Conclusion Due to the limitation evidence or trial available, we could not obtain meta analysis on the primary outcome. Nevertheless, this review suggests that polyphenol intervention does show favorable effect on surrogate endpoints which was total cholesterol levels. Besides, systolic blood pressure and diastolic blood pressure in trials which involves both men and women also shown an improvement. The high heterogeneity in this review also suggests that more evidence are needed to assess the effectiveness of polyphenol intervention in reducing cardiovascular event outcomes and risk factors in the future.

Ventricular Septal Rupture following Anterior Acute Myocardial Infarction: A Challenge to a Sub-District Physician

Background: Ventricular septal rupture (VSR) is one of the most serious mechanical complications following acute myocardial infarction (AMI). Although a rare complication, it is associated with significant mortality and morbidity. The purpose of this report was to present a case of VSR following anterior AMI in our hospital. Case Description: A 54-year old Javanese male presented persistent episode of breathlessness and lower limb swelling for the last two days with prior chest pain 7 days ago. Physical examination revealed a grade 3/6 holosystolic murmer loudest over the apex, S3 gallop, rales bibasally of the lung. Electrocardiographic evidence revealed for a recent anterior myocardial infarction. Chest X-Ray showed a cardiomegaly and pulmonary congestion. Transthoracic echocardiography revealed VSR at mid-anteroseptal with estimated length of 8-10 mm, preserved LVEF 51% with mid-apicoseptal akinesis. Multiple readmissions were noted for this patient in the follow-up with worsened conditions. Discussion: This is a challenging case report since our hospital is an incapable cath-lab sub-district hospital and far from PCI-capable center. It is critical that all patients with AMI have a brief evaluation for mechanical complications such as VSR. All patients who developed hemodynamic instability during AMI should be comprehensively examined for the murmur and any other heart sound that may provide valuable information. Conclusion: Every clinician especially in the low-resource setting should be aware of this potentially fatal mechanical complication as the mortality remains significantly high. Early prompt diagnosis and treatment is the key of achieving an optimal outcome.

Radiation-Induced Heart Disease: From Diagnosis to Prevention

Radiotherapy has become an important component of multimodal treatment of malignancy. After 50 years, there was a drastic increase in outcomes of patients with malignancy. However, improvement of the survival is also accompanied by some inevitable complications on cardiovascular system which are often called radiation-induced heart disease (RIHD). RIHD comprises a spectrum of heart disease including pericardial disease, coronary artery disease, valvular heart disease, conduction system abnormalities, cardiomyopathy, and medium or large vessel vasculopathy. The underlying mechanisms include direct effects on function and structure of the heart, or accelerate development of cardiovascular disease, especially with the presence of previous cardiovascular risk factors. Recent studies have identified non-invasive methods for evaluation of RIHD. Furthermore, potential options preventing or at least attenuating RIHD have been developed. This review provides an overview of pathogenesis, clinical manifestation, diagnosis, management, and prevention of RIDH. Keywords: malignancy, radiotherapy, radiation - induced heart disease.

Risk Stratification and Mortality in Mitral Stenosis Patients

Background: Rheumatic mitral stenosis is the most common valvular abnormalities found in developing countries. Mortality risk in those populations was poorly investigated. In addition, hemodynamic, morphological, and mechanical factors that influence or predict outcome of rheumatic mitral stenosis have not been identified. Aims: To determine predictive factors affecting outcome in rheumatic mitral stenosis patients. Method: This retrospective cohort study was conducted at the National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. The study recruited patients from the Valvular Heart Disease Registry from May 2014 to November 2020. New York Heart Association (NYHA) functional classification, invasive or surgical treatment, and incidence of death were recorded. The baseline rhythm from electrocardiography (ECG) was categorized as sinus rhythm and atrial fibrillation or atrial flutter. Based on the findings of trans thoracal echocardiography (TTE), subjects who had moderate to severe pure rheumatic mitral stenosis (or followed by mitral regurgitation and / or less significant tricuspid regurgitation as a natural history) and subjects with rheumatic mitral stenosis with a combination of other heart valve problems (of which severity more significantly) classified as groups I and II. The mitral valve area (MVA), mitral valve gradient (MVG), left atrial diameter (LA), and mean pulmonary artery pressure (mPAP) were then analyzed. Results: A total of 477 patients (mean age 44.08 ± 10.93 years; 71.5% female) were enrolled in this study. There were 61 deaths during the median follow up of 393 days of which 35 deaths occurred in group I and 26 deaths occurred in group II. Kaplan Meier curve shows the 1 year survival rate is higher in group I than group II which is 92.5% and 92%, respectively. Bivariate followed by multivariate analysis showed MVG and mPAP were predictive risk factors for mortality in group I with p = 0.020 and p = 0.021. MVG parameter values evaluated from echocardiography with a cut-off of more than 10 mmHg and mPAP parameters with a cut-off of more than 50 mmHg were independent predictive risk factors for mortality. Thus, patients were at higher risk of death if MVG > 10 mmHg and mPAP > 50 mmHg Conclusion: One year survival rate in group I was higher than group II. MVG and mPAP were risk factors for predicting mortality in group I.