PENYAKIT

KARDIOVASKULER PADA
USIA LANJUT
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Principal Hospital Diagnoses of
Elderly Age 85+ (2006)
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Muscle
Strength
& Aerobic
Capacity
Vasomotor
Instability
Bone
Density
Ventilation
Sensory
Continence
Altered
Thirst and
Nutrition
Fragile
Skin
Tendency
To Urinary
Incontinence
Immobilized
High Bed
Bed Rails

Plasma
Volume
Accelerated
Bone Loss
Closing
Volume
Sensory
Deprivation
Isolation

Barriers
Tether
Rx Diet
Immobilization
Sheering
Force
Diapers
Tether
Hazards of Bed Rest and Hospitalization
+ + + + + + + + +
Dehydration Malnutrition
Tube
Pressure
Sore
Infection
Functional
Incontinence
Catheter
Family
Rejection
Aspiration
Nursing Home
Cascade to Dependency
Deconditioning
Syncope
Fall
Fracture
pO2 Delirium
Physical
Restraint
Chemical
Restraint
False Label
Tardive
Dyskinesia
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DYSFUNCTION AND DISABILITY
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Etiology of deconditioning/tdk
sehat
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Consequences of deconditioning
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Hospital associated
deconditioning
Loss of ambulatory function or ADL or both in at
least 1/3 of hospitalized patients
Increased risk of death
Demand for rehabilitation will increase
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Cardiovascular Aging 1
Resting LV systolic function normal in absence
of CAD, Hypertension
SBP and pulse pressure increase with age
Sedentary lifestyle may impact on CV system
and obscure impact of aging changes
Lifestyle alterations may delay and partially
reverse changes of cardiovascular aging

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Cardiovascular Aging 2
Increased systemic vascular
impedence/menghalangi
Systolic hypertension
LV hypertrophy
Impaired ventricular diastolic relaxation and
compliance/pemenuhan
Increased cardiac interstitial collagen
Compensatory myocyte hypertrophy
Increased LVEDP, LA size
Predispose to atrial fibrillation
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Cardiovascular Aging 3
Diminished responsiveness to beta-
adrenergic stimulation
Reductions in maximum HR
1 & 2 effect
Impaired peripheral vasodilatation
2 effect
Altered myocardial energy metabolism
Impaired mitochondrial capacity to increase ATP

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Cardiovascular Aging 4
Clinical implications
Increased preload and afterload
Impaired augmentation of cardiac output
Physiologic stress (exercise)
Pathologic stress (e.g. MI, infection, surgery)


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Cardiovascular Aging 5
Echocardiography
LV wall thickness and mass increase linearly with
age
LVEF correlates strongly with presence of CAD
and HTN

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Traditional medical approaches do not cater/melayani for
the heterogeneity/beda2 of disease in the elderly!
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Spectrum of CV Disease
in the Elderly

Arrhythmias
atrial fibrillation
ventricular
Atherosclerotic vascular
disease
cerebrovascular disease
peripheral vascular disease
CAD
chronic stable angina
acute ischaemic syndromes
Conducting System
Disease
Congestive Heart Failure
Systolic
Diastolic
Hyperlipidemia
Hypertension
Hypertrophic
cardiomyopathy
Valvular Heart Disease
Aortic sclerosis
Aortic stenosis
Mitral annular calcification
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CV disease rises sharply with age
85% of CHD deaths are in patients
> 65 years of age
60 % of admissions for acute MI are in patients
> 65 years of age

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Age, years Men Women
30-39 5% 1%
40-49 11% 5%
50-59 20% 12%
60-69 29% 15%
70-74 26% 20%
Source: Framingham Heart Study. Am J Hypertens 1993;6:309S-313S
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Atypical Presentation of
Acute Illness,elderly
Only 40% of elderly fit the classic one
symptom
Acute myocardial infarction without chest
pain
Acute hyperthyroidism without tachycardia,
weight loss, etc.
Acute infection without rising WBC count or
typical fever
Fatigue as chief presenting complaint of
CHF
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Confusion
Self-neglect/mengabaikan
Falling
Apathy
Anorexia/weight loss
Dyspnea
Fatigue
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Hidden Illness:
You Must Ask, They Wont Tell!
Sexual dysfunction
Depression
Musculoskeletal stiffness
Alcoholism
Hearing loss
Memory loss
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Aging is NOT a disease
Learn to separate pathologic processes
from the aging process
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(Contd)
Normal aging
Crows feet/keriput
pojok mata
Presbycusis /kurang
pendengaran
Seborrheic
keratoses; loss of
skin elasticity
Benign forgetfulness
Increase in % body
fat

Disease
Macular
degeneration
Tympano-sclerosis
Basal cell CA
Dementia
Athero-sclerosis
Hypertension
Obesity

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61%
19%
6%
14%
53%
12%
5%
30%
CHANGES IN BODY COMPOSITION
with AGING
SOLID CELLS
BONE MINERAL
FAT
H2O
25 YEARS OLD
70 YEARS OLD
(Merriman, 1989)
Laboratory Values that Do Not
Change with Aging
Hepatic function (ALT, AST, GGPT, Bilirubin)
Coagulation tests
Chemistries: electrolytes, total protein,
calcium, phosphorus
ABGs: pH, PaCO2
Hemoglobin, RBC indices, platelet count
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The Hospital Cascade
of Disasters/petaka
Hospitalization new environment and new
medications acute delirium more new
drugs more agitation; Foley inserted poor
oral intake dehydration IV fluids increased
and/or NG tube placed for feeding
We now have the potential for congestive heart
failure, thrombophlebitis, pulmonary
embolism, aspiration pneumonia, falls and
fractures, pressure sores, urosepsis, septic
shock, etc . . .

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The Hospital is a
Hazardous/bahaya,penuh risiko
Place...
Drugs:
Polypharmacy
Alterations in drug disposition and tissue
sensitivity
Drug-to-drug interactions
Changes in renal/hepatic elimination
Medications errors
Medication side effects

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The Hospital is a
Hazardous Place... (Contd)
Bed rest and immobility
General cardiac and muscle deconditioning
Postural lightheadedness, hypovolemia,
hypotension
Constipation/fecal impaction
Atelectasis and pneumonia
Thrombophlebitis and thromboembolism

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Therapeutic and diagnostic procedures
Angiography
GI endoscopy and its preparation
Surgery and anesthesia
Nosocomial Infections
Pneumonia, C. difficile, MRSA

The Hospital is a
Hazardous Place... (Contd)
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Keep accurate medical and surgical
diagnosis lists
Prioritize medical therapies, addressing
reversible problems first
Carefully select diagnostics: Is this
procedure necessary and how will it
change my management?

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Medications
Make an accurate list of all medications on
admission, including OTCs and herbals
Always consider adverse drug effects as the
cause of new symptoms
Monitor appropriate blood levels (Digoxin)
Try to control pain without narcotics first
Monitor/review need for medications daily
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Albumin and total cholesterol signal poor
nutritional state
Provide vitamin supplementation
Adjust fluid therapy on an individual basis
Ask about nausea/anorexia, food
satisfaction daily
The hospital is an excellent place to obtain
a professional nutritional consultation

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Address anxiety, pain and insomnia early
Depression common: 20-60% of
hospitalized elderly; treat it
Frequently update family; hold
patient/family conferences to
allay/menghilangkan fears and clarify
the plan

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Goals of Geriatric
Assessment
Improve diagnostic accuracy
Define functional impairment
Recommend optimal living situation
Monitor clinical change over time

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Secara alami,elastisitas pada manusia akan
menurun dengan bertambahnya umur.
Akibat adanya perubahan dinding media
aorta,bukan karena perubahan intima,ok artero
sklerosis yg memang sering terjadi.
Secara histologis,ok perubahan yg progresif
pada fungsi jaringan elastis pada aorta.

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Penambahan usia tdk menyebabkan
jantung mengecil(atrofi),at terjadi justru
hipertrofi.
Pada batas umur 30-90 tahun,masa
jantung bertambah(+/- 1 gr/thn pd
laki,1,5gr pd wanita)(Lakatta,1987).
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Pengatur irama jantung oleh simpul SA
ternyata menurun dg bertambahnya usia.Juga
daya cadangan jantung
Isi semenit menurun rata rata 1% setahunnya
sesudah usia
pertenganhan(Pietro,1985).Aritmia didapat
>10%.tdk perlu pengobatan
Pada umur 20-80 thn,terjadi pengurangan 5%
pengisian ventrikel pd permulaan
diastole(Gerstenblith dkk,1977).
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GEJALA,TANDA,DIAGNOSIS PENYAKIT
JANTUNG PADA USIA LANJUT
Sifat penyakit pd usila yg bersifat umum,yi patologi
multipel,gejala dan tanda yg tersembunyi,tdk
khas,atipik,bervariasi,asimptomatik,progresif,kadang
bersifat kronis,shg menimbulkan invaliditas cukup lama
sblm meninggal(Stieglitz,1954,Boedi-Darmojo,1982).
Nyeri dada,sesak nafas,dirasa ringan.angina pektoris
jarang,ok hilangnya rasa pd ujung syaraf
sensorik(Caird dkk.1985).
Gejala kebingungan(cofusion),muntah,nyeri
perut,akibat bendungan hepar/insomnia,harus
dipikirkan dek.kordis.

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No ST Elevation ST Elevation
Acute Coronary Syndrome
Unstable Angina NSTEMI
STE MI
NSTEMI
Myocardial Infarction
Davies MJ
Heart 83:361, 2000
Ischemic Discomfort
Presentation
Working Dx
ECG
Biochem.
Marker
Final Dx
Hamm Lancet 358:1533,2001
PENYAKIT JANTUNG KORONER PADA
USIA LANJUT
PJK paling sering
ditemukan,pria(20%),wnita(12%)pd usila
>65thn(Kennedy dkk.1977)
Angina pektoris,rasa nyeri lebih ringan.Operasi
pintas koroner menunjukkan keberhasilan
95%)Knapp dkk,1985.Ketahanan hidup 5 thn
sebasar 80%.
IMA pd usila tidak khas(bingung akut,episode
sinkope,hemiplegi,oklusi,emboli,gagal
ginjal,muntah,kelemahan hebat,dalam
penelitian,25% gejala khas,40% atipis,31%
silent(Caird dkk 1985).

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PENYAKIT JANTUNG KORONER
PADA USIA LANJUT
Pengobatan IMA,sama,at pd usila masih
menjadi perdebatan u pemberian beta
bloker,trombolitik.
Hal ini ok pengobatan IMA didasarkan atas
pengalaman pd usia
pertengahan(Goodman,Amstrong,1994)
Riwayat alamiah IMA pd usila menunjukkan
secara signifikan lbh buruk dari usia muda dg
komplikasi lbh banyak di RS dan mortalitas lbh
tinggi.Pengobatan trombolitik bukan kontra
indikasi pd usila.Meskipun pd usila komplikasi
lbh banyak at pd golongan ini trombolitik lbh
menguntngkan(Goodman,Amstrong,1994)

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Components of Risk Stratification
Target Organ Damage/Clinical Cardiovascular
Disease
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Target end-organs should be assessed
by history and physical examination
Brain
Heart
Kidneys
Eyes
Arteries
Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46
RINGKASAN DAN SIMPULAN
Penyakit kardiovaskuler sbg penyebab
kematian,baik di negara berkembang maupun di
negara sedang berkembang.
Urutan penyakit kardiovaskuler pd usila,PJK,PJ
hipertensif,kardiomiopati,dg komplikasinya al
gagal jantung kongestif,aritmia kordis.
Faktor
risiko:merokok,hipertensi,dislipidemia,DM,inakti
fitas fisik,obesitas.
Tujuan utama pengobatan al menghindari
disabilitas,mortalitas
prematur,mempertahankan fungsi dan
perbaikan kualitas hidup.
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THE END
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Health is not Everything,
but Life without Health is Nothing.
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