1.g what is the patofisiology of continous pounding of the hears in the case?

Caffeine as a competitive inhibitor is antagonistic to adenosine receptors. Caffeine has a

structure similar to adenosine which will bind to adenosine receptors on the cell surface
wall without causing activation of the receptor> decreased adenosine activity> increased
activity of dopamine neurotransmitters. This increase in dopamine activity is the basis of
the stimulating effects of caffeine.

 Adenosin> glomerular afferent arteriolar constriction, so that inhibition of adenosine

receptors> arteriole vasodilation> increased Renal Blood Flow (RBF) and Glomerulus
Filtration Rate (GFR) increases. This competitive inhibitory mechanism also inhibits
pathways that regulate nerve conduction by suppressing post-synaptic potential>
epinephrine and norepinephrine or noradrenaline released through the hypothalamic-
pituitary-adrenal axis. Caffeine reduces uptake or metabolism of catecholamines in non-
nerve tissues. While at high doses, caffeine can interfere with the uptake and storage of
Calcium (Ca2 +) ions in the sarcoplasmic reticulum. Caffeine can diffuse freely into cells
and cause intracellular calcium release from the sarcoplasmic reticulum> there is an
increase in the strength and duration of contraction of the skeletal muscles and heart
muscle > continous pounding (katzung, 2012)

1.h what is the risk factor of Aritmia?

Answer:

Risk factors for heart rhythm disorders.

 The following things increase the risk of arrhythmias, namely:

1. Heart attack

2. Heart failure or cardiomyopathy

 This condition will weaken the heart muscle which affects the impulse conductivity
process.

 3. Heart valve disorders In conditions of valve disorders, the heart works harder than
usual so that it can cause heart failure.
 4. Congenital heart disease The presence of congenital heart abnormalities can result in
disorders of the anatomy and physiology of the heart.

5. hypertension

 High blood pressure will increase resistance to pumping blood from the left ventricle.
This will cause the heart to work harder.

 6. Myocarditis and Pericarditis

7. Diabetes

 Diabetes can increase the risk of hypertension and coronary artery disease.

8. Sleep apnea

Can cause damage to the heart because the heart does not get enough oxygen.

9. Disorders of thyroid function (hypothyroidism and hyperthyroidism)

 10. Use of drugs that can trigger arrhythmias Medications that can trigger arrhythmias
are quinidine, fluoxetine (antidepressants), class III antiarrhythmics (such as sotalol,
dofetilide, ibutilide, and azimilide), as well as cocaine, amphetamines and ecstasy.

 11. Pregnancy A

Rhythm usually occurs during pregnancy in women with normal or abnormal heart
structures, with or without a previous history of arrhythmia. Women with congenital heart
disease, structural heart disease, and previous arrhythmia have a higher risk. Heart rate
increases by 30-50% due to adrenergic activity. The exact cause of arrhythmias in
pregnancy is still unclear, but hormonal changes (increased estrogen, B-human chorionic
gonadotropin, and adrenergic activity), hemodynamics, and autonomic changes are
thought to play a role in causing arrhythmias. Preeclampsia is characterized by
hypertension and proteinuria during pregnancy. after the age of 20 weeks gestation.

 12. Consumption of alcohol

 Excessive and chronic alcohol consumption can cause arrhythmias, especially the type of
supraventricular tachyarrhythmias. The alcoholic arrhythmogenic mechanism is still
unknown. It is suspected that subclinical heart muscle damage due to chronic alcohol
consumption can cause cardiac conduction barriers.

 13. Unbalance of electrolytes

Potassium metabolic disorders have the greatest influence on arrhythmias compared to

other electrolyte disorders. Hypokalemic conditions have arithmogenic properties on the
basis of mechanisms for prolonging ventricular repolarization, slowing conduction, and
abnormal pacemaker activity.

 14. Congestive Heart Failure In congestive heart failure there are several conditions that
can cause atrial fibrillation, such as:

 A. Ionic channel remodeling and gap junction which cause interference with the action
potential, increase in Ca2 +, and heterogeneous distribution of connexin (protein forming
gap junction). This condition will cause cellular excitation and disruption of the
conduction process.

B. Mechanical remodeling due to increased pressure and strain in the left atrium. This
condition will result in increased ectopic activity from the pulmonary vein, fibrosis with
impaired conduction, and ischemia.

C. Neurohormonal activation, namely Renin-AngiotensinAldosterone System (RAAS)

and adrenergic stimulation, which causes fibrosis and ischemia These three conditions
can lead to ectopic activity and reentry which is the initiator of the occurrence of atrial
fibrillation.

15. Sepsis Sepsis can decrease blood pressure (systolic blood pressure <90mmHg or
decrease in systolic blood pressure> 40mmHg) which is accompanied by signs of
circulatory failure even though adequate fluid resuscitation has been performed or
requires a vasopressor to maintain blood pressure and organ perfusion. This condition is
referred to as septic shock. In the early phase of septic shock excessive inflammation
occurs which results in vasodilation and capillary leakage which affects preload and
cardiac cardiac output. This condition causes severe hypovolemia and arterial
hypotension which will stimulate massive sympathetic system activation in an effort to
maintain perfusion of vital organs. Sympathetic system activation will result in
tachycardia and vasoconstriction as compensation for systemic vasodilation. Tachycardia
in septic shock is considered the main compensation mechanism for maintaining cardiac
output. (Danielle and Andreas, 2017)

2.b what is the meaning Ms.Elga also consumed 2 glasses of coffee everynight with a
chief complain?

Answer:

Because, Caffeine also works as a competitive inhibitor of the cAMP phosphodiesterase

enzyme (cAMP-PDE), which converts cyclic AMP (cAMP) in cells to non-cyclic forms,
so that cAMP will accumulate in cells. cAMP plays a role in activating Protein Kinase A
(PKA) to initiate phosphorylation of specific enzymes used for glucose synthesis.
Resulting from the mechanism of action of caffeine above can cause a strong increase in
heart contraction. (Katzung,2012)

Dapus:

Katzung ,Bertram G.2012.Farmakologi Dasar dan Klinik Ed 10. Jakarta:EGC

Daniella KarenWidjaja and Andreas Arie Setiawan. 2017. Arrhythmia In Patients With
Hyperthyroid,Undergraduate Thesis. Student Of Medical Faculty Diponogoro University.