CURRICULUM VITAE

Name : Dede Kusmana

Title : MD, PhD, FACC
Place and date of birth : Garut, January 10, 1943
Addres : Jl. Kelapa Dua Wetan No.72, Cibubur, Jakarta Timur
Marriage : Married with 3 children, and 2 grand children
Education : 2003 : Professor of Cardiology, Fac.of Medicine, Univ.of Indonesia
2002 : Doctor of Cardiology, Fac.of Medicine, Univ.of Indonesia
1975 : Cardiologist, Fac.of Medicine, Univ.of Indonesia
1968 : Medicine Doctor, Fac.of Medicine, Univ.of Indonesia
Current Position : Chief of Depart. of Cardiology and Vascular Medicine Faculty of Medicine Univ. of Indonesia
Membership : Fellow of ACC, member of ISFC, past President of AFC, Chairman of Prevention and control
of Cardivascular Disease AFC
Training : 1. Cardiac rehabilitation, Benedict Kreutz Rehabilitationzentrum fur Herz- und
Kreislaufkranke,
Bad Krozingen, Jerman, 1984
2. Five Day Asian Pacific Teaching Seminar on the epidemiology and Prevention of Cardiovas-
cular disease, Fukuoda, Japan, 1993
3. Integrated Community-Based Prevention of Major noncommunicable diseases in SEAR –
Report of an informal consultation, WHO/SEARO, New Delhi, India, 2003
4. Informal meeting on the implementation and evaluation of the WHO CVD – Risk
Assalamu’alaikum Wr. Wb.
May God Bless Us

Dede Kusmana
Causes of Death : Distribution of Cardiovascular deaths in developed, developing and in Indonesia
1985, 1990, 1997
1985 1990 1997
Developed

51 49 48 46
52 54
World*

16 17
Developing

24
World*

84 83 76

5.9 9.1
94.1 90.09 19
81
HHS

HHS =House Hold Surveys, * WHO Geneva. The world health report 1998. Life in the 21 st century a vision for all
Cardiovascular Non Cardiovascular
 Kardiovaskular 42.9

Stroke 26.8

Paru 9.8

Kanker 5.4

Lain 3.6

Kecelakaan 2.7

Ginjal 2.7

Asm a 1.8

Liver 1.8

Sal. Cerna 1.8

0 10 20 30 40 50

Gam bar 4.5.2. Penyebab kem atian secara

keseluruhan
Changes in VO2 max with bed rest and training

I/ min MAKSIMAL OKSIGEN UPTAKE

50 50

40 40

30 30

20 20

10 10

0 0
0 21
10 20 30 40 50 60

Days

Reproduced from Saltin B, et al, Circlation , Suppl 1986

 LV Dysfunction LV stabilization or improvement

Vasoconstriction Reduced Catabolic Anabolic Increased Vasodilation

simphato-exicitation peripheral State State peripheral parasimphatic
Vagal with drawal blood flow Blood flow domination
(Vagal improvement)

Modification: Skeletal & Skeletal & Modification:

-Muscle structure respiratory respiratory -Improve muscle structure
-Vascular structure myopati improvement -Vascular structure
-Autonomic tone -Autonomic & muscle reflex
-Muscle reflex

Physical deconditioning
Inactivity
Physical conditioning
Activity

Muscle fatigue, Muscle strength increase,

Dyspnoea Dyspnoea disappear

Figure 1. Peripheral abnormalities leading to physical deconditioning are responsible for some of the
exercise intolerance symptoms in left ventricle dysfunction subject (geriatric or heart failure); exercise
training is able to partially reverse peripheral and autonomic abnormalities to slow or block the vicious
circle
EXERCISE is the MOVEMENT of Major
SKELETAL MUSCLE Groups and
according to Webster’s definition as “Body
exertion for the sake of developing and
maintaining physical fitness”. It is therefore
defined as any activity that results in skeletal
muscle contraction.
 AEROBIC EXERCISE
• LIVING IN AIR • ACTIVITIES THAT
REQUIRE OXYGEN FOR
• UTILIZING PROLONGED PERIODS
AND PLACE SUCH
OXYGEN DEMANDS ON THE
BODY THAT IT IS
• KENNETH H REQUIRED
COOPER TO IMPROVE ITS
• THE AEROBICS PROGRAM CAPACITY TO HANDLE
FOR TOTAL WELL BEING, OXYGEN
BANTAM BOOKS 1982
VO2 max decrease with increasing age
   Improvement in Aerobic Exercise
Capacity
Improvement in cardiac output during exercise
    Improvement in muscular strength

Improvement in Symptoms of Exertion Intolerance

Improvement in myocardial perfusion and
reduction in myocardial ischemia

  Improvement in Emotional Factors

Autonomic control and neurohumoral activation
Improvement in EDRF
•A result of exercise training (intensity 65 % -75 % of
VO2 max) maximal oxygen uptake (VO2 max) may
increase 10 to 30 % or more for a duration of 3 to 6
months.
•Improvement as a result of adaptation of the oxygen
transport system. An increase in A-VO2 (arterial-
mixed venous oxygen difference) as a primary
training effect of peripheral adaptation of skeletal
muscle.
•Increase in capillary density, oxygen extraction and
oxidative metabolism through mitochondria enzyme
activity.
IMPROVEMENT AFTER CARDIAC REHABILITATION
IN THE ELDERLY, Kusmana, D, APSC 1988

CABG (17) AMI-IHD (33)

AGE 62.5 65.1
TT 1 6’12’ (4 - 8) 4 (1 - 8)
TT 2 8’17’ (5 - 10) 6 (3’42’ - 8)
F.Capacity (9 Mets (6 Mets0
HR max - 1 131 (103 - 154) 125 (80 - 160)
HR max - 2 147 (117 - 163) 138 (101 - 160)
WALKING 3.5 KM/30M 3 KM/30 M
•Improvement in CO is still controversial.
•Some early studies has shown an increase in CO as
reported by Ehsani in cardiac patients with higher
intensity (85% of VO2 max), longer duration (60
minutes per session) and 5 days per weeks.
• After 3 - 4 months training an average increase in
SV (stroke volume) by 18%
• Increase exercise LVEF (left ventricle ejection
fraction) but rest LVEF unchanged.
• Several studies have demonstrated that weight
training of moderate intensity is safe and give
improvement in muscular strength in selected
cardiac patient.
•Circuit training may be introduced one month
after hospitalization for stable heart and relative
good LV function or Low Risk patients.
•In the elderly with good left ventricular patient
weight training should be performed after phase II
with light weight.
• In the elderly with CHF this form of training is
prohibited.
Many patients with CAD always complain of
effort related angina, dyspnea, fatigue or
claudication during exercise. The absent of
all subjective symptoms as an importance
aim of cardiac rehabilitation as a result of
improvement in myocardial oxygen
requirement, reduction in BP and HR
during rest or exercise.
. In coronary artery disease imbalance between
myocardial blood supply and demand is the basic
pathophysiological concept of myocardial
ischemia which can be detected by
electrocardiographic ST segment changes or
thallium myocardial perfusion.
Several studies showed improvement in
myocardial perfusion or reduction in myocardial
ischemia after training combine with diet and
controlled usual coronary risk factors
•Patients suffered from CAD always elicit intense emotional
response, such as panic and anxiety as results of unfamiliar
environments and the threat of death.
•Depression may occur as early as 3 days after the event or
after discharge from the hospital.
•Some patients become denial that is some times beneficial
and some times worst. Beneficial if patients support the
program and becomes worst if the patients rejects.
Comprehensive Cardiac rehabilitation shows
significant improvement in various emotional
disorders in exercise group compare with
controlled.
 Depression
Severe depression
20
10
15
% of patients

% of patients
10
5

0 0
before after before after rehabilitation
rehabilitation rehabilitation rehabilitation

Figure 4. Effect of cardiac rehabilitation programs on the

prevalence of depression (symptom questionnaire score > 7
units) and severe depression (symptom score > 10 units) in
268 elderly coronary patients. From: Milani RV, Levie CJ,
1998.
•Before training, an overall increase in autonomic
control was observed in both vagal and
sympathetic limbs.
•It was evident the physical training maintained
and improved circadian variations of sympatho-
vagal balance : these beneficial changes may
lessen the predisposition to ventricular
arrhythmia.
•Physical training improves autonomic control in
heart failure with a reduction in sympathetic tone
and an increase in vagal tone. A reduction in nor-
adrenaline spillover.
 Improvement in EDRF

Endothelial
Suspension mode :
Direct Direct

4
mL/ min

Pulsatile flow
PGF 2
4 mL/ min
Figure 3. Effect of Increased flow rate under bioassay conditions. The relaxation is
augmented by increasing the flow rate to 4 ml/min.
 Shear Stress Respons

< 1 minute 1 mninute – 1 hr

Signal MAP kinase
K –chanel activation Activation ofi NFkB
Increase of IP3, DAG Controlling SSRE – dependent
Concentration Ca ++, PDGF – B
G protein activation Increase density of b FGF
Changes the type of sitoskeleton

Release of
NO and PG

6 hrs 1hr - 6 hrs

Reorganization of cell Gen controlling – SSRE dependent
surface (NOS, tPA, TGFb, ICAM–1, c–Fos,
Increase mechanical MCP–1)
stifness Stimulation HSP 70
Decrease Tm, Fn density Decrease of ET–1 density
There are several clearly defined
benefits from exercise training of
cardiac patients.
 1.1

1.0
KESIN TASAN

.9

Aktifitas fisik

Berat
.8
Sedang

Ringan

.7 Tidak ada
-2 0 2 4 6 8 10 12 14

WAKTU (TAHUN)

Survival Curve & Hazard

.3
Ratio of Physical Activity,
Kusmana D,2002
.2
R A SIO B A H A YA

.1

Aktifitas fisik

Berat
0.0
Sedang

Ringan

-.1 Tidak ada

0 2 4 6 8 10 12 14

WAKTU (TAHUN)
Table 1. Relationship of Activity/Fitness Index Classification to High-
density Lipoprotein Cholesterol concentration.

Inactive Active Difference p

HDL C HDL C mg/dl
mg/dl mg/dl

Men 20-39 (n 627) 43.9±10.2 (n330).46.5± 12.1 2.6 0.001

40-49 (n 718) 44.6 ±11.7 (n 298). 47.1±12.4 2.5 0.005

Woman. 20-39(n 775) 54.5±13.6 (n139) 59.5±14.5 5.0 0.001

40-49 (n 767 ) 59.1±15.9 (n 89 ). 64.5± 18.8 5.4 0.01
 Typical Maximal Data in patient with moderately severe
Coronary heart disease (left ventricular dysfunction but no
angina
Pectoris), a normal sedentary subject, and a long-distance runner
The benefits of Cardio-respiratory fitness on risk factors. Cited
from the Journal of Clinical Endocrinology & Metabolism 2000
Vol. 85, No.3 957 - 963
Odds ratios for development of type 2 diabetes in 8,633
healthy men, adjusted for age, examination year, BMI,
smoking habit, alcohol intake, parental history of diabetes,
and elevations in blood pressure and lipids in Blair et al study
 Cardiac events according to study group and cause
Group T Group C Absolute
(n=59) (n=59) Difference* Relative risk p
n (%) n (%) % (95%CI)# value

Cardiac deaths 0 0 0 - -
Coronary angioplasty 4 (6.8) 11 (18.6) -10.2 0.84 (0.76-1.05) 0.19
Acute myocardial infarction 1 (1.7) 3 (5.1) -3.4 1.05 (0.68-1.59) 0.31
Coronary artery bypass surgery 2 (3.4) 5 (8.5) -5.1 0.99 (0.76-1.46) 0.26
All@ 7 (11.9) 19 (32.2) -20.3 0.71 (0.60-0.91) 0.008

*Difference between the percentage of events in th trained group and the percentage of events
in the control group; #relative risk and CI were estimated from the Cox proportional-hazards model; @all
patients who underwent a new coronary angioplasty or bypass surgery were hospitalized for unstable
angina, low-threshold effort angina (8) or low-threshold myocardial ischemia during exercise stress testing.
CI = confidence interval. (From Belardinelli et al. JACC 2000; 37;7:1891-900)
Rates and relatively risks of fatal heart attack in longshoremen,
1951 – 1972, by energy expenditure o work and age of death

Relative Risk Low above bars

High
• decreased blood pressure,
• increased HDL cholesterol ,
• decreased LDL cholesterol,
• decreased body fat,
• decreased glucose-stimulated insulin secretion ,
• increased heart and lung function and efficiency,
• decreased anxiety, tension, and depression.
EFICACY of Training
Comparison of energy expenditure during three modes of locomotion. The oxygen
uptake during walking was less than that during race walking and, in turn, less than
during joging-running. The order reversed above 5 miles per hour.
From Franklin B, Hellerstein HK, Moir RW.
Classification of exercise intensity based on Borg
Scale and VO2 max

VO2 max
Intensity Borg scale (ml/kg . min)

Very lihgt 9 < 25

Light 11 25 – 44
Moderate 10 – 13 45 – 59
Hard 14 – 15 60 – 84
Very hard 16 – 17 > 85
Maximal 18 - 20 100
 Actual and projected changes in life expectancy

120
Projected
Mean life span (yrs)

100
80
60
40
20
0
1800 1900 1940 1950 1960 2000s*

Public health Nutritional Antibiotics Vaccines Life

sanitation general Acute style
care changes
medicine

* Projections include the use of drugs that prolong cell life, antioxidants, new hormones,
and gene therapy

Figure 5. Increase in life expectancy have been marked by significant advances in medicine and public
health. Source: Prepared for geriatrics by Christine K. Cassel, MD in Milani RV, Levie CJ. Am J Cardiol
1998;81:1233-1236.
 Physical inactivity, sedentary lifestyles and low
levels of cardio-respiratory fitness confers a relative
and attributable risk for death that is similar to that of
other major modifiable risk factors .
To keep your HEARTS and LUNGS healthy, stay in healthy
lifestyle particularly managing EXERCISE regularly because
IT IS CHEAP, SIMPLE AND PRACTICAL but BRINGS
MANY BENEFITS FOR OUR HEALTH
 AMIIIIN AMIIIIN

SELAMAT IDUL FITRI 1 SYAWAL 1425 H

SEMOGA KEMBALI FITRAH MEMPEROLEH KEMENANGAN TETAP
FIT DAN MENJAGA OLAH RAGA TERATUR DALAM KEHIDUPAN
SEHARI - HARI
SALAM KAMI SEKELUARGA
 ALHAMDULILLAH
Terima kasih
Thank you
Matur nuwun
Hatur Nuhun
Matur Suksma
Tereumang Gasih
SYUKRON
Assalamu’alaikum Wr. Wb