Rarsari Soerarso

4 THE DIFFERENCE ON STRAIN AND STRAIN RATE PARAMETER OF LEFT VENTRICLE FUNCTION BETWEEN CONTROLLED HYPERTENSION AND UNCONTROLLED HYPERTENSION

Background: Hypertension (HT) is associated with left ventricle (LV) diastolic and systolic dysfunction, even in patient with normal ejection fraction. Speckle tracking echocardiography (STE) has a high sensitivity in evaluating LV systolic and diastolic dysfunction. No published study evaluating the difference of LV systolic and diastolic function using STE between uncontrolled and controlled hypertension in Indonesia. Objective: This study sought to assess the difference of intrinsic left ventricle function between controlled HT and controlled HT. Methods: Cross-sectional study with 119 subjects consisting of 59 uncontrolled HT subjects and 60 controlled HT subjects, underwent STE study with global longitudinal strain (GLS) as a parameter to assess LV systolic function and strain rate as a parameter to assess LV diastolic function. Results: There is a significant difference of GLS between uncontrolled and controlled HT (−19,77 ± 3,10% vs −23,85 ± 2,25%, p < 0,0001). In subgroup analysis with left ventricle hypertrophy (LVH) also has a significant difference of GLS between uncontrolled (n = 36) and controlled HT (n = 25). (−19,50 ± 3,27% vs −23,50 ± 1,99%, p < 0,0001). There is no difference of E/SRE ratio between uncontrolled and controlled HT (46,48 (27,03–79,31 vs 45,35 (30,86–69,44), p = 0,539). There is significant difference of SRA between uncontrolled and controlled HT (1,40 (0,4–2,64) vs 1,19 (0,80–2,20), p < 0,0001). In subgroup of LVH and no-LVH, there is no difference of E/SRE ratio between uncontrolled and controlled HT (47,58 (27,03–79,31) vs 49,11 (32,33–67,42), p = 0,965; and 43,2 (30,36–65,63) vs 44,76 (30,86–69,44), p = 0,775 respectively). Conclusion: There is a significant different on GLS as a parameter of LV systolic intrinsic function between uncontrolled and controlled HT. There is no difference of E/SRE as a parameter of LV diastolic function between uncontrolled and controlled HT. But there is a significant difference of SRA between those groups.

[PP.04.23] A DIASTOLIC DYSFUNCTION SCORING SYSTEM (DSS) FOR DETECTING LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN HYPERTENSIVE PATIENTS

Objective: To identify factors related to left ventricular diastolic dysfunction in hypertensive patients, and to create a scoring system from those related factors. Design and method: A cross sectional study was conducted in Tarakan General District Hospital North Borneo with hypertensive subjects on October 2016. Patients characteristics, all factors related to left ventricular diastolic dysfunction, and echocardiographic data were collected and analysed. Results: There were 132 total samples in this study, and left ventricular diastolic dysfunction was found in 40,2% samples. From logistic regression analysis, age more than 55 years old (OR 4.97, 95% CI 1.60–15.42), poor blood pressure control (OR 22.33, 95% CI 4.11–121.48), left ventricular hypertrophy (OR 4.23, 95% CI 1.14–15.72), and abnormal fasting plasma glucose (OR 13.24, 95% CI 2.89–60.67) were found to have a significant relation with left ventricular diastolic dysfunction and became a final model variables of scoring system. Left ventricular diastolic dysfunction scoring system could be generated from those variables final models. Calibration and internal validation tests for this scoring system showed good results. Conclusions: A scoring system can be generated to detect left ventricular diastolic dysfunction in hypertensive patients.

[PP.28.02] FACTORS INFLUENCING THE OUTCOMES OF HYPERTENSIVE HOSPITALIZED PATIENTS: THE IMPORTANCE OF GLYCEMIC CONTROL

Objective: To assess the extent of diabetic involvement towards adverse events and LOS of hypertensive hospitalized patients. Design and method: This is a cross-sectional study of hypertensive samples which were hospitalized at National Cardiovascular Center Harapan Kita Indonesia from 2015 until mid-2016. Samples were taken consecutively among non-new ACS patients according to inclusive and exclusive criteria. Bivariate and multivariate analysis were done using SPSS-20 program. Results: Among 263 hypertensive samples hospitalized, the occurrence of worsening renal failure (WRF), length of stay (LOS) > 5 days, and in-hospital death were 23.2%, 62.5%, and 3.3% respectively. After adjusted with other independent variables, only diabetic status was significant in producing longer LOS (OR 2.21; p .028) and occurrence of WRF (OR 2.9; p .004). Systolic BP > 140 mmHg also had a role in worsens the renal (OR 4.13; p < .001). Likewise, admission random blood glucose level > 200 mg/dl became the only significant predictor towards in-hospital death (OR 2.4; p .017). Surprisingly, senility, anemia, LVEF and baseline s-Cr were not one of them. Conclusions: In hypertensive hospitalized patients, we should pay more attentions to diabetic status and blood glucose level not only to prevent WRF and in-hospital death, but also to shorten LOS.

8 A Scoring System for Detecting Left Ventricular Diastolic Dysfunction in Hypertensive Patients

Introduction: Hypertension is the most common condition seen in primary care and a risk factor for diastolic dysfunction. Diastolic dysfunction occurred before heart failure in hypertensive patients with preserved ejection fraction, therefore early diagnosis of diastolic dysfunction is very important. Several factors have been known to be associated with left ventricular diastolic dysfunction and a new scoring system could be generated from those factors. Methods: A cross sectional study was conducted in Tarakan General District Hospital North Kalimantan with hypertensive subjects on October 2016. Patients characteristics, all factors related to left ventricular diastolic dysfunction, and echocardiographic data were collected and analysed. Results: There were 132 total samples in this study, and left ventricular diastolic dysfunction was found in 40.2% samples. From logistic regression analysis, age ≥55 years old (p = 0.006), poor blood pressure control (p < 0.001), left ventricular hypertrophy (p = 0.003), and abnormal fasting blood glucose (p = 0.001) were found to have a significant relation with left ventricular diastolic dysfunction and became a final model variables of scoring system. Left ventricular diastolic dysfunction scoring system could be generated form those variables final models. Calibration and internal validation tests for this scoring system showed good results. Conclusion: A scoring system can be generated to detect left ventricular diastolic dysfunction in hypertensive patients.

Early Experience of MitraClip Procedure at National Cardiovascular Center Harapan Kita, Jakarta

Background: Percutaneous mitral valve repair (PMVR) with MitraClip is considered as an optional treatment for patients with significant MR who are high risk for having surgery. This novel therapy is less invasive, safe, and effective for MR reduction, and hence improve symptoms of heart failure, as well as reverse left ventricle remodeling. The purpose of this study was to report the early experience of Mitraclip procedure for treating significant MR at the National Cardiovascular Center Harapan Kita. Methods: This retrospective study was conducted at National Cardiovascular Center Harapan Kita Hospital, Jakarta. The data was retrieved from computerized database and medical records from February 2014 to January 2015, and then analyzed with SPSS. Results: A total of 6 patients with age 51 75 years old, underwent MitraClip procedure. Of all patients, the MR were severe in 5 patients and moderate in 1 patient. One was female and 5 were male. Among these patients, 2 were degenerative MR and 6 were functional MR. Two patients were treated with single MitraClip and 4 patients required double MitraClip. Post proccedure, there was reduction of MR to mild was achieved in 2 patients and to moderate in 4 patients. The left ventricular end diastolic dimension decreased from 66 ± 6.5 mm at baseline to 59 ± 7.3 mm (p=0.04) and end systolic dimensions decreased from 50 ± 10.6 mm at baseline to 48 ± 10.0 mm before discharge (p=0.27) as evaluated from predischarge echocardiography. At one month after procedure, 2 patients were in New York Heart Association (NYHA) functional class I and 4 patients were in class II. In-hospital mortality was 0%. Only 1 patient was re-hospitalized after procedure due to heart failure. Conclusion: From our early experience, MitraClip was considered an effective and safe option for patients with functional and degenerative MR who are at high risk for open-heart surgery. Left ventricle dimension, NYHA functional class, MR reduction, and re-hospitalization rate were improved after procedure.

Uncontrolled Blood Pressure as Predictors for Multivessel Disease in Hypertensive Young Adults With Acute Coronary Syndrome At National Cardiovascular Centre Harapan Kita

Introduction: Hypertension may affect any age, including young adults. Acute coronary syndrome (ACS) is one of the devastating complicationsof hypertension, and a common reason for hospitalization. Previous studies have found that having 2 or more risk factors increases the risk for multivessel disease. Objective: To review the role of hypertensionas a predictor for multivessel disease inhypertensive young adults with ACS at National Cardiovascular Centre Harapan Kita (NCCHK) Methods: A retrospective study ofhypertensive young adults (18–40 years old)hospitalized due to ACS atNCCHK. The data were collected from medical records. The coronary angiography data from patients with at least 2 or more risk factors were analyzed. Results: From 194 hypertensive young adults hospitalized in NCCHK during 2011–2013, 100 patients (51.5%) were admitted with ACS. 61 patient underwent coronary angiography, and the result was 10 patients with normal coronary artery, 23 patients with single vessel disease, and 28 patients with multivessel disease. The odds of multivessel disease were 1.06 in patients with uncontrolled blood pressure (95% CI = 0.33–3.45), 0.91 in patients with diabetes (95% CI = 0.29–2.88), 1.04 in patients with family history of CAD (95% CI = 0.34–3.19), 0.9 in smokers(95% CI = 0.28–2.89), and 0.12 in patients with dyslipidemia(95% CI = 0.02–0.61). Conclusion: ACS was the most common reason for hospitalization of hypertensive young adults in NCCHK. Among the traditional risk factors, uncontrolled blood pressure has the highest odds in the development of multivessel disease.

Characteristics of Patients Diagnosed with Chronic Kidney Disease and Hypertension in Gatot Subroto Army Hospital

Background: the prevalence of hypertension with chronic kidney disease in Indonesia is quite high. 60% patient with renal impairment develops to hypertension. Both of the diseases affect each other and still cause high mortality and morbidity in the worldwide. Objective: knowing the characteristic patients diagnosed with hypertension with chronic kidney disease and its risk factors from Gatot Subroto Army Hospital. Method: all patients data diagnosed with hypertension and CKD, enrolled from outpatient department of Gatot Subroto Army Hospital Nephrology Department, Jakarta from July until August 2014, are recorded by researcher. Result: samples from this study are 66.7% male and 33.3% female. The patients’ age which below 60 years old are 66.7% with means 56.95 + 11.727. 89.7% patients diagnosed with End stage of Chronic Kidney Disease. Proteinuria 0 are 3.4%, +1 are 44.8%, +2 are 31.0%, +3 are 20.7%. Hypertensive patients are 74.4% from samples, while 12.8% of the samples are diagnosed with diabetes mellitus with their blood glucose levels are 129.45 + 40.543 mg/dl. Sodium levels are 139.9211 + 4.994 meq, while potassium are 5.5711 + 6.4555 meq while 23.7% of the samples have potassium levels more than 5 meq. Creatinine more than 1.2 mg/dl are 97.4% of population, and albumin less than 3.5 mg/dl are 60.9% percent. Conclusion: the characteristics suspected affecting the condition of patients with hypertension and CKD are: age, sex, stage of CKD, diabetes mellitus, proteinuria, clearance creatinine, kalium, blood ureum, and albumin. Further researcher are needed to know more detail how much each risk factor affect hypertension and CKD. Figure. No caption available.

Improvement of Flow Mediated Dilatation Index Correlates with Decreasing of Blood Pressure in Subjects with Hypertension and Pre-Diabetic

Background: The vascular effect of insulin resistance had been known to cause serious damage on endothelial function, especially nitric oxide (NO) system, that may cause an earlier onset of cardiovascular disease, such as hypertension. Objective: To explore the correlation between improvement of endothelial function and achievement of targetted blood pressure. Method and Results: A quasi experimental study of 62 hypertensive and pre-diabetic (IGT) patients showed a significant improvement of Flow Mediated Dilatation (FMD) within 3 months in those who received added theraphy of Metformin 500 mg twice daily (n = 23) on their routine anti-hypertensive drugs (p < 0,001). It also showed a moderate correlation between improvement of FMD that reflects the endothelial function with good achivement of targeted blood pressure (R 0,421). Linear regression analysis (adjusted analysis to confounder factors such as age, sex, BMI, history of smoking, aspilet added therapy, anti-hypertensive drugs) showed Metformin as the only factor that influenced the improvement FMD (OR 7,88; p < 0,001). Conclusion: This study showed thatMetformin 2x500 mg as an add-on therapy in hypertensive pre-diabetic subject plays a positive role in improving the endothelial function as seen on the FMD measurement

Role Of Renin Angiotensin System Blocker In Predicting Hospital Outcome In Controlled Diabetic With Chronic Kidney Disease On Routine Hemodialisa

Background: Patients with diabetes have increased risk for adverse cardiovascular events. Angiotensin-converting enzyme inhibitors are protective in type 2 diabetes. Studies that analyzed the effects of inhibition of the renin–angiotensin system on the risk for cardiovascular complications included a substantial number of patients with diabetes or were done exclusively in patients with diabetes and chronik kidney disease. Many studies demonstrated that angiotensin-converting enzyme (ACE) inhibitors had a statistically significant advantage over placebo or alternative agents in decreasing the risk for several cardiovascular events. However, no definitive studies have examined the use of angiotensin-receptor blockers in type 2 diabetes with chronik kidney disease on routine hemodialisa. To address this issue we investigate the difference of length of stay (LOS), rate of readmission, acute lung oedema (ALO) and cardio vascular accident (CVA) rate based on antihypertensive therapy. Objectives: To compare three months outcome of well controlled diabetic patient with chronic kidney disease on routine hemodialysa who received conventional antihypertensive therapy with an angiotensin-receptor blocker (valsartan) or a calcium-channel blocker (amlodipine). Methods: The study was conducted with retrospective cohort design to compare outcomes in 30 patients with CKD on routine hemodyalisa with controlled diabetes (HbA1C < 6.3%) who classified in two groups based on antihypertensive therapy. Fifteen subjects recieved valsartan and another fifteen subjects recieved amlodipine. The evaluated outcomes LOS, rate of readmission, ALO and CVA. X2 statistical test and Independent T test was used to analyze differences in outcome between groups. Results: The two groups were statistically different in the composite of inhospital outcome but among the components of the composite, there was a trend toward subjects on amlodipine, to have a longer length of stay than those on valsartan (p-value = 0,065 < &agr; = 10%). The relative risk of less than 12 days hospitalization is four-times greater in subjects on amlodipine. Likewise, episodes of ALO in valsartan group are less than amlodipine group (p-value = 0,195 > &agr; = 5%). The relative risk of ALO is three-times higher in the amlodipine group. The occurence of cardio vascular accident in both groups are same, which are two subjects for each group (p-value = 1.000 > &agr; = 5%). the relative risk of cardio vascular accident is no difference between two groups. More subjects in amlodipine group who are rehospitalized than valsartan (p-value = 0.099 < &agr; = 1%). The relative risk of rate of no readmission is greater by four-fold in subjects consuming valsartan than those consuming amlodipine. In other words, the relative risk of readmission for amlodipine group is higher than valsartan Conclusion: The length of stay, rate of readmission, acute lung oedema and cardio vascular accident rate differ in well controlled diabetic patient with chronic kidney disease on routine hemodialysa treated with valsartan or amlodipin. These findings suggested that valsartan-based regimen was more effective and have better outcome than amlodipin in this population.

The Association between Proteinuria and Incidence of Heart Failure in Hypertensive Young Adult Patient

Background: Hypertension is closely related to both cardiovascular and kidney disease. Proteinuria also has been known as a risk factor for cardiovascular morbidity and mortality. The prevalence of hypertension by RisetKesehatanDasar (RISKESDAS) 2013 was 24.8% (age 18–44 year). However, the relationship between proteinuria and incidence of heart failure (HF) in hypertensive young adult patient is not well defined. Objective: To examine the association of proteinuria with incidence of HF in hypertensive young adult patient. Methods: We collected registry data of hypertensive young adult patient(age 18–40 year)at NCCHK Jakarta fromJanuary 2011 –December 2013 and then studied retrospectively. We divided the patients into proteinuria and non-proteinuria group and evaluated the occurrence of heart failure in each group. Proteinuria was tested by dipstick analysis. Results: The study population consists of 148 patients, with 113 males and 35 females. The median age was 37 (range 20–40). Sixty-one (41.2%) of all patients were undergoing screening urinalysis, where 25 patients had proteinuria, while 36 patient without proteinuria. Thirty-seven patient were diagnosed with HF. In proteinuria group, 20 (54.1%) patients experienced HF, while in non-proteinuria 17 (45.9%) patients occurred HF (p = 0.016). Conclusion: Routine screening urinalysis to detect proteinuria is not optimally done among hypertensive young adults patient. In our observation there was an association between proteinuria and the occurrence of heart failurestatistically. However, further evaluation and routine screening urinalysis needs to be done in patient with proteinuria in hypertensive young adult patient to preventworsening cardiovascular and kidney disease.