Aging dan Tidur pada Gangguan KardioVaskular

Agung Dwi W W

Pokok BahasanProses Aging dan gangguan KardiovaskularGangguan Tidur pada Kelainan Kardiovaskular

Proses Aging dan gangguan Kardiovaskular

Demografi PenuaanUS proporsi manula berusia 65 th dan lebih tua meningkat dari 12.4 % (35 million) pada tahun 2000 menjadi 19.6 % pada 2030 (71 million) dan 82 million pada 2050. Manula 80 th menjadi double dari 9.3 million pada 2000 menjadi 19.5 million pada 2030 dan lebih dari triple pada 2050. Wanita 59 % dari manula 65 th pada 2000 dan estimasi menjadi 56 % pada 2030 Populasi Dunia manula > 65 th meningkat dari 973 million atau 12 % pada 2030 dan 20 % populasi pada 2050.

Penyakit Cardiovascular dan PenuaanPenyakit kardiovaskular sering terdeteteksi pada manula dan sering menjadi penyebab kematianHipertensi, atau 2/3 pada manula lebih dari 65 tahunHeart failure (HF) sering terjadi pada manula dan Dx KRS RS manula di ASProfil penyakit berbeda dari dewasa muda. Systolic, but not diastolic, tekanan darah meningkat pada manula menjadi Systolic hypertension , terutama pada wanitaHeart failure terjadi karena fungsi sistolik Coronary artery disease (CAD) juga terjadi pada manula

Hub Usia, SBP dan risk CHD

Penyakit Kardiovaskular

Perubahan Vaskular

Perubahan Jantung

Perubahan Jantung

Gagal jantung

Penyakit Katup Pada Manula Perubahan Usia terjadi perubahan fibromuscular skeleton pada jantung mengalami degenerasi dan infiltrasi yang menyebabkan sklerosisSclerosis katub yaitu the aortic valve 30 % pada manula usia 65 th Bertambahnya usia lanjut menyebabkan calcification of the aortic valve leaflets, aortic annulus, base of the semilunar cusps, and the mitral annulus. Aortic sclerosis berhubungan dg kejadian atherosclerotic progression di pembuluh darah. Ini menjelaskan adanya risk of MI dan kematian pada penderita aortic sclerosis tanpa stenosis.Risk factors : hypertension; hyperlipidemia; smoking; end-stage renal disease; congenital bicuspid valves; diabetes, shorter stature, and male sex.

Aritmia pada manula Kehilangan sel pada penuaan di sinus node, sampai atria, the central fibrous body, dan cytoskeleton jantung.Perubahan ini merusak area sinus node hingg 90 percent of cells pada usia 75 th.Kerusakan sinus menyebabkan sinoatrial conduction menurunPerubahan juga terjadi pada atrioventricular (AV) node juga pada His bundle. Terjadi penurunan konduksi ke ventrikelTerjadi perubahan pola listrik jantung pada gambaran EKG P-R interval meningkat dan gelombang R, S, dan T amplitudonya menurun. QRS axis mergeser ke kiri

HEART FAILURE HF penyebab utama kelainan pada Manula HF menyumbang 20 % pada penderita manula pada 65 th Kematian meningkat hingga 85 % pada usia lebih dari 85 tahun Asymptomatic LV systolic dysfunction estimasi 3 hingga 5 % pada komunitas manula. Insiden dan prevalens lebih tinggi pada Laki-laki dari pada wanita. (CAD risk).

Approach to the Older Patient with Heart Failure (HF)Symptoms may be nonspecific in the older patientsuspect HF. Consider HF diagnosis in patients with fatigue, dyspnea, exercise intolerance, or low activity. Diagnosis may be assisted by use of echocardiography or serum markers of HF.HF may be present in the older patient with preserved systolic function (ejection fraction), especially older women.Aggressive treatment of hypertension or diabetes when present may improve HF outcomes.

Approach to the Older Patient with Heart Failure (HF)Treat symptoms with a goal of improving quality of life and morbidity: Control blood pressure-systolic and diastolic. Treat ischemia. Control atrial fibrillation rate. Promote physical activity. Adjust medications for age and disease-related changes in kinetics and dynamics. Educate and involve patients, family members, or caregivers in management of HF: Monitor weight. Consider use of multidisciplinary team approaches.

Hypertension Diastolic (>90 mm Hg) dan atau systolic (>140 mm Hg) hypertension hingga 2/3 pada manula 65 th dan 75 % pada 80 th.Prevalensi beragam karena Ras (atau genetics) meningkat pad aorang kulit berwarna The profile of hypertension is altered by aging. Systolic hypertension becomes more prevalent with agingSystolic blood pressure rises with aging in both men and women but rises more steeply in women. A large percentage of people are unaware that they have hypertension, and hypertension is not controlled in many older patients, especially older women and those older than 80 years of age.

Approach to Hypertension in Older Patients

Systolic and diastolic hypertension should be treated; current recommendations are based on brachial artery measurements: Diastolic target is

Approach to Hypertension in Older PatientsMultiple medications are usually required in older patients, and combinations should be based on concomitant diseases Drug dosing regimens should be adjusted for age- and disease-related changes in drug metabolism and potential drug-drug interactions Patients should be monitored for adverse effects and drug interactions, especially: Postural hypotension and postprandial hypotension Hypovolemia with diuretics Hyperkalemia with angiotensin-converting enzyme, angiotensin receptor blocker, or aldosterone antagonists

Approach to the Older Patient with StrokePrevention is key Treat hypertension, diabetes, smoking, physical inactivity, elevated lipids, obesity, and sleep apnea and limit alcohol intake Anticoagulate patients with atrial fibrillation (in the absence of contraindications) Acute stroke treatment Evaluate rapidlyuse neuroimaging for diagnosis and to guide therapy Aspirin within 48 hr

Approach to the Older Patient with StrokeAnticoagulation is not recommended Initiate rehabilitation early Routinely evaluate and treat for depression Secondary prevention: Aspirin (at lower doses), clopidogrel, or aspirin plus extended release dipyridamole Aspirin + clopidogrel is not recommended Consider warfarin for patients with strokes while receiving aspirin

Gangguan Tidur pada Kelainan Kardiovaskular

Normal sleep

The possible function of sleepProtective behaviourEnergy conservationBrain restorationHomoeostasisImproving immune functionTemperature regulation

Kleitmans dictum,-Tell me first what is the function of wakefulness and then I will tell you what is the function of sleep.

The characteristics of sleep architecturehypnogram over a 7.5-hour sleep period

Characteristics of REM sleep

Characteristics of REM sleepThe possible functions of REM sleep and dreamingConsolidation of memory and processing newly learned materialStimulation to the brainSolving daytime problems and conflicts

Consequences of sleep deprivation

The effect of behavioural state on the cardiovascular system

The predominant neurotransmitters in the various behavioural states

Changes in sleep content and length with age

Gangguan TidurHypersomniaSleep apnoea syndromeInsomniaParasomnias: sleep walking,night mare, Sleep enuresis

Obstructive sleep apnea and cardiovascular diseaseObstructive sleep apnea (OSA), along with smoking, diabetes, dyslipidemia, and hypertension, is an important risk factor for coronary artery disease. In large epidemiological studies, the association between heart disease and OSA is independent of such confounders as obesity and age.

The acute pathophysiological effects of the apneaarousal cycle include: The acute pathophysiological effects of the apneaarousal cycle include: hypoxemia increased negative intrathoracic pressure decreases in cardiac output activation of the sympathetic nervous system acute hypertension.

Pathophysiological effectsChronic pathophysiological changes associated with this process include thefollowing persistent elevations: sympathetic tone platelet activation inflammatory mediators C-reactive protein vascular endothelial dysfunction.All of these effects have been suggested to promote artherogenesis in OSA.

Other important cardiovascular effects of OSA includeEssential hypertension. 40% of hypertensive adults have some degree of sleepdi sordered breathing, which increases to 80% in treatment-refractory hypertension.Cardiac arrhythmias. Bradyarrhythmias, prolonged sinus pauses, and increased ventricular ectopy are common; atrial fibrillation is also markedly increased in people with OSA. Pulmonary hypertension. In most cases the elevations are modest with the exception of the overlap of OSA and chronic obstructive pulmonary disease, where pulmonary hypertension and cor pulmonale are common (see Respiratory disease and sleep, below). Insulin resistance (see Other medical illness and sleep, below).

Congestive heart failureSeveral cardinal symptoms of congestive heart failure (CHF), i.e., orthopnea and paroxysmal nocturnal dyspnea, involve disruption of sleep. Sleep-disordered breathing is common in CHF, with 1530% of individuals with CHF diagnosed with OSA, and 3040% diagnosed with central sleep apnea (CSA). OSA is believed to exacerbate CHF through its effect on blood pressure, cardiac output, and ventricular function.

Nocturnal anginaNocturnal angina may herald an acute coronary event. Several sleep-related factors predispose to coronary artery ischemia at night: nocturnal hypoxemia secondary to OSA nocturnal autonomic surges associated with REM sleep nocturnal hypotension and bradycardia associated with NREM sleep vasospasm associated with Prinzmetals variant angina (most commonly occurs between midnight and 07:00 during REM sleep).

Nocturnal arrhythmia and sudden deathCommon and normal rhythm changes seen in sleep include: sinus pauses sinus bradycardia first-degree AV block.The Brugada syndrome is characterized by distinct ST segment elevations in the right precordial ECG leads and is associated with a mutation in a gene encoding a cardiac sodium channel. A family history of sudden death is common. Kiroshi, a Japanese term, is used to describe sudden death in otherwise healthy young people following prolonged episodes of overwork and sleep deprivation.Both are causes of sudden cardiac death due to ventricular fibrillation, predominantly between 20:00 and 08:00, affecting young, healthy men without structural heart disease, with a higher incidence in Asian countries.