KEL. JANTUNG DIDAPAT (ACQUIRED)KEL. JANTUNG DIDAPAT (ACQUIRED) KELAINAN JANTUNG KARENA INFEKSI KELAINAN JANTUNG KARENA INFEKSIDI INDONESIA YANG TERBANYAK:DI INDONESIA YANG TERBANYAK:1.DEMAM REUMATIK(DR), 2. DIFTERIA DAN 1.DEMAM REUMATIK(DR), 2. DIFTERIA DAN 3.ENDOKARDITIS LENTA3.ENDOKARDITIS LENTA1.DEMAM REUMATIK: OK MENYEBABKAN 1.DEMAM REUMATIK: OK MENYEBABKAN KEL. JANTUNG KE-2 PADA ANAK SETELAH KEL. JANTUNG KE-2 PADA ANAK SETELAH KEL.JANTUNG KONGENITAL DI USA. KEL.JANTUNG KONGENITAL DI USA. DI INDONESIA DR DI INDONESIA DR PENYEBAB UTAMA.PENYEBAB UTAMA.DR PERLU DIDIAGNOSA CEPAT, DAN DIOBATI DR PERLU DIDIAGNOSA CEPAT, DAN DIOBATI SEGERA SEGERA DPT MENCEGAH KEL. KATUP J.DPT MENCEGAH KEL. KATUP J.[BIAYA BANYAK & ANGKA KEMATIAN TINGGI][BIAYA BANYAK & ANGKA KEMATIAN TINGGI]

INSIDENS ± 3% PADA MASA EPIDEMIK DAN INSIDENS ± 3% PADA MASA EPIDEMIK DAN INSIDENSNYA ± 0.3% PD MASA ENDEMIK INSIDENSNYA ± 0.3% PD MASA ENDEMIK ETIOLOGINYA:STREP. BETA HEMOL.GRUP A, ETIOLOGINYA:STREP. BETA HEMOL.GRUP A, -DR SERING TERJADI BERSAMAAN URI-DR SERING TERJADI BERSAMAAN URI-ASRAMA MILITER, KELOMPOK MASY. YG -ASRAMA MILITER, KELOMPOK MASY. YG TERISOLIR SERING EPIDEMI. TERISOLIR SERING EPIDEMI.-INSIDENS DR PARALEL DGN INSIDENS URI -INSIDENS DR PARALEL DGN INSIDENS URI OK GABHS. OK GABHS.

Pathology :-Aschoff bodies antigen presenting cells- Acute phase : inflammation process

in pericard, myocard & pericard- Chronic phase : injury of the valve- Difference of clinical and pathologi cal manifestation in some countries- Host immunological response take main role in clinical manifesta tion

Diagnosis :Diagnosis :

1944 : Dr.T.Duckett Jones : Jones Criteria 1944 : Dr.T.Duckett Jones : Jones Criteria 1955 : Modification of Jones Criteria1955 : Modification of Jones Criteria

1965 & 1984 : Revised of Jones Criteria1965 & 1984 : Revised of Jones Criteria

1992 : Update Jones Criteria1992 : Update Jones Criteria

Jones Criteria (focused) Jones Criteria (focused)

Problems : over diagnosis or under Problems : over diagnosis or under diagnosis diagnosis

1965 Jones Criteria (revised)• Major

manifestation • Carditis• Polyarthritis• Chorea• Subcutan nodule• Erythema

marginatum

• Minor manifestation

• Fever• Arthralgia• Prolonged PR

interval ECG• Increase BSR• C reactive protein

(+)• Leucocytosis• Previous history

RF / RHD inactive

Evidence of previous Strept. Infection CULTURE / ASTO

Diagnosis

1992 Jones Criteria (Updated)Major manifestation CarditisPolyarthritis ChoreaSubcutan noduleErythema margina tum

Minor manifestationFeverArthralgiaIncrease BSRC reactive protein (+) LeucocytosisProlonged PR interval ECG

Evidence of previous Strept. infection

Diagnosis

13.

GABHS – Cardiogenik GABHS – Cardiogenik Rheumatic fever / RHD - pathogenesisRheumatic fever / RHD - pathogenesis

Jones Criteria Mayor “CAPOCHES”

19.

Treatment RF & RHD• 1. Primary preventions :• to eradicate Streptococcal infectcion : • during acute RF attack• 2. Secondary prevention :• to prevent relaps of cute RF• 3. Relief the symptoms :• - carditis / CHF• - arthritis• - Chorea

Treatment RF & RHD

•1. Primary prevention :• 1. Benzatine PNC G injection 1 X / i.m.• (BW > 27 kg 1,2 million unit)• (BW < 27 kg 600.000 unit)• 2. Pencilline V : 250 mg/400.000 unit QID• / oral : 10 days• Erythromycine : 40 mg /kg BW / day• TID-QID / oral : 10 days• Clindamycine, Nafcillin, Amoxycillin, • Cefalexin

•Duration secondary prevention•Categori Duration

• RF with carditis & permanent minimal 10 years• valve abnormalities until 40 yrs or longlife

• RF with carditis without perma 10 years or until• nent valve abnormalities adult

• RF without carditis 5 years or until 21 years

Treatment RF & RHD

Relief the symptoms

•A. Carditis :• Anti inflammatory • - Carditis : Prednison : 2 mg/kg BW/day tapp.

– 2-6 weeks off– - Mild Carditis : Aspirin 90-100 mg/kg BW 4-6– 4-8 weeks week

•B. Arthritis• - Aspirin : 100 mg/kg BW/ day : 2 weeks• 2-3 weeks : doses decrease

Treatment RF & RHD

•C. Heart Failure :• - Bedrest - Digoxin• - Diuretics - Vasodilator• - Fluid & salt restriction•D. Chorea :•- Physical stres & emotional must be controlled•- Anti inflammation drug : controversial•- Phenobarbital : 15-30 mg TID-QID•- Haloperidol : 0,5 mg ---> 2 mg TID•- Valproic acid / Chlorpromazine / Diazepam

Treatment RF & RHD

Table. Guidelines for Bed Rest and Ambulation and Recommended antiinflammatory agents

• Arthritis Carditis Carditis Carditis• alone minimal moderate severe•Bed Rest 1-2 wk 2-3 wk 4-6 wk 2-4 mo•Indoor ambulation 1-2 wk 2-3 wk 4-6 wk 2-3 mo•Outdor activity 1-2 wk 2-3 wk 4-6 wk 2-3 mo•(school)•Full activity 1-2 wk 2-3 wk 4-6 wk 2-3 mo

•Prednisone 0 0 2-4 wk 2-6 wk•Aspirin 0 0 2-4 wk 2-6 wkMinimal Carditis Questionable cardiomegaly ; Moderate carditis definite but mild cardiomegaly, Severe carditis, marked cardiomegaly or CHF

Surgical treatment and invasive intervention•Surgical treatment :•1. Valve Replacement :• - MR• - MS• - AR•2. Valvuloplasty

•Invasive Intervention :•- Ballon Mitral Valvuloplasty (BMV) with • Inoue ballon : MS

DCDCDecompensatio CordisDecompensatio Cordis

Gagal JantungGagal Jantung

Conto: Mitral insuffisiensiSetiap ventric.sist, ada darah naik ke Atrium Kilama2Stagnasi di Atrium Ki V.Pulm. vasc.paru pe-numpukan cairan inf. Batuk kronik.

darah masuk ke Ao Jantung kerja keras (HR=Tachycardia)Jantung membesar (Cardiomegali), Bila kerja,perlu O2 banyak napas

(Dyspnoe d’effort, sampai orthopnoe ). Tanda2 DC kiri

PS darah berkurang masuk ke A.Pulm. Darah banyak ter kumpul dalam V.Ki, A.Ki VCS (TVC) VCI (Hepatomegali) Edem pretibial, Edema dorsal pedis, Ascites Jantung kerja keras (Cardiomegali) dan Kalau kerja sesak napas (Tachypnoe). Freq.Jantung naik (Tachycardi)

Tanda DC Kanan

PENGOBATAN DCPENGOBATAN DC1. DIGITALIS1. DIGITALIS2. DIURETIK2. DIURETIK

Dosis dan cara pemberianDosis dan cara pemberianharus diperlajari baik-baikharus diperlajari baik-baik

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