PENCEGAHAN PENY JANTUNG PENCEGAHAN PENY JANTUNG DAN PEMB DARAHDAN PEMB DARAH

DR. I K. GERUDUG., MPH.BAG. ILMU KESEHATAN MASYARAKAT DAN KEDOKTERAN

PENCEGAHAN FAKULTAS KEDOKTERAN UNIVERSITAS MATARAM

Mataram, 2013

GLOBAL DEATHS BY CAUSE, ALL AGES 2005GLOBAL DEATHS BY CAUSE, ALL AGES 2005

*NCD are the mayor of deaths in the world**Sumber: WHO dan WorldBank 2005

CARDIO-VASCULAR DISEASES

CANCER

CHRONICRESPIRATORY

DISEASEDIABETES

17.528.000

7.586.000

4.057.000

1.125.000

MALARIATUBER-

CULOSIS

HIV/AIDS 883.0001.607.000

2.830.000

10 PERINGKAT UTAMA PENYAKIT MENURUT DTD PENYEBAB 10 PERINGKAT UTAMA PENYAKIT MENURUT DTD PENYEBAB KEMATIANKEMATIAN DI RUMAH SAKIT INDONESIA TAHUN 2002 DI RUMAH SAKIT INDONESIA TAHUN 2002

Catt:• DTD: Daftar Tabulasi Dasar• Sumber: Statistik RS di Indonesia Ed. 2003, Ditjen Yanmed

• Kecenderungan peningkatan Incidens dan prevalensi sejak 3 dekade terakhir

• Transisi epidemiologi dari penyakit menular--- peny. tidak menular

• Double-burden• Perubahan pola struktur masy, scr global,

regional dan lokal dari agraris ke industri -perub. sosial ekonomi, gaya hidup.

Preventive medicine encompasses both the care of individual patients, and public health practice, and as is evident in the name, focuses on the prevention of disease rather than treatment, per se.

The fields of preventive medicine and public health share the objectives of

• promoting general health, • preventing specific diseases, • and applying the concepts and techniques• of epidemiology toward these goals.

(Leavell and Clark, 1965), all physician and other health professional activities have the goal of prevention. What is to be prevented depends on the context, and the patient’s position on the spectrum from health to disease.

Primary prevention keeps the disease process from becoming established by eliminating causes of disease or increasing resistance to disease. Secondary prevention interrupts the disease process before it becomes symptomatic. Tertiary prevention limits the physical and social consequences of symptomatic disease.

• The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress.

• These goals are embodied in the word

"prevention"

Determinants of Prevention

• Successful prevention depends upon: – a knowledge of causation, – dynamics of transmission, – identification of risk factors and risk groups, – availability of prophylactic or early detection and

treatment measures, – an organization for applying these measures to

appropriate persons or groups, and – continuous evaluation of and development of

procedures applied

Leavell’s Levels of Prevention

Stage of disease Level of prevention Type of response

Pre-disease Primary Prevention Health promotion and Specific protection

Latent Disease Secondary prevention Pre-symptomatic Diagnosis and treatment

Symptomatic Disease Tertiary prevention •Disability limitation forearly symptomatic disease•Rehabilitation for lateSymptomatic disease

PENCEGAHAN :

* PRIMORDIAL• MENCEGAH MUNCULNYA

PREDISPOSING FACTORS

Primordial prevention

• Primordial prevention consists of actions and measures that inhibit the emergence of risk factors in the form of environmental, economic, social, and behavioral conditions and cultural patterns of living etc.

Primordial prevention (cont.)

• In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles

• The main intervention in primordial prevention is through individual and mass education

Primordial prevention (cont.)• It is the prevention of the emergence or

development of risk factors in countries or population groups in which they have not yet appeared

• For example, many adult health problems (e.g., obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed (for example, smoking, eating patterns, physical exercise).

PRIMER• PENYULUHAN FAKTOR RESIKO

TERUTAMA KELOMPOK RISTI.

Primary prevention

• Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.

• It signifies intervention in the pre-pathogenesis phase of a disease or health problem.

• Primary prevention may be accomplished by measures of “Health promotion” and “specific protection”

Primary prevention (cont.)

• It includes the concept of "positive health", a concept that encourages achievement and maintenance of "an acceptable level of health that will enable every individual to lead a socially and economically productive life".

• Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures.

Approaches for Primary Prevention

• The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established:

– a. Population (mass) strategy – b. High -risk strategy

Population (mass) strategy• “Population strategy" is directed at the whole population

irrespective of individual risk levels.

• For example, studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease

• The population approach is directed towards socio-economic, behavioral and lifestyle changes

High -risk strategy

• The high -risk strategy aims to bring preventive care to individuals at special risk.

• This requires detection of individuals at high risk by the optimum use of clinical methods.

SEKUNDER :

• MENCEGAH BERULANG• MERUBAH POLA HIDUP• MEMPERTAHANKAN NILAI PROGNOSTIK DAN MENURUNKAN KEMATIAN

Secondary prevention• It is defined as “ action which halts the progress of a disease at its

incipient stage and prevents complications.”

• The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs….) and adequate treatment.

• Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.

• It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Secondary prevention (cont.)• Secondary prevention attempts to arrest the

disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.

• It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Early diagnosis and treatment

• WHO Expert Committee in 1973 defined early detection of health disorders as “ the detection of disturbances of homoeostatic and compensatory mechanism while biochemical, morphological and functional changes are still reversible.”

• The earlier the disease is diagnosed, and treated the better it is for prognosis of the case and in the prevention of the occurrence of other secondary cases.

TERSIER :• MENCEGAH KOMPLIKASI YANG LEBIH BERAT

Tertiary prevention

• It is used when the disease process has advanced beyond its early stages.

• It is defined as “all the measures available to reduce or limit impairments and disabilities, and to promote the patients’ adjustment to irremediable conditions.”

• Intervention that should be accomplished in the stage of tertiary prevention are disability limitation, and rehabilitation.

• Penyakit jantung koroner• Stroke• Diabetes komplik.• Penyakit pembuluh darah• Kanker• Penyakit paru   obstruksi kronis

Titik AkhirFaktor Risiko /

Penyakit Antara

•HipertensiHipertensi•DiabetesDiabetes•ObesitasObesitas•HiperlipidemiaHiperlipidemia

Faktor RisikoFaktor RisikoPerilakuPerilaku• Tembakau• Gizi• Alkohol• Aktifitas Fisik

Risiko Yg Melekat•Umur, Sex •Keturunan

Kondisi Sosio-economi, Budaya &

Lingkungan

Faktor Risiko PTM Faktor Risiko PTM dan Titik Akhir dan Titik Akhir

Maximilian de Courten - Surveillance, NMH

Interrelationship between Various NCD and Modifiable Risk Factors, USAInterrelationship between Various NCD and Modifiable Risk Factors, USA

Cardiovas dis Cancer PPOK Diabetes

Rokok + + +Alkohol +

Hipercholest + Hipertensi +Diet +

+ +

Inact.phsys +

+ +

Obesitas + + +Low Sosec +

+ + +

Pass .smok + +Pekerjaan +

+

Pollusi + + +

Trend Prevalensi Faktor Risiko di Daerah Studi Intervensi Trend Prevalensi Faktor Risiko di Daerah Studi Intervensi Proyek Monica di 3 Kecamatan Jakarta Selatan Proyek Monica di 3 Kecamatan Jakarta Selatan

Tahun 1988 s.d. 2001Tahun 1988 s.d. 2001

FAKTOR RISIKO

JENIS KELAMIN

SURVEI NASIONAL

MONICA (di 3 Kecamatan Jakarta Selatan

2001 1988 1993 2000

Hipertensi*Laki-lakiPerempuan

27%29%

13,6%13,6%

16,5%17,0%

22,0%22,7%

Obesitas*Laki-lakiPerempuan

1,3%4,6%

2,6%8,9%

3,6%10,3%

6,3%12,0%

Hiperkolesterolemia*

Laki-lakiPerempuan

12,3%16,0%

14,8%17,8%

12,2%17,1%

PerokokLaki-lakiPerempuan

54,5%**1,2%**

59,9%5,9%

56,9%6,2%

38,5%1,8%

Olah raga >3 per minggu 14,3% 22,5% 22,7% 59,2%

Sumber: Kusmana Dede dkk, RSJHK, 2001

* Population over 25 years of age

** Population over 10 years of age

F A K T O R R E S I K OF A K T O R R E S I K O

PENGERTIANPENGERTIAN

RISK FACTORS ARE CHARACTERISTICS, RISK FACTORS ARE CHARACTERISTICS, SIGNS, SYMPTOMS IN DISEASE FREE SIGNS, SYMPTOMS IN DISEASE FREE INDIVIDUAL WHICH ARE STATISTICALLY INDIVIDUAL WHICH ARE STATISTICALLY ASSOCIATED WITH AN INCREASED ASSOCIATED WITH AN INCREASED INCIDENCE OF SUBSEQUENT DISEASE INCIDENCE OF SUBSEQUENT DISEASE (SIMBORG D.W.)(SIMBORG D.W.)..

KEGUNAAN IDENTIFIKASI FAKTOR RESIKOKEGUNAAN IDENTIFIKASI FAKTOR RESIKO

1. PREDIKSI Utk meramalkan kejadian penyakit. Misal : perokok berat

mempunyai kemungkinan 10 kali untuk kanker paru daripada bukan perokok.

2. PENYEBAB Kejelasan faktor resiko dapat mengangkatnya menjadi

faktor penyebab, setelah menghapuskan pengaruh dan faktor pengganggu ( Confounding Faktor ).

3. DIAGNOSIS Membantu proses diaognosis

4. PREVENSI Jika satu faktor juga sebagai penyebab, pengulangan

dapat digunakan untuk pencegahan penyakit meskipun mekanisme penyakit sudah diketahui atau tidak.

FAKTOR RESIKOFAKTOR RESIKO

• FAKTOR PENYEBAB + FAKTOR EPIDEMIOLOGIS YG BERHUBUNGAN DENGAN PENYAKIT.

•  FAKTOR YANG TAK BISA DIUBAH :– UMUR – JENIS KELAMIN– ANATOMI– METABOLISME

• YANG BISA DIUBAH :       HIPERTENSI       MEROKOK       KOLESTEROL       KENCING MANIS       STRES       MAKAN SALAH       LIFE STYLE       FRAKSI LEMAK ( TG, HDL, LDL)       OLAH RAGA.

What is a “healthy diet”?

• Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products;

• Includes lean meats, poultry, fish, beans, eggs, and nuts; and

• Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.

The United States Department of Agriculture (USDA) Dietary Guidelines describe a healthy diet as one that:

Information for this section taken from the following Web site: www.mypyramid.gov

Food tips:• Vary your veggies• Focus on fruit• Go lean with protein• Get your calcium

rich foods• Make half your grains whole • Find your balance between food and

physical activity

Limit sugar intake:• Foods high in sugar often

have too many calories and not enough nutrients.

• Sugar also promotes tooth decay.

Limit salty foods:

Salty foods can increase your risk of high blood pressure.

Choose a diet high in fruits, vegetables and grain products.

These foods provide vitamins, minerals, fiber and complex carbohydrates.

This will reduce your risk of heart attack, certain cancers, and will help maintain a healthy weight.

Eat foods that are low in fat, saturated fat and

cholesterol.

Limit alcohol intake:

Alcohol is high in calories and provides little or no nutrition.

BERDASARKAN ANGKA INSIDENCE DAN PREVALENSI PERHATIAN DIARAHKAN PD PENY. JANTUNG DAN PEMBULUH DARAH UTAMA YAITU:

•ARTEROSKLEROSIS, •HYPERTENSI, •PENY. JANTUNG KORONER•CEREBROVASKULER.

• MAJOR FACTORS MENURUT FRAMINGHAM STUDY ADALAH :– HIPERTENSI, – HIPERKOLESTEROL, DAN – ROKOK.

HIPERTENSIHIPERTENSI• Prevalensi 6 – 15 % pada orang dewasa Sebagai suatu proses degeneratif,

hipertensi tentu hanya ditemukan pada gol. Dewasa. Ditemukan kecenderungan peningkatan prevalensi menurut peningkatan usia.

• 50 % penderita tdk menyadari diri sebagai penderita HT. Karena itu mereka cenderung untuk hipertensi yg lebih berat karena tdk berubah dan menghindari faktor rIsiko.

• 70 % adalah HT ringan Karena itu hipertensi banyak

diacuhkan atau terabaikan sampai saat menjadi ganas ( Hipertensi ringan ).

• 90 % HT esensial , mereka dengan HT yang tdk diketahui seluk beluk penyebabnya. Artinya sulit untuk mencari bentuk intervensi dan pengobatannya.

• Penentuan batasan hipertensi sangat penting karena perubahan tingginya hipertensi sangat mempengaruhi perhitungan prevalensi dalam populasi.

Sebagai contoh : Perubahan prevalensi hipertensi akibat

perubahan batasan hipertensi pada pendudukan lelaki putih Amerika Serikat usia 65 – 74 tahun berikut ini :Tekanan darah

( Sistolik/Diastolik)

Presentase Populasi

> 140 / 90 > 160 / 95 > 170 / 95

532417

PJKPJK

• PENYAKIT YANG BERHUBUNGAN DENGAN TERGANGGUNYA SUPLY DARAH KE OTOT JANTUNG YANG MENGAKIBATKAN KURANGNYA OKSIGEN DAN SEGALA MANIFESTASINYA.

Faktor Resiko Hipertensi Adapun faktor – faktor yg dapat dimasukkan sebagai

faktor resiko Hipertensi adalah :1. Umur : BP meningkat sesuai umur, > 40 thn2. Ras/Suku : Orang kulit hitam > white

Besar variasi antarsuku di Indonesia Terendah : Lembah Balim Jaya ( 0,6 % )

Tertinggi : Sukabumi, Jabar ( 28,6 % )3. Urban/Rural : Kota > Desa4. Geografis : Pantai > pegunungan5. Seks : Wanita > lelaki6. Gemuk : Gemuk > Kurus7. Stres8. Personality type A : A > B9. Diet : Tinggi garam

10. DM11. Water composition : - Sodium : inconsistent

- Cadmium : ada bukti dari studi

- Lead : kemungkinan ada hubungan.

12. Alhokol : Meninggi bila minum > 3 X/hari Moderate amount may be protective

13. Rokok : non significant14. Kopi : Belum ditemukan15. Pil KB : Riks meninggi dengan lama pakai,

Meninggi 5 kali dibandingkan pakai 1 tahun

PJKPJK

– BENTUK UTAMA DARI SAKIT JANTUNG– PENYEBAB KEMATIAN TERBESAR– DAPAT DITULARKAN MELALUI

PENULARAN SOSIAL– MENGENAI BANYAK ORANG NAMUN

SELEKTIF– MODERNISASI DIANGGAP SEBAGAI

AGENT– SANGAT BERBAHAYA, NAMUN DAPAT

DICEGAH

PERJALANAN PENYAKIT--------PERJALANAN PENYAKIT--------, KRONIK, KRONIK • GEJALA KLINIK :

– ANGINA PEKTORIS– BAJI MATI JANTUNG– PAYAH JANTUNG– MATI MENDADAK

•  TANDA TANDA UMUM :– NYERI DADA (CHEST PAIN)– SAKIT DIBAWAH BELIKAT KIRI– RASA SAKIT MENJALAR DARI LENGAN BAWAH

KE ATAS, BAHU KIRI, LEHER DAN RAHANG BAWAH

FREKWENSI DAN DISTRIBUSIFREKWENSI DAN DISTRIBUSI

• NEGARA BERKEMBANG KEJADIAN >> • PERKOTAAN >> PEDESAAN• SOS. EK MENEGAH KEATAS >> LEMAH• PRIA >> WANITA ; KEMATIAN WANITA >>• FREK. MENINGGI PADA GOL UMUR 40

TAHUN, RESTI --- 50 TAHUN• KEMATIAN >> HIDUP

Kematian karena Komplikasi PJK / Dekompensasi

Kondisi lingkungan dan sosial tidak menguntungkan Kesehatan

Pola Perilaku merugikan Kesehatan

Populasi dengan Faktor Risiko tinggi

Kematian Mendadak/ Serangan Pertama

Berisiko untuk Kambuh kembali/ Hendaya(cacat)

Realitas Saat Ini

Hidup berkualitas baik sampai meninggal

Kondisi Lingkungan dan Sosial menguntungkan Kesehatan

Pola Perilaku yang mempromosikan Kesehatan

Risiko Populasi rendah

Kejadian Kasus sedikit/ Kematian jarang

Resiko kambuh rendah / kapasitas fungsional maksimal

Visi Masa Depan

Pencegahan

KEBIJAKAN DAN STRATEGI DALAM PENGENDALIAN PENYAKIT JANTUNG DAN PEMBULUH DARAH DI INDONESIA

PJ dan PDTotal populasi256.455.954

Total populasi256.455.954( >75%)

Merokok 62%TD tinggi 14%TC 13,6% DM 12,8% obesitas 18%

StrokeMIGagal jantung Kongestif

StrokeMIGagal jantung Kongestif

Target populasi

Peningkatan Hidup Sehat dan Berkualitas(Qaly)

GOL 1

Masyarakat Indonesia Sehat 2010

GOL 2 GOL 3 GOL 4

Eliminasi Disparitas

PerubahanPerilaku Deteksi Faktor Risiko &

Pengendalian Faktor risiko

Program-Program Intervensi

PengobatanKebijakan dan Perubahan Lingkungan

Layanan Gawat Darurat dan Manajemen Kasus Akut

Rehabilitasi dan Manaj.Kasus Jangka Panjangpanjang

Perawatan sampai Akhir Hayat

Terima kasihTerima kasih