“ Overweight ” and CardioVascular diseases

1. “Overweight” and CardioVascular diseases 22nd December 2015 Peringatan Hari Ibu (ke-87), Dharma Wanita Persatuan KJRI Osaka, Jepang Hokusetsu General Hospital Edhi Sudjono Gunawan. M.D., Ph.D. (医学博士　黄俊　貴文）

2. Obesity, a growing problem in the nation • Elly Burhaini Faizal, The Jakarta Post, Jakarta | National | Thu, April 05 2012, 10:17 AM • Undernutrition in early life • Increases the risk of overnutrition in later life • Children with undernutrition in their early lives are more susceptible to infectious diseases, which may lead to death

3. Obesity trends and determinants in Indonesia • Department of Agricultural Economics and Rural Development, Georg-August-University of Goettingen, Platz der Goettinger Sieben 5, 37073 Goettingen, Germany  • Over the past 20 years, obesity has increased remarkably in Indonesia across all population groups, including rural and low income strata • The problem is particularly severe among women • Nutrition awareness and education campaigns, combined with programs to support leisure time exercise especially for women, seem to be most promising to contain the obesity pandemic

4. IRIN humanitarian news and analysis • JAKARTA, 5 June 2013 (IRIN) – • The Indonesian Ministry of Health reports • Non-communicable diseases • Strokes, hypertension and diabetes • Replaced communicable diseases • As the leading cause of death in the country • Deaths from non-communicable diseases • 41% (1995) • 60% (2007)

5. Communicable disease • An infectious diseasetransmissible • Direct contact • Indirect contact (vector) • Noncommunicable diseases (NCDs) • Chronic diseases, are not passed from person to person. • Long duration and slow progression • The 4 main types of noncommunicable diseases • Cardiovascular diseases (like heart attacks and stroke) • Cancers • Chronic respiratory diseases (chronic obstructed pulmonary disease and asthma) • Diabetes

6. Dr. Elvina Karyadi, the director for the Micronutrient Initiative in Indonesia • People in Jakarta don't have time to exercise and people go by car • People also like junk food and snacking • They say they don't have time to prepare healthy food • Starting from childhood, parents give children money • They can buy their own food instead of preparing them a meal • This is a change of lifestyle

8. Effects of obesity on women's health • Overweight and obesity are associated with elevated mortality from all causes in both men and women • The risk of death rises with increasing weight • Obesity, especially abdominal obesity, is central to the metabolic syndrome and is strongly related to polycystic ovary syndrome (PCOS) in women • Obese women are particularly susceptible to diabetes, and diabetes, in turn, puts women at dramatically increased risk of cardiovascular disease (CVD). • Obesity increases the risk of several major cancers in women • Postmenopausal breast cancer and endometrial cancer

9. Obesity and cardiovascular disease • Overweight may develop • Hypertension, diabetes and atherosclerosis.  • These conditions • High risk of cardiovascular disease • Central obesity/Abdominal obesity

10. CardioVascular ? Disease

11. Cardiovascular disease • A diseases that involve the heart or blood vessels • Includes coronaryartery diseases (CAD) • Angina (penyempitan pembuluh darah jantung) • Myocardial infarction (heart attack) • Other CVDs • Stroke, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, atrial fibrillation, congenital heart disease, endocarditis, aortic aneurysms, peripheral artery disease and venous thrombosis

12. CardioVascular ? Disease

13. The underlying mechanisms • Depending on the disease • Coronary artery disease, stroke, and peripheral artery disease, aneurysm involve atherosclerosis. • Caused by high blood pressure, smoking, diabetes, lack of exercise, obesity,high blood cholesterol, poor diet, and excessive alcohol consumption • Rheumatic heart disease may follow untreated streptococcusthroat infection

14. Cardiovascular disease 　　　　　　　　　　　　　　and Sudden death • Coronary disease • Aortic Aneurysm • Cerebrovascular disease • Perpheral artery disease • Thrombosis/Embolism

17. Sudden death Causes • Coronary artery disease is the leading cause of sudden cardiac arrest • Many other • Cardiac • Non-cardiac conditions

18. Sudden death • Cardiac • Coronary artery disease • Myocardial infarction • Non-ischemic heart disease • Cardiomyopathy, cardiac rhythm disturbances (arrythmia) • Hypertensive heart disease (Tekanan darah tinggi) • Congestive heart failure (Gagal Jantung) • Non Cardiac • Bleeding • Gastrointestinal bleeding, aortic rupture, or intracranial hemorrhage • Overdose,drowning and pulmonary embolism • Cardiac arrest can also be caused by poisoning

19. Cardiovascular disease 　　　　　　　　　　　　　　and Sudden death • Coronary disease • Aortic Aneurysm • Cerebrovascular disease • Peripheral artery disease (PAD) • Thrombosis/Embolism

20. 1. Coronary artery disease 　　　　　　　　　　　　　　 ⇒MI

21. Therapy of Coronary artery disease

22. Stent(PCI = percutaneous coronary intervention)

23. PCI = percutaneous coronary intervention

24. Unstable Angina Clinical Presentation • Ischemic pain • heaviness, tightness, aching, fullness, or burning of the chest, epigastrium, or arm or forearm (usually the left) • Involve the lower jaw, neck, or shoulder • Associated symptoms : • dyspnea, generalized fatigue, diaphoresis, nausea and vomiting • flulike symptoms, lightheadedness or abdominal pain • The intensity of pain does not correlate with diagnosis or prognosis • Elderly and female patients are more likely to present with atypical signs and symptoms

25. 2. Aortic aneurysm

26. Aneurysm • An aneurysm or aneurism  • from Greek:"dilation", "to dilate“ • localized • Blood-filled balloon-like bulge in the wall of a blood vessel • Risk factors • Diabetes, obesity, hypertension, tobacco use,alcoholism, high cholesterol, copper deficiency, increasing age, and tertiary syphilis and TBC infection

27. Therapy

28. Abdominal aneurysm

29. Case Study • Oct 12th 2015, 21p.m. • Chest discomfort • chest pain • Emergency unit • Lab:Normal limit • BP 185/102 • Chest Rontgent • Inpatient recommended • Rejected

30. Aortic aneurysm rupture • Oct 13th, 07 a.m. • Brushing teeth • She felt down suddenly (Collaps) • Emergency services called and Cardiopulmonary resuscitation start • 08:14 a.m. confirmed death • R-1, R-2, R-3

31. Aortic aneurysm Symptoms • Many aneurysms do not have symptoms • Detected during a routine physical exam or • X-ray evaluation for another disorder • Symptoms occur • When the aneurysm grows/disrupts the wall of the aorta • Symptoms depend on the size and location • Pain in the abdomen or in the lower back • Constant pain occurring over hours or days • Sudden onset of severe stabbing pain • Unusual sensation of pulsing in the abdomen • Cough, shortness of breath (thoracic aortic aneurysm) • Fainting, Chest pain

32. Subarachnoid haemorahge 3. Cerebrovascular disease • 66 years old man • 2 days ago • Headeche • Vomit • General malaise • Walking to Hospital • BP 207/85 • Concious • SAH.wmv

33. SAH (Subarachnoid haemorrhage) • acute nontraumatic headache • maximum intensity within 1 hour • “Worst headache of my life" • 30-40% of patients are at rest at the time of SAH • The remaining 60-70% of cases • Physical or emotional strain • Defecation, coitus, and head trauma

35. SAH Prodromal events • Signs and symptoms • Ruptured cerebral aneurysm (10-50% of cases.) • 10-20 days prior to rupture • The most common symptoms • Headache (48%) • Dizziness (10%) • Orbital pain (7%) • Diplopia (4%), Visual loss (4%) • Sensory or motor disturbance (6%) • Seizures (4%), Dysphasia (2%), Ptosis (3%)

36. Prodromal signs and symptoms • Sentinel leaks • Headaches, nausea, vomiting, photophobia, malaise, neck pain. • These symptoms may be ignored by the physician • Mass effect (aneurysm expansion) • Emboli

37. Cerebrovascular disease (head injury) • 92 years old woman • Fall down, Head injury • Headeache, nausea, vomiting • Right Intracranial haemorrhage • (Epidural hematoma) • Sarcopenia

38. Cerebrovascular disease, Cerebrovascular infarct (Stroke) • 47 years old woman • Past history : Iron Defficiency Anemia • 28th Oct 2015 • Suddenly fall down and feel dysarthria • 29th Oct 2015 night • Numbness left hand and leg • 30th Oct 2015 Emergency department • No sign of paralysis, walking to hospital • BP 182/104 • Head MRI exam • 脳梗塞（DWI).wmv脳梗塞（MRA 1）.wmv • 脳梗塞（MRA-2).wmv脳梗塞（頚動脈－１）.wmv

39. Internal carotid artery oclusion

40. 4. Peripheral artery disease (PAD) • Narrowing of the arteries • Other than the heart or brain • classic symptom • Leg pain when walking, resolves with rest • Intermittent claudication • Other symptoms • Skin ulcers, bluish skin, cold skin, or poor nail and hair growth in the affected leg  • Complications • Infection or tissue death  • May require amputation • 50% are without symptoms

41. Symptom Screening

42. Therapy of Peripheral artery disease

43. Peripheral artery disease • 72 Years old Man (Inpatient caused by Osteomyelitis) • Diabetes Mellitus • Hypercholesterol, Hyperlipidemia • Hypertension • Bilateral Leg PAD

44. 5. Pulmonary embolism • Inhospital caused by lower extremities infection • Oct 6th 22 p.m. • Suddenly • Chest pain, dyspnea • Cold sweat • ECG: look like Angina or MI • PE-造影０１.wmv • PEー造影２.wmv • PEー造影３D.wmv

45. A former minister for health in Indonesia, • The rates of infectious diseases have gone down, while non-communicable diseases have gone up tremendously • The non-communicable diseases are not included in our health insurance schemes

46. 90% of CVD : preventable • Prevention of atherosclerosis by decreasing risk factors • Healthy eating, exercise • Avoid tobacco smoke • Limiting alcohol intake • Treating high blood pressure and diabetes  • Treating people who have strep throat with antibiotics can decrease the risk of rheumatic heart disease • Avoid or reduce exposure to air pollution

47. Cardiovascular disease　 = Obesity only? • Visceral fat (abdominal fat) • Body fat that exists in the abdomen  • Surrounds the internal organs  • Cholesterol Ratio • L/H Ratio • Air Pollution

48. Cardiovascular disease = Obesity only? Air Pollution　＝　PM2.5

49. Air pollution • Currently, PM2.5 is the major focus • short- and long-term exposure • Increased rate of atherosclerosis and inflammation • Effects on cardiovascular disease • Estimated 8–18% CVD mortality risk  • Women had a higher relative risk coronary artery disease than men did  • 5 days of exposure, a rise in Blood pressure • Irregular heart rhythm, reduced heart rate variability, and heart failure • Artery thickening • Increased risk of acute myocardial infarction

50. Respiratory system