The Impact of Cognitive Behavioral Therapy (CBT)-based Intervention for Improving Physical and Psychological Function in Coronary Heart Disease Patients: A Meta-analysis

Abstract

Current cardiac rehabilitation (CR) in general is still focused on physical rehabilitation to improve heart functions and quality of life for patients undergoing rehabilitation for coronary heart disease (CHD). However, psychological rehabilitation is believed to maximize the impact of CR on CHD patients’ recovery. Cognitive behaviour therapy (CBT) has been shown to have a positive correlation with psychological aspects in general populations, as suggested by studies. This study aims to evaluate the impact of CBT in physical and physiological outcome among CHD patients. A systematic literature searching was conducted using 3 databases (Cochrane, PubMed, Science Direct) in July 2023. The quality of the included studies was assessed using the Cochrane Risk of Bias. Pooled data analysis of primary and secondary outcomes was performed with Review Manager 5.4. A total of 7 trials comprising 894 CHD patients fulfilled the inclusion criteria and were eligible to be quantitatively analysed in our meta-analysis. Our analysis revealed that the integration of CBT-based intervention led to higher physical exercise [SMD 0.81; 95% CI 0.21-1.41; p < 0.00001], self-efficacy
expectation [SMD 1.05; 95% CI (-0.62)-2.72; p < 0.00001], quality of life (QoL) score [SMD 1.12; 95% CI (-0.35)-2.59; p < 0.00001], and psychological score [OR 1.01; 95% CI 0.03-1.98; p < 0.00001] compared to control. The overall meta-analysis results suggest the inclusion of CBT-based intervention in CR programs had impact on enhancing patients’ physical function and psychological well-being. These findings suggest reasonable approach to integrate standardized CBT-based psychological interventions into current CR programs to improve overall CHD patients’ health.

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ABSTRACT
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Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815

ABSTRACT
ii Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
CHAIRMAN FOREWORD
As the COVID-19 pandemic has been resolved,
we are glad to welcome our colleagues to visit
the paradise island, Bali, while joining our annual
meeting, the 12th Bali Cardiology update that
will be held oine. We organises workshops,
symposiums, plenary talks, lectures with
international and national keynote speakers, and
interactive gatherings from throughout regions
to discuss cutting-edge discoveries to advance
the profession and medications specializing in
cardiovascular disease managements, providing
an absolutely superb framework for professionals
in cardiovascular health, researchers, scientists, healthcare specialists, academicians,
and individuals with interest in cardiology. This is your best opportunity to network
with the most individuals from hospitals, academic institutions, heart associations,
and research facilities because there are people from all over the world interested in
nding a few solutions in the eld of cardiology. The opportunity to network with
colleagues and hear from renowned cardiologists and cardiovascular researchers at
this cardiology summit is unmatched.
Agung Pradnyana Suwirya
Intisari Sains Medis 2023, Volume 14, Number 2: 1-10
P-ISSN: 2503-3638, E-ISSN: 2089-9084
DOI: 10.15562/ism.v14i2.1815
Published by Intisari Sains Medis

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Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Editorial Board
INTISARI SAINS MEDIS
Intisari Sains Medis 2023, Volume 14, Number 2: 1-10
P-ISSN: 2503-3638, E-ISSN: 2089-9084
DOI: 10.15562/ism.v14i2.1815
Editor in Chief
I.B. Amertha Putra Manuaba, SKed, MBiomed,
AmerthaManuaba@gmail.com / Amertha_Manuaba@unud.ac.id
Editor in Chief Intisari Sains Medis, Founder Medical Scientic Community,
Magister at Biomedical Sciences, Universitas Udayana, Indonesia
(Scopus ID), (Google Scholar), (ORCID), (Researcher ID) (Researchgate)
Associate Editor
Benny Wantouw, MS, Sp.And
Pembantu Dekan III Bidang Kemahasiswaan,
Fakultas Kedokteran Universitas Sam Ratulangi Manado,
Periode 2008-2013., Indonesia
A.A Gde Marvy Khrisna Pranamartha, S.Ked., MARS
Editorial Board Member Intisari Sains Medis,
Humas ISM Cabang Denpasar Bali, Universitas Udayana, Indonesia
(Scopus ID), (Google Scholar)
Administrative
I Gede Krisna Yoga Pratama, S.Ked
Administrative Intisari Sains Medis, Humas ISM Cabang Denpasar Bali,
Universitas Udayana, Indonesia
Editorial Board for Regional Australia
Prof. Dr. Edward R. Tiekink,
Sunway University, Petaling Jaya Solid-state Chemistry, Medicinal Chemistry,
Inorganic Chemistry Ph.D. (Uni. Melb.) 1985; D.Sc. (Uni. Melb.) 2006, Malaysia
(Scopus ID)
Prof. Dr. David James Young,
Head of School | School of Science and Engineering, Professor Young has undertaken numerous
consultancies for AusAID in Indonesia, teaching chemistry and assisting with research projects at
universities in West Java, Bali, Lombok and West Timor., Australia
(Scopus ID)
Editorial Board for Regional Asia
G Sai Sailesh Kumar,
Department of Physiology, Little Flower Institute of Medical Sciences and Research, Angamaly,
Kerala, India., India
(Scopus ID)
Published by Intisari Sains Medis

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iv Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Editorial Board for Regional Eropa
Prof. Harald Hoekstra,
Universitair Medisch Centrum Groningen, Division of Surgical Oncology, Groningen the Netherland
(Scopus ID)
Editorial Board Member
dr Deasy Ayuningtyas Tandio MPH-MBA,
James Cook University Austalia Master of Public Health Master Of Business Administration, Indonesia
(Orcid ID)
I Gede Putu Supadmanaba, SKed,M.Sc.
Assistant Lecturer Biochemistry Departement Udayana University, Indonesia
Biochemistry Department Faculty of Medicine Udayana University, Oncology Master Program Vrije
Universiteit Medical Center Amsterdam
(Scopus ID), (Google Scholar), (Orcid ID)
Dwijo Anargha Sindhughosa, SKed,Sp.D.
Department of Internal Medicine, Faculty of Medicine, Universitas Udayana,
Prof. dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia
(Scopus ID),(Google Scholar),(Orcid ID),(Researcher),(Researchgate)

Putu Bagus Anggaraditya, SKed.MARS
Editorial Board Member Intisari Sains Medis,
Humas ISM Cabang Denpasar Bali, Udayana University., Indonesia
I Putu Yuda Prabawa, S.Ked., M.Biomed
Lecturer of Clinical Pathology Department, Faculty of Medicine Universitas Udayan, Indonesia.
(Scopus ID),(Google Scholar),(Orcid ID),(Researcher ID),(Researchgate)
Agha Bhargah., S.Ked., M.Biomed
Faculty of Medicine Udayana University, Indonesia.
(Scopus ID),(Google Shoolar),(Orcid ID), (Researchgate), (Researcher)
Pande Agung Mahariski., S.Ked. M.Biomed
Faculty of Medicine Universitas Udayana, Indonesia
(Scopus ID) (Orchid ID)

ABSTRACT
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Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
TABLE OF CONTENTS
Foreword
Agung Pradnyana Suwirya
Chairman ................................................................................................................................................................................................................................................................ ii
Editorial Board Intisari Sains Medis ........................................................................................................................................................................................................................ iii
Table of Contents ............................................................................................................................................................................................................................................................. V
BEST RESEARCH
The Compression stocking in venous insuciency post endovenous laser ablation, is it benecial or not?
a systematic review and meta-analysis ................................................................................................................................................................................................... 1
Muhammad Rifqi Arya Putra, Nabilah Hanifah Mukti, Ariikah Dyah Lamara, J. Nugroho Eko Putranto
Prognostic values of right ventricular echocardiography functional parameters for mortality prediction in precapillary pulmonary
hypertension: a meta-analysis of nineteen cohort studies ........................................................................................................................................................... 1
Bryan Gervais de Liyis
Optimal timing of dual antiplatelet de-escalation in acute coronary syndrome: systematic review and meta-analysis ............................... 2
Ida Bagus Satriya Wibawa, Gusti Ngurah Prana Jagannatha, Fanny Deantri, Etik Nurhidayati,I Made Junior Rina Artha
The impact of cognitive based therapy (CBT)-based intervention for improving physical and psychological functions in coronary heart
disease patients: a meta-analysis............................................................................................................................................................................................................... 2
A.A.I.K Arini, Amanda V. M. Sitepu, Stevanus C. Surya, A.A.G.B.R Widiagung, Alif H. Alamsyah
Correlation between bioimpedance analysis and echocardiography in determining uid status of patient with acute decompensated
heart failure treated in intensive cardiology care unit Mangusada Hospital ....................................................................................................................... 2
Felita Surya Rini, I Made Agus Endra Permana
The ecacy of tolvaptan in patients hospitalized for acute decompensated heart failure with advanced chronic kidney disease ....... 3
F.S.M Pratistha, I.W.S Ardiana
Comparison of history and electrocardiogram-only score manchester acute coronary syndromes (HE-MACS) and emergency department
assessment of chest pain score (EDACS) in hospital mortality: a prospective cohort study ......................................................................................... 3
Maya Paramita Wijaya, I Putu Gede Eka Ariawan Suyasa
Complications and ecacy of surgical versus transcatheter closure for pediatric ostium secundum atrial septal defect: a meta-analysis of
fourteen cohort studies .................................................................................................................................................................................................................................. 3
Bryan Gervais de Liyis, Jane Carissa Sutedja
Endurance sports athletes and the risk of atrial brillation: a systematic review of the supposedly heart-protective pursuit ................. 4
Rifqi Rizkani Eri, Sania Zahrani
High blood pressure in children across primary schools in rural Bali ...................................................................................................................................... 4
Hanselim, Anak Agung Gede Indrayana Putra, Andrew Sunarto, I Gede Bagus Gita Pranata Putra
Intisari Sains Medis 2023, Volume 14, Number 2: 1-10
P-ISSN: 2503-3638, E-ISSN: 2089-9084
DOI: 10.15562/ism.v14i2.1815
Published by Intisari Sains Medis

ABSTRACT
vi Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
BEST CASE REPORT
Captivating type a aortic dissection as the symptoms imitateanterior st-elevation myocardial infarction; a ticking bomb inside ....... 5
Samuel Widodo, I Dewa Gede Dwi Sumajaya
An enigmatic case of isolated cardiac sarcoidosis: how to disclose? ........................................................................................................................................ 5
K. J. Sandi1, J. Christopher, S. H. Wicaksono, F. Hutomo, L. P. Suciadi
Modied valsalva maneuver for cardioversion of supraventricular tachycardia in rural hospital: a safe and
cost-eective treatment ................................................................................................................................................................................................................................. 5
D. Yobel, P. Kurniawan, Y. Alexander, S.L. Purwowiyoto
Current modalities for the diagnostic and management approach of Buerger’s disease: a case report ................................................................ 6
Putu Eka Dianti Putri, Agung Pradnyana Suwirya,
I Gusti Ayu Wijayanty Permatasari, Bagus Ari Pradnyana
Implementation of novel risk stratication for pulmonary embolism -SIRENA- in a patient with massive right atrial thrombus: An
Experience in EastNusaTenggara ............................................................................................................................................................................................................. 6
Agatha D. S. Diamanta, Krishna A. Nugraha
Pericardiocentesis with modied CVC Kit in 13-year-old boy with idiopathic pericardial eusion: a rare case from a remote district
hospital ................................................................................................................................................................................................................................................................... 6
Eliza, I Gede Sumantra
Occult acute aorta dissection in a woman with pneumonia presentation ............................................................................................................................ 7
Udtiek M, Hisyam A2
Antiplatelet and Anticoagulant strategies in STEMI patients with thrombocytopenia at Non-PCI centre hospitals ....................................... 7
Komang Gede Adhyaksa Dharma Kusuma, IGA Raka M, I Ketut Susila
Managing atrial brilation with wol-parkinson-white syndrome and hyperthyroid in regional hospital, what we can do? ................... 8
Rizky Darmawan, Desak Ayu Sri Cinthya Uttari, Gusti Ayu Suryawati
Supraventricular tachycardia in pregnancy: a rare case series and dilemmatic antiarrhythmic drug in rural area .......................................... 8
Ngurah Agung Reza Satria NP, Ida Bagus Komang Arjawa, Aditya Prabawa
LIST OF DISPLAYED POSTER BALI CARDIOLOGY UPDATE 2023 ................................................................................................................................................................ 9

ABSTRACT
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Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Intisari Sains Medis 2023, Volume 14, Number 2: 1-10
P-ISSN: 2503-3638, E-ISSN: 2089-9084
DOI: 10.15562/ism.v14i2.1815
BEST RESEARCH
Compression stocking in venous
insuciency post endovenous laser ablation,
is it benecial or not? a systematic review
and meta-analysis
Muhammad Rifqi Arya Putra1,2, Nabilah Hanifah Mukti3,
Ariikah Dyah Lamara1,2, J. Nugroho Eko Putranto1
1Department of Cardiology and Vascular Medicine, Faculty of Medicine,
Airlangga University - Dr. Soetomo General Academic Hospital, Surabaya, East
Java, Indonesia;
2Cardiovascular Research and Innovation Center, Surabaya,Indonesia,
3Faculty of Medicine; Brawijaya University, Malang, East Java, Indonesia
Backgrounds: Endovenous laser ablation or EVLA are widely used as an
alternatives to surgery for treatment of venous insuciency. Compression
believed could relieve pain and reduce complications post-operative. We aim
to nd the benet of compression stocking in patients with venous insuciency
treated with EVLA.
Materials and Methods: Study was designed according to PRISMA guidelines.
Literature searching was done systematically for the latest 10 years of
publication through several databases including Pubmed, SCOPUS, and Web of
Science, until July 2023. Primary outcomes measured are pain score. Secondary
outcomes are Aberdeen Varicose Vein Questionnaire (AVVQ), quality of life, days
return to work and complications. Statistical analysis used random-eects
model was used to derive standardized mean dierence (SMD) and risk ratios
(RRs) with 95% condence interval (CI) using Review Manager (Revman) 5.4.1
Software.
Results: Five RCT and 1 cohort comprising 939 patients were included in
this meta-analysis. There was signicantly dierence in pain score between
compression group and no compression group in the rst 7 days [MD: -1.90
(95% CI:-3.55 to -0.24) but not signicantly dier after 28 days [MD: -0.04
(95% CI:-0.30 to 0.21). Time return to work was also signicantly dierent [MD:
-1.24 (95% CI:-2.41 to 0.07). Both AVVQ score followed for 7 days [MD: −1.47
95% CI, −3.10 to 0.16; p=0.08)] and ≥30 days showed no signicant dierence
[MD:0.45 95%CI, −0.20 to 1.10; p=0.17)]. No signicant dierences in post-
procedural complications were shown, thrombophlebitis (OR −0.01,95% CI
−0.06 up to 0.03,p=0.23) and paresthesia (OR −0.03, 95% CI −0.09 up to
0.02,p=0.23). Through 1 week versus ≤6 weeks quality of life questionnaire
evaluations, there were no dierences in physical function either.
Conclusion: Benet of compression stocking in venous suciency post EVLA
was associated with 7 days post-operative pain and improve days return-to-
work but may not associated with better quality of life and further complications.
Keywords: Endovenous laser ablation, EVLA, venous insuciency, compression
stocking, elastic bandage
Prognostic values of right ventricular
echocardiography functional parameters
for mortality prediction in precapillary
pulmonary hypertension: a meta-analysis of
nineteen cohort studies
Bryan Gervais de Liyis1
1Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
Background: Considering the progressive nature of precapillary pulmonary
hypertension, accurate risk stratication and mortality prediction are crucial.
However, existing studies often lack easily accessible and reliable prognostic
markers, underscoring the need to explore novel and non-invasive modalities
like echocardiography for improved prognostication. We aimed to examine the
prognostic value of right ventricular echocardiographic functional parameters in
predicting mortality among patients with precapillary pulmonary hyper tension.
Methods: A systematic search was conducted in the MEDLINE and EMBASE
databases for longitudinal studies published until July 2023, examining
the relationship between right ventricular echocardiographic ndings and
mortality without language constrains. Pooled statistical analysis was utilized
to assess the statistical means and hazard ratios (HRs) of key right ventricular
parameters, namely right ventricular longitudinal strain (RVLS), tricuspid
annular plane systolic excursion (TAPSE), right ventricular systolic pressure
(RVSP), and right ventricular ejection fraction (RVEF).
Results: Comprehensive analysis was conducted on nineteen cohort studies,
encompassing a total of 2,034 patients. Pooled statistical analysis yielded
compelling results, indicating the compound mean values for key right
ventricular parameters in precapillary pulmonary hypertension as follows:
RVLS at -16.62% (95%CI: -20.17 to -13.06), TAPSE at 16.63 mm (95%CI:
13.58 – 19.68), RVSP at 48.52 mmHg (95%CI: 45.12 – 51.72), and RVEF at
38.11% (95%CI: 26.72 – 49.49). Univariate HRs analysis revealed compelling
associations between these right ventricular parameters and mortality in
patients aicted with precapillary pulmonary hypertension. Specically, all
evaluated parameters, including RVLS (HR: 2.88, 95%CI: 2.15 – 3.61, p < 0.05),
TAPSE (HR: 1.26, 95%CI: 1.16 – 1.36, p < 0.05), RVSP (HR: 1.19, 95%CI: 1.13
– 1.26, p < 0.05), and RVEF (HR: 2.87, 95%CI: 1.85 – 3.89, p <0.05), emerged
as signicant independent prognostic markers for mortality in precapillary
pulmonary hypertension.
Conclusions: RVLS, TAPSE, RVSP, and RVEF hold considerable promise as
valuable prognostic indicators for mortality prediction in individuals with
precapillary pulmonary hypertension.
Keywords: right ventricular, echocardiography, pulmonary hypertention.
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ABSTRACT
2Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Optimal timing of dual antiplatelet de-
escalation in acute coronary syndrome:
systematic review and meta-analysis
Ida Bagus Satriya Wibawa1, Gusti Ngurah Prana
Jagannatha1, Fanny Deantri1, Etik Nurhidayati1,I Made
Junior Rina Artha2
1Bachelor of Medicine and Medical Profession Study, Faculty of Medicine,
Udayana University, Denpasar, Bali, Indonesia
2Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana
University, Denpasar, Bali, Indonesia.
Background: De-escalation strategy is benecial to prevent the risk of bleeding
that commonly happens in acute coronary syndrome (ACS) patient with dual
antiplatelet therapy (DAPT), especially Asians. However, the exact timing and
outcome of de-escalation remain unclear. This meta-analysis aims to evaluate
the outcome and optimal timing of the de-escalation strategy.
Methods: A systematic search for studies comparing the outcome of early DAPT
de-escalation with postponed DAPT de-escalation was conducted on multiple
databases. Primary outcomes included major adverse cardiac events (MACE),
major bleeding, minor bleeding, all-cause mortality (ACM), cardiovascular
death. Secondary outcomes were identical to primary outcomes but specic to
Asians. All outcomes were subjected to subgroup analysis based on the timing
of de-escalation (week 1 and 4). Study eligibility was assessed based on the
Cochrane Risk Bias and all outcomes were analyzed using the Review Manager
5.4 by random-eect Mantel-Haenszel risk ratio (RR).
Results: Twenty studies with 33,698 patients were included. De-escalation
strategy was generally signicant in reducing the incidence of MACE [RR=0.77,
95%CI=0.63–0.94, P=0.01, I2=52%]. In the subgroup analysis, only de-
escalation at week 4 signicantly reduced MACE, ACM, and cardiovascular death
[RR=0.61; 95%CI=0.45–0.82, P=0.0010, I2=53%; RR=0.65, 95%CI=0.55–
0.77, P<0.00001, I2=37%; RR=0.35, 95%CI=0.21–0.57, P<0.0001, I2=0%,
respectively]. De-escalation strategy at both weeks signicantly reduced major
bleeding [RR=0.80, 95%CI=0.68–0.94, P=0.007, I2=0% and RR=0.54,
95%CI=0.42–0.71, P<0.00001, I2=65%, respectively]. Only de-escalation
at week 1 signicantly reduced minor bleeding [RR=0.79, 95%CI=0.65–
0.95, P=0.01, I2=37%]. In Asians, de-escalation at week 4 was signicantly
associated with lower MACE, major bleeding, minor bleeding, ACM, and
cardiovascular death (All P-value <0.05).
Conclusion: DAPT de-escalation has a better safety prole and comparable
ecacy to conventional methods. De-escalation at week 4 in Asians has the
potential to provide optimal outcomes.
Keywords: Acute coronary syndrome, antiplatelet, de-escalation, bleeding,
major adverse cardiac events
The impact of cognitive based therapy (CBT)-
based intervention for improving physical
and psychological functions in coronary
heart disease patients: a meta-analysis
A.A.I.K Arini1, Amanda V. M. Sitepu1, Stevanus C. Surya1,
A.A.G.B.R Widiagung1, Alif H. Alamsyah1
1Faculty of Medicine, Udayana University, Prof. Dr. I G.N.G. Ngoerah General
Hospital, Bali, Indonesia
Background: Current cardiac rehabilitation (CR) in general is still focused
on physical rehabilitation to improve heart functions and quality of life for
patients undergoing rehabilitation for coronary heart disease (CHD). However,
psychological rehabilitation is believed to maximize the impact of CR on CHD
patients’ recovery. Cognitive behaviour therapy (CBT) has been shown to have
a positive correlation with psychological aspects in general populations, as
suggested by studies. This study aims to evaluate the impact of CBT in physical
and physiological outcome among CHD patients.
Methods: A systematic literature searching was conducted using 3 databases
(Cochrane, PubMed, Science Direct) in July 2023. The quality of the included
studies was assessed using the Cochrane Risk of Bias. Pooled data analysis of
primary and secondary outcomes was performed with Review Manager 5.4.
Results: A total of 7 trials comprising 894 CHD patients fullled the inclusion
criteria and were eligible to be quantitatively analysed in our meta-analysis. Our
analysis revealed that the integration of CBT-based intervention led to higher
physical exercise [SMD 0.81; 95% CI 0.21-1.41; p < 0.00001], self-ecacy
expectation [SMD 1.05; 95% CI (-0.62)-2.72; p < 0.00001], quality of life (QoL)
score [SMD 1.12; 95% CI (-0.35)-2.59; p < 0.00001], and psychological score
[OR 1.01; 95% CI 0.03-1.98; p < 0.00001] compared to control.
Conclusions: The overall meta-analysis results suggest the inclusion of CBT-
based intervention in CR programs had impact on enhancing patients’ physical
function and psychological well-being. These ndings suggest reasonable
approach to integrate standardized CBT-based psychological interventions into
current CR programs to improve overall CHD patients’ health.
Keywords: Cognitive Based Therapy, Coronary Heart Disease
Correlation between bioimpedance analysis
and echocardiography in determining uid
status of patient with acute decompensated
heart failure treated in intensive cardiology
care unit Mangusada Hospital
Felita Surya Rini1, I Made Agus Endra Permana2
1Clinical Nutrition Sta, Mangusada Hospital, Mangupura, Badung
2Cardiology Sta, Mangusada Hospital, Mangupura, Badung
Background: Acute decompensated heart failure (ADHF) is generally
considered to be a problem of uid overload. Bio impedance analysis uses the
electrical properties of the human body to alternate current ow and measures
resistance values to estimate body water content. Analysis of BIA specically can
be used to measure extracellular, intracellular, and total body water. The aim of
this study is to compare uid status measured with BIA and echocardiography.
Methods: This is an analytic study with cross sectional method. Inclusion criteria
was all ADHF patient admitted to ICCU during July 2nd – 15th 2023, exclusion
criteria were patient with chronic kidney disease stage V, hypoalbuminemia,
and pulmonary hypertension. Bioimpedance analysis (BIA) measurements and
echocardiography were carried out in the rst 24 hours patients admitted to the
ICCU. The variables measured were height and body weight to determine body
surface area (BSA). From BIA we measure total body water (TBW), extracellular
water, and edema index (ECW/TBW). From echocardiography we measured
inspiratory and expiratory inferior vena cava (IVC) diameter to determine
estimated right atrial pressure (ERAP), caval index, and vena cava diameter
(VCD) index (IVC max/BSA).
Results: The number of samples in this study were 10 samples. Median age
of patients was 69 (49-80 years), 70% were female, mean body weight was

ABSTRACT
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Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
48.45+5.56 (35-90) kg, mean body mass index was 22.78+1.55 (15.88–30.42)
kg/m2. The mean percentage of TBW was 57.92+2.92 (40.1–69.2)%, the mean
ECW was 27.7+1.88 (17.7–39.2)%. All samples have edema index >0.39. The
patient’s Caval index averaged 42.82+6.20 (7.00–74.33) and the patient’s
ERAPS was 3 mmHg 10%, 8 mmHg 60%, and 15 mmHg 20%. There is a strong
correlation between TBW and ERAP, with r = 0.766 with p = 0.010 and between
TBW and VCD index with r 0.782 and p=0.001.
Conclusion: TBW-BIA showed a strong correlation with ERAP and VCD index
and can be used to determine uid status of ADHF patient.
Keywords: bioimpedance analysis, echocardiography, uid status.
The ecacy of tolvaptan in patients
hospitalized for acute decompensated heart
failure with advanced chronic kidney disease
F.S.M Pratistha1, I.W.S Ardiana1
1Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia1
Background: Heart failure (HF) and chronic kidney disease (CKD) often coexist
and pose signicant management challenges for clinicians. Hospitalization
for Acute decompensated heart failure (ADHF) in patients with CKD requires
careful consideration of therapeutic options. Tolvaptan, a selective vasopressin
V2 receptor antagonist, has shown promise in managing uid retention and
congestion in patients with HF. However, its ecacy and safety in patients with
CKD remain less explored.
Methods: A retrospective study was conducted on hospitalized patients with
ADHF and CKD (dened as an estimated glomerular ltration rate <30 mL/
min/1.73 m²) who received tolvaptan as part of their treatment regimen.
Electronic health records were analyzed to assess changes in renal function,
uid balance, and clinical outcomes during the hospitalization period.
Results: A total of 50 patients met the inclusion criteria and were included in
the analysis. Among the study participants, 70% had stage 4 CKD, and 30% had
stage 5 CKD. The administration of tolvaptan resulted in a signicant reduction
in total body weight (p < 0.001) and improvement in dyspnea scores (p < 0.05)
within the rst 48 hours of treatment. Despite a transient decline in estimated
glomerular ltration rate (eGFR) during the initial 24 hours (p = 0.02), eGFR
levels returned to baseline by the end of the hospitalization period (p = 0.08).
Hospital length of stay was not signicantly dierent between patients treated
with tolvaptan compared to those who did not receive it (p = 0.42).
Conclusions: Tolvaptan appears to be eective in managing uid overload
and symptoms of ADHF in patients with CKD during hospitalization. Although
a temporary decline in eGFR was observed, it recovered to baseline levels
without signicant adverse eects on renal function. Further studies, including
randomized controlled trials, are needed to validate these ndings and
establish the long-term safety and ecacy of tolvaptan in this specic patient
population.
Keywords: heart failure, chronic kidney disease, tolvaptan, decompensated
heart failure, uid overload, vasopressin V2 receptor antagonist.
Comparison of history and
electrocardiogram-only score manchester
acute coronary syndromes (HE-MACS) and
emergency department assessment of chest
pain score (EDACS) in hospital mortality: a
prospective cohort study
Maya Paramita Wijaya1,
I Putu Gede Eka Ariawan Suyasa2
1Singasana Public Hospital, Tabanan, Bali
2Cardiology Department, Tabanan General Hospital, Tabanan, Bali
Background: Early diagnosis of ACS is the most eective method in reducing
the mortality burden of this disease. Serial troponin examination as a gold
standard requires a long time. Stratication of patients using simple scoring
systems such as the HE-MACS and EDACS scores can be used as an alternative
method.
Methods: This prospective cohort study was conducted at Tabanan General
Hospital from October 2022. The inclusion criteria were patients with acute
coronary syndrome aged 18 to 80 years. While the exclusion criteria were
patients with symptoms more than 24 hours before hospital admission, patients
with hemodynamic instability, patients with pulmonary embolism, patients
with acute aortic syndrome, and patients with pain suspected of not originating
from the heart. Patients who met the criteria then recorded their ECG, HE-MACS
score, EDACS score, TIMI score, GRACE score and were followed. After the data
was collected, a descriptive and ROC analysis was performed using SPSS where
the value of p <0.05 was considered signicant.
Results: In this study, a total of 51 patients with acute coronary syndrome were
found with an average age of 63.06 ± 11.49 years where most of the patients
were male with a diagnosis of UAP. Based on the HE-MACS score assessment,
45.2% of patients were classied as high or high risk, 60.8% of patients were
not low risk on the EDACS score. In this study, there was no signicant dierence
in the HE-MACS and EDACS scores on the risk of mortality during hospitalization
(HE-MACS score: AUC (0.439); p=0.536) (95% CI: 0.246-0.631); sensitivity
54.5% and specicity 52.5%. EDACS score: AUC (0.634); p = 0.177 (95% CI:
0.458-0.810); sensitivity 63.6% and specicity 65%). Whilst in the GRACE and
TIMI scores, both scores were found to provide a signicant dierence in the
risk of in-hospital mortality (TIMI score: AUC (0.709); p=0.035 (95% CI: 0.531-
0.886); sensitivity 36.4 % and 87.5% specicity GRACE score: AUC (0.876),
p=0.000 (95% CI: 0.742-1.000), 81.8% sensitivity and 82.5% specicity.
Conclusions: There was no signicant dierence in the HE-MACS and EDACS
scores on the risk of mortality during hospitalization.
Keywords: HE-MACS, EDACS, in-hospital mortality, ACS.
Complications and ecacy of surgical versus
transcatheter closure for pediatric ostium
secundum atrial septal defect: a meta-
analysis of fourteen cohort studies
Bryan Gervais de Liyis1, Jane Carissa Sutedja1
1Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
Background: The optimal approach for pediatric ostium secundum atrial
septal defect (ASD) closure remains uncertain, with limited comprehensive

ABSTRACT
4Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
studies comparing surgical and transcatheter methods. This study aims to
assess complications and ecacy of both closures.
Methods: Systematic search in Medline, Cochrane, and EMBASE databases
identied cohort studies until July 2023. Complications (cardiac arrhythmias,
pericardial eusions, pulmonary complications, fever) and length of hospital
stay were evaluated. Ecacy outcomes included successful closure and residual
shunting. Subgroup analysis considered ethnicity, ASD size, age, and rim
deciency involvement.
Results: Fourteen cohort studies involving 9,695 patients were
comprehensively analyzed. In relation to complications, the pediatric patients in
the surgery group exhibited higher occurrences of cardiac arrhythmia (OR: 1.87,
95%CI: 1.22 – 2.87, p=0.004), pericardial eusion (OR: 14.30, 95%CI: 6.97 –
31.43, p<0.00001), and pulmonary complications (OR: 2.58, 95%CI: 1.73 –
3.85, p<0.00001) compared to those in the transcatheter group. However, no
signicant dierence in fever incidence was observed between both groups (OR:
2.57, 95%CI: 0.90 – 7.34, p=0.08). Furthermore, length of hospital stay was
notably shorter in the pediatric transcatheter group (MD: 4.00, 95%CI: 1.71 –
6.29, p=0.0006). Regarding ecacy, both the surgery and transcatheter groups
demonstrated similar rates of successful closure (OR: 1.97, 95%CI: 0.56 – 6.92,
p=0.29) and residual shunting (OR: 0.55, 95%CI: 0.17 – 1.77, p=0.31) in the
pediatric cohort. Subgroup analysis revealed that surgical residual shunting was
notably lower in the European pediatric population (OR: 0.18, 95%CI: 0.07 –
0.45, p=0.0002), in cases with ASD size exceeding 15 mm (OR: 0.19, 95%CI:
0.08 – 0.49, p=0.0006), and in pediatric patients below 8 years old (OR: 0.33,
95%CI: 0.12 – 0.92, p=0.03). Interestingly, residual shunting involving complex
ASD with rim deciency was more pronounced in the surgery group (OR: 2.66,
95%CI: 1.33 – 5.32, p=0.006).
Conclusions: Both surgical and transcatheter closures are equally eective,
with transcatheter closure showing signicantly fewer complications.
Keywords: Surgical Closure, Transcatheter Closure, Atrial Septal Defect
Endurance sports athletes and the risk of
atrial brillation: a systematic review of the
supposedly heart-protective pursuit
Rifqi Rizkani Eri1, Sania Zahrani2
1General Practitioner, Bagas Waras General Public Hospital, Klaten, Indonesia
2Medical Student, Faculty of Medicine, University of Indonesia, Jakarta,
Indonesia
Background: Studies on atrial brillation (AF) risk in endurance sports athletes
have yielded varied outcomes. Several studies suggest that they may face higher
AF risk due to long-term high myocardial workload, leading to atrial structural
changes and cardiac remodeling. This study aims to analyze whether endurance
sports athletes indeed have increased AF risk.
Methods: A thorough search in four databases (Pubmed, PMC, ClinicalTrials.
gov, and EMBASE) using ‘athlete’ and ‘atrial brillation’ as keywords was
conducted. Clinical trials, cohort, and cross-sectional studies were included. Two
independent reviewers performed searching and quality assessment.
Results: Out of 1713 articles, four were included after duplicates removal
and full-text assessment. Johansen et al’s 10-year study on older endurance
sports athlete showed higher AF prevalence in athletes compared to general
population (28.5% vs. 17.8%), with risk ratio of 1.64. Molina et al found higher
lone AF incidence in marathon runners compared to sedentary individuals
(4.92% vs. 0.69%), with hazard ratio of 8.80. Moreover, Aggarwal et al’s
prospective cohort study on 20 moderately trained athletes observed 5% AF
prevalence but was limited by small sample size and lack of control group.
Additionally, Thornton et al’s cross-sectional study on retired Canadian athletes
reported 3% male athletes’ AF prevalence, adding that males have ve-fold
higher AF risk compared to females.
Conclusions: Conicting results have been observed regarding the higher risk
of AF in endurance sports athletes. While most of the studies attribute it to
long-term endurance training, leading to long-term hemodynamic stress and
subsequent cardiac remodeling, we believe further research is essential to gain
a deeper understanding of the pathophysiology of atrial brillation in athletes
and to better assess its risk.
Keywords: Athletes, Atrial Fibrillation, Endurance.
High blood pressure in children across
primary schools in rural Bali
Hanselim1, Anak Agung Gede Indrayana Putra1,
Andrew Sunarto1, I Gede Bagus Gita Pranata Putra1
1Sanjiwani General Hospital, Bali, Indonesia
Background: While hypertension has traditionally been associated with
adulthood, emerging evidence suggests its occurrence in childhood and
adolescence, leading to essential hypertension in adulthood and subsequent
cardiovascular diseases. This study aims to bridge the knowledge gap by
assessing the prevalence of high blood pressure in children in Bali and exploring
its association with body mass index (BMI) as a potential risk factor.
Methods: The study included 1,939 Gianyar elementary school students.
Blood pressure measurement and classication was conducted according to the
American Academy of Pediatrics 2017 pediatric hypertension guidelines. Body
weight, height, and blood pressure were measured. Children with elevated
blood pressure and hypertesion were dened as having high blood pressure
(HBP).
Results: In children aged 6-9 years, the prevalence of HBP was 6.3% for boys
and 6.8% for girls. For children aged 10-13 years, the prevalence increased
to 9.6% for boys and 16.7% for girls. Irrespective of gender or age, a higher
BMI was consistently linked to an elevated prevalence of HBP (P < 0.001). For
children aged 6-9 years, obesity was signicantly associated with HBP in both
boys (OR: 11.709, 95% CI: 2.601 - 52.718, P = 0.001) and girls (OR: 12.069, 95%
CI: 1.443 - 100.970, P = 0.002). Similar signicant associations were found in
the 10-13-year-old age group, with boys (OR: 15.019, 95% CI: 3.250 - 69.401, P
= 0.001) and girls (OR: 25.964, 95% CI: 3.145 - 214.346, P = 0.002).
Conclusions: Our study highlights the higher prevalence of high blood pressure
among children in Gianyar compared to the global prevalence. Additionaly,
there is a signicant association between high BMI and HBP, emphasizing the
role of obesity in contributing to elevated blood pressure levels in children.
Keywords: blood pressure, children, measurement.

ABSTRACT
5
Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
BEST CASE REPORT
Captivating type a aortic dissection as the
symptoms imitateanterior st-elevation
myocardial infarction; a ticking bomb inside
Samuel Widodo1, I Dewa Gede Dwi Sumajaya2
1Intern at Department of Cardiology and Vascular Medicine, Tabanan General
Public Hospital, Bali, Indonesia
2Department of Cardiology and Vascular Medicine, Tabanan General Public
Hospital, Bali, Indonesia
Background: Acute aortic syndrome (AAS) might be dicult to detect
as its symptoms may mimic acute myocardial infarction. Although it is a
rare occurrence, both conditions can manifest simultaneously. However,
distinguishing between them could be challenging as incorrect therapy
protocol, delayed intervention may result fatal events.
Case presentation: A 31-year-old male presented with substernal torn-like
chest pain radiating to the mandible, resulting in shortness of breath for the
past 3 weeks. He has used marijuana and methamphetamine in the past.
Physical examination showed hypotension, tachycardia, tachypnea, weak
peripheral pulses, and prolonged CRT. ECG revealed persistent anterior ST
elevation. Chest radiology displayed heart-shaped globular cardiomegaly and
mediastinal widening. Due to the presence of unusual signs, the attending
physician refrained from administering ACS protocol therapy. Consequently, it
was determined that the rst step would be to perform an echocardiogram,
which revealed aortic root dilation with intimal ap, false lumen with turbulent
(+), severe aortic regurgitation, and RWMA (+). Loading for anti-platelet
and anti-coagulant were not given, but hemodynamic optimalisation was
administered using dobutamine, norepinephrine, and epinephrine. The patient
was referred to Prof. Ngoerah General Hospital to receive further medical
evaluation and therapy.
Discussion: Identifying acute AD Stanford A from true AMI is challenging
and misdiagnosis is very common in patients with ST-segment elevation
on initial ECGs. AMI is primarily diagnosed based on clinical symptoms,
electrocardiogram, and troponin level, whereas the diagnosis of AD can only
be conrmed by imaging modalities. Based on this case, the patient has a
specied characterization of chest pain, history of consuming marijuana
and methamphetamine, and an aortic regurgitation murmur on physical
examination.
Conclusions: Patients presenting with symptoms suggestive of ACS
should consider AD as a possible etiology. Missed diagnosis of AD could be
fatal, as antiplatelet therapy and cardiac catheterization, are two absolute
contraindications to AD treatment.
Keywords: Aortic Dissection, Myocardial Infarction
An enigmatic case of isolated cardiac
sarcoidosis: how to disclose?
K. J. Sandi1, J. Christopher1, S. H. Wicaksono2,
F. Hutomo3, L. P. Suciadi4
1Heart Failure Clinic of Siloam Hospitals Kebon Jeruk; Jakarta, Indonesia
2Cardiology and Vascular Medicine Department of Faculty of Medicine
Universitas Indonesia; Jakarta, Indonesia
3Nuclear Department at Siloam Hospitals Mochtar Riady Comprehensive Cancer
Center; Jakarta, Indonesia
4Siloam Heart Institute at Siloam Hospitals Kebon Jeruk; Jakarta, Indonesia
Background: Cardiac sarcoidosis (CS) is an inammatory cardiomyopathy that
resulting to heart failure (HF). Isolated CS is rarely reported since most cases are
presented as a multi-organ involvement.
Case illustration: A 47-year-old female presented with progressive
breathlessness and orthopnea for the last 2 months. At the initial presentation,
she appeared dyspneic and tachycardic, with stable hemodynamic and signs
of pulmonary congestion. Electrocardiogram showed sinus tachycardia with
the typical characteristic of left ventricular hypertrophy. Diagnosis of HF was
conrmed by the echocardiography ndings of dilated cardiomyopathy with
LVEF 18% and NTproBNP of 10,247 pg/mL. Cardiac MRI revealed patchy brosis
at multiple areas of myocardium, suggestive of CS. Cardiac CT angiography
indicated normal coronary arteries. Meanwhile, lung involvement was ruled
out by chest CT scan. Eventually, isolated CS was veried by FDG-PET/ CT scan
which interestingly disclosed a high metabolic activity conned to the left
ventricle with the pattern of local on diuse. Since then, prednisolone 20 mg
daily was given on top of standard HF regimens. At the 3-month follow up, she
gained dramatic improvement on clinical symptoms and echocardiography
parameters which showed an improved LVEF to 41% and normalized cardiac
chambers. The latest FDG-PET/ CT scan ascertained the inactivation status of
cardiac inammation.
Discussions: CS workup requires clinical suspicion and multi-imaging
modality. Meanwhile, FDG-PET/ CT scan is crucial in diagnostic conrmation
and evaluation in response to steroid.
Conclusion: CS should be considered in unexplained cardiomyopathy as this
etiology might be treatable. Steroid is the mainstay of the therapy.
Keywords: Cardiac sarcoidosis, dilated cardiomyopathy, heart failure, multi-
imaging modality.
Modied valsalva maneuver for
cardioversion of supraventricular
tachycardia in rural hospital: a safe and cost-
eective treatment
D. Yobel1, P. Kurniawan2, Y. Alexander2,
S.L. Purwowiyoto3
1General Practitioner; Indosehat 2003 Hospital; Subang; Indonesia
2General Practitioner; Mardi Rahayu Hospital; Kudus; Indonesia
3Department of Cardiology; Siloam Jantung Diagram Hospital; Depok; Indonesia
Background: Valsalva maneuver is the rst line treatment for supraventricular
tachycardia (SVT), a common and ubiquitous cardiac arrythmias. However,
cardioversion rate is very low (<20%), necessitating the use of antiarrhythmic
agents, which often are not available in rural hospital.
Case Illustration: A 22-year-old male with no signicant past medical or
family history presented to the emergency department for palpitation that
occurred 2 hours before admission. Physical examination was unremarkable
except for tachycardia. Initial workup showed normal blood count, electrolyte,
and thyroid function. Baseline electrocardiography demonstrated SVT with 251
beats/minutes (Figure 1). Modied valsalva manuever was performed, patient
in semi-recumbent position connected to a cardiac monitor, was instructed to
forcefully expire for 15s, blowing into a 10 mL syringe to just move the plunger.

ABSTRACT
6Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Immediately after the strain, patient was laid at with his legs raised at an angle
of 45 degrees for 15s. Patient then returned to the semi-recumbent position for
re-assessment. Modied valsalva manuever was carried out twice without any
side eects and ECG was recorded after successful conversion.
Discussion: Latest consensus guideline published recommended valsalva
maneuver to increase vagal tone as rst line treatment of SVT.1 A modication
of valsalva maneuver may improve the SVT conversion rate compared to
standard valsalva. Modication adds a postural change, supine positioning
with passive leg elevation immediately after the valsalva strain. This promotes
further peripheral blood drain to right heart by gravity, increasing venous
return and vagal stimulation. Furthermore, it increases cardiac parasympathetic
tone, slowing atrioventricular node conduction, and suciently interrupts
the electrical activity of SVT. Appelboam, et al in REVERT trial and Chen, et al.
showed successful conversion rates of 43% and 46% using the modied valsalva
maneuver, respectively.
Conclusions: Modied valsalva maneuver is safe, cost-eective, and can be
used as the routine initial treatment for episodes of SVT, especially in rural
hospital.
Keywords: valsava maneuver, cardioversion, supraventricular tachycardia
Current modalities for the diagnostic and
management approach of Buerger’s disease:
a case report
Putu Eka Dianti Putri1, Agung Pradnyana Suwirya2,
I Gusti Ayu Wijayanty Permatasari3,
Bagus Ari Pradnyana2
Faculty of Medicine, Hang Tuah University, Surabaya, East Java, Indonesia.
2Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana
University, Denpasar, Bali, Indonesia.
3Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
Background: Thromboangiitis obliterans (TAO or Buerger’s disease) is a
peripheral vascular disease usually related to smoking. Until now, there is no
consensus establishing the diagnosis and standard treatment.
Case Illustration: A female 74 years old with a history of uncontrolled
hypertension and smoking complained of blackening and painful ngertips
in both upper limbs. On upper-extremities examination, we found necrotic
gangrene at the 3rd ngertips of the right hand, the 2nd and 4th ngertips
of the left hand, with limitation of the movement at the aected nger due
to the pain. The pulsation of the radial and ulnar arteries of the left hand
was weakened, whereas the brachial arteries of both hands were palpable,
and the Ankle Brachial Index was 0.9 for both extremities. On laboratory
ndings, we found leukocytosis, mild Anemia, no coagulopathy, and normal
ANA IF autoimmune screening. Doppler Ultrasonography showed vascular
incompetence of the left palmar arch artery, with no deep or supercial vein
thrombotic, and cutaneous and subcutaneous edema of the left hand. Then,
arteriography was performed and revealed multiple stenosis of the Left Radial
artery and Right Ulnar artery with collateral corkscrew-shaped. The patient
was diagnosed with peripheral Chronic Limb Threatening Ischemia caused by
Buerger’s disease, which underwent conservative management for 10 days and
Percutaneous Trans Angioplasty (PTA) ballooning.
Discussion: Buerger disease is more common in Asian races than in others,
which commonly aects smoker men between 40-45 years old. Shinoya and
Olin’s criteria were the most common diagnosis criteria for diagnosing Buerger’s
disease. Although the ecacy of surgical revascularization is still controversial,
but PTA ballooning can be an option for the management of Buerger disease
other than conservative management.
Conclusions: Awareness of the entity and familiarity with the clinical,
angiographic, and pathologic features are the key to a prompt and correct
diagnosis of Buerger’s disease.
Keywords: Bueger’s Disease
Implementation of novel risk stratication
for pulmonary embolism -SIRENA- in a
patient with massive right atrial thrombus:
An Experience in EastNusaTenggara
Agatha D. S. Diamanta1, Krishna A. Nugraha2
1General Practitioner, Samuel J. Moeda Navy Hospital, East Nusa Tenggara
2Cardiologist, Samuel J. Moeda Navy Hospital, East Nusa Tenggara
Background: Pulmonary embolism (PE) as a catasthropic disease can occur
at any age of life. A risk stratication model is paramount for physicians to
decide the therapeutic approach and prognosis of the disease. This case report
highlights the role of SIRENA as a novel risk stratication scoring system for
patient with clinical sign of PE.
Case Illustration: A 30-year-old man, active and without any risk for CVD
was admitted to ER due to worsening dyspneu and chest pain in the last three
days. No history of syncope, cyanosis and immobilization. Physical examination
revealed normal blood pressure, tachycardia and decreased oxygen saturation to
85% at room air. The ECG showed T-wave inversion in precordial lead. The chest
X-ray was normal without sign of congestion. Transthoracic echocardiography
(TTE) revealed normal LV function, a large thrombus visualized in Right Atrium
(RA), mild tricuspid regurgitation, and Mc-connel sign. The D-dimer level was
elevated 7.6 mg/L. However, we couldn’t perform pulmonary CTA due to limited
facility. We conclude the patient was PE likely with low severity risk based on
sPESI and SIRENA score. The anticoagulant therapy was given immediately
until we achieved desired INR value. After seven days of treatment, the patient
showed remarkable clinical improvement. From the TTE evaluation, the
thrombus was not seen.
Discussion: Pulmonary embolism (PE) provide a diagnosis challenge in rural
area. Once the diagnosis has been made, risk stratication is required to provide
patient assurance about the severity of the disease and prognosis regarding in-
hospital mortality. In our patient, the SIRENA score may improve the accuracy
for predicting the prognosis and treatment modality.
Conclusion: PE severity classication can help clinicians, especially in rural
area, in deciding treatment and prognosis. Furthermore, the implementation
of SIRENA score has the potential to be develop into a large study to assess its
accuracy in Indonesian population.
Keywords: Pulmonary embolism, SIRENA score
Pericardiocentesis with modied CVC Kit in
13-year-old boy with idiopathic pericardial
eusion: a rare case from a remote district
hospital
Eliza1, I Gede Sumantra2

ABSTRACT
7
Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
1General Practitioner at Waikabubak District Hospital, Sumba, East Nusa
Tenggara
2Departement of Cardiology at Bandung Advent Hospital, Bandung, West Java
Background: The etiologies of pericardial eusion (PE) are various. Idiopathic
pericarditis accounts for 37% to 68% of inpatient admissions for pericardial
eusion or acute pericarditis in children. Eusions that develop slowly can be
asymptomatic, and if rapidly accumulated, it can present as cardiac tamponade.
Pericardiocentesis can be used as a diagnostic tool and also denitive treatment
if the etiology is unclear.
Case Illustration: A 13-year-old boy was admitted with 3 months of dyspnea
on eort and 4 days of mild fever. Physical examination showed mued heart
sounds and low-pitch vesicular sound at the base of the lungs. Laboratory
ndings showed leukocytosis at 12,240. Chest X-ray revealed cardiomegaly with
a dierential diagnosis of pericardial eusion, and bilateral pleural eusion.
ECG showed sinus tachycardia (heart rate 108 bpm). Echocardiography showed
large pericardial eusion with signs of cardiac tamponade, mild MR and TR,
reduced RV contractility, and minimal pleural eusion. Pericardiocentesis was
performed with a double lumen CVC kit (Seldinger Technique), modied with a
14G peripheral venous catheter. The modication was necessary because there
was only number 12 CVC kit available, which vascular access needle was too
short. After indwelling drainage for 3 days, an echocardiography evaluation was
showed a reduction in pericardial eusion from 30-35 mm to 3-4 mm, mostly at
posterior of the cardiac. Total collected pericardial uid was 450 cc. The patient
also underwent the WSD procedure on the right hemithorax, resulting in a total
of 1,500 cc of uids. The microscopic examination of both uids showed no signs
of infection, including TB. The patient was discharged 10 days after admission
in stable condition.
Discussion: This patient had mild symptoms of pericardial eusion. In
auscultation, we found mued heart sounds which is unique to cardiac
tamponade. Chest X-ray and echocardiography showed a large pericardial
eusion with signs of tamponade. Pericardiocentesis with a subxiphoid
approach was performed it was the safest method to reduce the uid
accumulation. The uid then tested and the result was negative for bacteria or
TB. Because we did not have culture and serologic test capabilities to nd other
etiologies, a nal diagnosis of an idiopathic pericardial eusion was made.
Conclusions: Echocardiography can be used as a modality of imaging to conrm
the suspicion of pericardial eusion and as a guide to denitive treatment. The
denitive treatment of pericardial eusion is to reduce the pericardial uid and
minimize the pressure by doing pericardiocentesis.
Keywords: Pericardial Eusion, Pericardiocentesis, Modied CVC kit, Idiopathic
Pericardial Eusion
Occult acute aorta dissection in a woman
with pneumonia presentation
Udtiek M1, Hisyam A2
1General Practitioner, Kraton Hospital Regency, Pekalongan, Indonesia.
2Cardiologist Consultant, Departmen of Cardiology, Kraton Hospital Regency,
Pekalongan, Indonesia.
Background: Dyspnea is rare symptom in aorta dissection patients. Severe
chest/back pain are the major symptoms. Aorta dissection occurs in 75%
hypertension patients (2). In this case, a patient with denied hypertensive and
pneumonia symptoms blurring aorta dissection diagnosis.
Case Illustration: 59th-year-old women come to ED with shortness of breath
worsened in three days. She also had fever and productive cough. She has a
history of asthma since childhood. History of hypertension and smoking is
denied. She often feels non-radiating back pain. She was alert, BP: 122/71
mmHg, HR: 130 bpm, RR: 24, t: 37,9 C, Spo2: 89 room air -> 95 with 8 lpm
non rebreathing mask. Physical examination showed irregular heart sound, no
murmur. Wheezing and rhonchi in both lungs.
She was treated with b-agonist and steroid inhalation, bisoprolol 5 mg once a
day but switched to 100 mg of diltiazem due to worsening wheezing. BP was
unstabled during treatment (130-180 mmHg). Dyspnea was not fully resolved
with medication then she was referred to advanced hospital.
Discussions: Aorta dissection is a tear in the intimal layer result in progression
of the dissection due to the entry of blood between intima and media.
Hypertension is the most important risk factor (1). Acute onset was dened
under 14 days of onset (3). Tearing chest/back pain are main symptom (2). In
this case, the patient’s physical examination mimicked pneumonia. Ct scan
showed unexpected aortic dissection Standford B which aects the descending
thoracic aorta without any involvement of the ascending aorta (4). This type
of dissection, primarily treated medically to reduce aortic wall tension where
surgical treatment is needed in patients with rupture (2,4).
Conclusion: Patients with aorta dissection could present mimicking asthma to
pneumonia symptoms. Unstable blood pressure obscuring hypertension as the
main risk factor for aorta dissection.
Keywords: Aortic dissection, pneumonia, woman.
Antiplatelet and Anticoagulant strategies in
STEMI patients with thrombocytopenia at
Non-PCI centre hospitals
Komang Gede Adhyaksa Dharma Kusuma1,
IGA Raka M2, I Ketut Susila2
1Departement of Cardiology and Vascular Medicine
2Faculty Medicine, Pendidikan Ganesha University, Buleleng General Hospital,
Buleleng
Background: STEMI management the use of antiplatelet agents, particularly
dual antiplatelet therapy with aspirin and P2Y12 receptor antagonists. However,
managing antiplatelet therapy in STEMI patients with thrombocytopenia
presents unique challenges due to the increased risk of bleeding and ischemic
events.
Case Illustrations: A patient arrived with chest pain persisting for 4 hours. The
vital signs revealed blood pressure 160/90 mmHg and a heart rate 110 bpm.
The patient had previously received 4 lpm of nasal cannula oxygen, aspirin 160
, and clopidogrel 300 mg at Pratama Hospital. An ECG and laboratory tests,
revealing inferoposterior STEMI and a platelet count of 60 x 103 /µL. The patient
received streptokinase 1.5 million units over 30 minutes. Echocardiography
indicated mid anterolateral and apical lateral hypokinesia, ejection fraction of
48%, and a TAPSE of 2.1. The patient was treated with fondaparinux and GDMT.
The patient was discharged with a prescription for ramipril 5 mg o.d, bisoprolol
5 mg o.d, clopidogrel 75 mg o.d, atorvastatin 40 mg o.d, and spironolactone 25
mg o.d. The platelet count at discharge was 78 x 103 /µL.
Discussion: Thrombocytopenia, dened as a platelet count 50 x 103 /µL.
Currently, there are no guidelines or consensus on managing STEMI patients
with thrombocytopenia. In this case, the selected management strategy
involved categorizing patients based on the degree of thrombocytopenia,

ABSTRACT
8Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
evaluating the presence of bleeding, and considering the absence of PCI, which
led to the administration of clopidogrel monotherapy and a PPI. Although the
likelihood of heparin-induced thrombocytopenia was low, fondaparinux, a
non-heparin anticoagulant, was selected. The decision to use clopidogrel as
monotherapy over aspirin was based on the CARPIE study4.
Conclusion: For STEMI patients at non-PCI centers with thrombocytopenia and
a platelet count > 50 x 103 /µL, the preferred treatment options include non-
heparin anticoagulants, clopidogrel monotherapy, and PPI usage.
Keywords: antiplatelet, anticoagulant, STEMI, Thrombocytopenia
Managing atrial brilation with wol-
parkinson-white syndrome and hyperthyroid
in regional hospital, what we can do?
Rizky Darmawan1, Desak Ayu Sri Cinthya Uttari1,
Gusti Ayu Suryawati2
1General Practitioner, Bangli General Hospital, Bangli, Indonesia
2Cardiologist, Bangli General Hospital, Bangli, Indonesia
Background: Prevalence of wol-parkinson-white (WPW) is estimated to be
1–3 in 1000 individuals. Majority of individuals are asymptomatic, but those
who have symptoms can experience palpitations, recurrent supraventricular
tachycardia, or sudden cardiac death (SCD). Individuals with hyperthyroidism
are at increased risk of cardiac arrhythmias, especially atrial brillation (AF).The
occurrence of AF in a patient with an accessory pathway (AP) can be detrimental,
causing ventricular stimulation, which induces ventricular brillation (VF)
Case Illustration: We reported a case of 69-year-old female came with
bloody diarrhea, but without fever, chest pain, or feeling palpitated, with
history of WPW pattern and hyperthyroid. Physical examination showed
unstable hemodynamic, lab results showed high level FT4 and normal TSH,
with ECG showed irregular wide complex tachycardia in the form of pre-excited
AF, Unfortunately, we didn’t do electrical cardioversion because the patient
and family refused it. We only gave inotrophic drip, antibiotics, propanolol.
Conversion from AF to sinus rhythm happened in day 4th hospitalization. Patient
was treated for 6 days and discharged with stable condition.
Discussion: According to current guidelines, electrical cardioversion was
recommended in unstable AF with WPW. But it remains challenging if we
can’t do cardioversion. Close monitoring and controlling the cause of AF was
mandatory.
Conclusion: In patient with documented AF, associated condition favouring
arrhythmia such as hyperthyroidism and infection should be corrected. AF in
WPW syndrome is life-threatening arrhythmia. Electrical cardioversion was
recommended in AF WPW and ablation was recommended in long term therapy
to prevent recurrence of tachyarrhythmia.
Keywords: atrial brillation, WPW syndrome, accessory pathway, hyperthyroid,
ablation.
Supraventricular tachycardia in pregnancy:
a rare case series and dilemmatic
antiarrhythmic drug in rural area
Ngurah Agung Reza Satria NP1,
Ida Bagus Komang Arjawa2, Aditya Prabawa3
1General Practitioner, BaliMed Buleleng Hospital, Buleleng, Bali
2Cardiologist, BaliMed Buleleng Hospital, Buleleng, Bali
3Obstretician and Gynecologist, BaliMed Buleleng Hospital, Buleleng, Bali
Background: The management of pregnancy with cardiovascular diseases
needs multidisciplinary collaboration among physicians. Hospitalization due
to arrhythmias in pregnancy is associated with increased mortality and fetal
complications. Arrhythmias can develop spontaneously during pregnancy or be
exacerbated by pregnancy. Pregnancy planning is critical for women who have
a history of cardiovascular disease to maximize the health of the mother and
fetus.
Case Illustrations: There were two cases of pregnant women: a 35-year-
old (third trimester) and a-25-year old (second trimester). Both patients
complained of shortness of breath and palpitations. The rst patient was in
her sixth pregnancy, with three live births and two abortions. Meanwhile, the
second patient was in her rst pregnancy and had no history of abortion. The
rst patient’s pulse rate was 180 beats per minute. Then, the second patient’s
pulse rate was 160 beats per minute. In both cases, 12-lead electrocardiography
revealed a supraventricular tachycardia rhythm. Initially, both patients were
given carotid artery massages for 3 minutes. Following the carotid artery
massage, the rst patient returned to normal sinus rhythm (HR 85 BPM).
However, carotid artery massage didn’t work in the second patient. Then, a slow
bolus of 0.5 mg digoxin IV was administered. After 30 minutes of observation,
the patient’s heart rhythm was restored to normal sinus rhythm (HR 94-100 x/
min). Both patients were also admitted to the intensive care unit.
Discussion: Supraventicular tachycardia (SVT) in pregnancy has a complicated
and multifactorial etiology. increased blood volume can cause atrial distention,
predisposing the heart to electrical changes. High levels of estrogen and
circulating catecholamine have a signicant eect on cardiac tissue excitability,
resulting in arrhythmias. Pregnancy should not prevent the treatment of
tachyarrhythmias. The clinical presentation and trimester of pregnancy play
a signicant role in the management of SVT during pregnancy. In mild cases,
vagal maneuvers can be used to treat this arrhythmia. Medical management is
preferable when vagal maneuvers fail.
Conclusion: The treatment of SVT in pregnancy is largely determined by the
patient’s symptoms, pregnancy stage, and body response to treatment. More
research is needed to determine the best way to treat SVT during pregnancy
and labor.
Keywords: Pregnancy, Arrhythmia, Supraventricular Tachycardia.

ABSTRACT
9
Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
LIST OF DISPLAYED POSTER BALI
CARDIOLOGY UPDATE 2023
Right Heart Failure on Chronic Pulmonary Disease
Himami Firdausiyah, Aditha S Maulana, Nadia S Holifa
Viability and Prognostic Assessment by Cardiac
Magnetic Resonance Imaging After ST-Segment
Elevation Myocardial Infarction Anterior: A Case
Report
Gede Surya Ambara, Celly Anantaria Atmadikoesoemah,
Elen Sahara, Sony Hilal Wicaksono, Manoefris Kasim
Cardiorenal Syndrome Type-5 in Systemic Lupus
Erythematosus: A Rare Case Report
Bryan Gervais de Liyis
Ecacy of Single High-Dose Statin Prior to
Percutaneous Coronary Intervention in Acute
Coronary Syndrome: A Meta-Analysis of Fifteen
Randomized Conrolled Trials
Udtiek M, Hisyam A
Evolution of aVR ST Elevation with TAVB in a Woman
with Hypertension Emergency
Etik Nurhidayati, Marcell Dion Wibowo, Quratul Aini
Hamsi, I Gede Agus Aprianta
Case Report of The Use Combination Antihypertensive
Therapy in Resistant Hypertension in Young Adult
Patients
Ngurah Agung Reza Satria NP, I Ketut Susila
Ortner’s Syndrome (Cardio Vocal Hoarnesses) A
Forgotten, Classic, and Uncommon Case in the Rural
Area
Soeharto, DF, Permana, IS
Reversible Total Atrioventricular Block as a
Manifestation of Cardiorenal Syndrome an Unique
Case Report
Made Pury Pratiwi, Noer Halimatus Syakdiyah, Dinar
Rakanita Bestari
Management and Outcome of Acute Coronary
Syndrome Patients in Ibnu Sina Gresik Regional Public
Hospital with No Catheterization Laboratory
A. Kusuma, Y. Hertanto, S. Sutarmin
Correlation Between Neutrophil-to-Lymphocyte
Ratio and Thrombolysis In Myocardial Infarction Risk
Score In ST Elevation Acute Myocardial Infarction Non
Revascularization In Bali Mandara General Hospital
Aef Mulyawijaya , Firman Fauzan AL
A Case Report of Atrial Fibrillation in Cases of
Hypertensive Emergencies and Acute Decompensated
Heart Failure : What is The Most Common Cause?
Gupta Arya Gumilang P, Dony Astika Wiguna P, Susila
I K
Eectivity Oral Salbutamol to Treat Symptomatic
Bradycardia: A Case Report
S. P. Yogita, SAN Y. Sutarmini, I G.A.B. K. Jayantika
A Closer Look at Thoracic Aortic Aneurysm: Could
Previous History of Primary Lung Tuberculosis be the
Culprit?
Saraswati Putri Yogita, Putu Ayu Widyastuti, SAN Yuli
Sutarmini, I G.A.B. Krisna Jayantika
Comparison of Percutaneous Mechanical Support
Impella and Intraaortic Balloon Pump in Myocardial
Infarction Complicated by Cardiogenic Shock: A
Systematic Review and Meta-Analysis
Saraswati Putri Yogita, Putu Ayu Widyastuti, SAN Yuli
Sutarmini, I G.A.B. Krisna Jayantika
The Relationship between Coee Consumption and
Cardiovascular Events in Patients with Type 2 Diabetes
Mellitus: an Evidence-Based Case Report from a
Systematic Review and Meta-Analysis
Ahmad Yani Mansur, Dian Pratiwi
Digoxin Induced Multifocal Extrasystole Ventricle
In Congestive Heart Failure and Atrial Fibrillation
Patients: Case Report
Rian Mourbas, Iga Nuryanti, Zulfahmi
Lipid Variable Asoociation to Acute Coronary Syndrome
“STEMI AND NSTEMI” in Bangil General Hospital on
April – June 2023
Desak Ayu Sri Cinthya Uttari, Rizky Darmawan, Gusti
Ayu Suryawati
Rheumatic Heart Disease with Severe Mitral
Stenosis and Recurrent Chest Pain: When to Perform
Percutaneous Mitral Commissurotomy or Surgical
Mitral Valve Replacement?
Puspa Sari, NKA; Widyawati, DG
Intracranial Hemorrhage Associated with Fibrinolytic
Therapy. Are we overlooking other risk factors in non-
contraindicated patients?
AA N A Pradnya Iswara Wirawan, Komang Yoga
Suryawan, Luh Oliva Saraswati Suastika
Eectiveness and Safety Prole of Early Ablative
Therapy in First-Onset Ventricular Tachycardia: A
Literature Review
I Made Erda Indranata
Complete Resolution of Total Atrioventricular Block

ABSTRACT
10 Published by Intisari Sains Medis | Intisari Sains Medis 2023; 14(2): 1-10 | doi: 10.15562/ism.v14i2.1815
Immediately after Failed Fibrinolytic Therapy on
Inferior ST-segment Elevation Myocardial Infarction in
Limited Facility: A Case Report
F. Deantri, D.L. Mulya, A. Gabriella
Mitral stenosis in rst decade of life : Echocardiography
screening of children in Sumba
B. Suhuyanly, I. G. Sumantra
Long Flights and Deep Vein Thrombosis: What We
Know So Far?
Putu D.P. Lestari, Bagus APD Sutanegara, Agung P
Suwirya
Deep Vein Thrombosis in Cervical Cancer Patient: a
Case Report
Anthony Setiawan, Ni Made Ayu Wulan Sari
A Case report of Severe Rheumatic Mitral Regurgitation
with unplanned Pregnancy: Implementation of New
Strategies for an Old Disease?
E. Susilowati, Rani Paramitha Iswari Maliawan
Complex Case Management: Acute Aorta Dissection
In Patients With Severe Coronary Artery Disease And
Refusing Coronary Artery Bypass Graft
Kristianto Yusi Adiputra, Agung Pradnyana Suwirya,
Bagus Ari Pradnyana Dwi Sutanegara