While the guidelines for the managements of heart diseases have been well-developed and updated periodically, they do not guarantee to reduce the number of heart disease morbidity and mortality. Since the holistic approach is not carefully applied, this morbidity rate may not be significantly reduced. The holistic approach to managing heart disease has broad aspects, but the most important aspect is regarding physician adherence to Guideline-Directed Medical Therapy (GDMT). This paper aimed to discuss the physician adherence to GDMT, and its role in reducing morbidity and in-hospitalization in heart disease patients. Several large scale studies have revealed that good adherence to heart failure treatment guidelines among physicians improved not only quality of life but also resulted in a better prognosis. On other hands, because the main target of physicians adherence to GDMT is to achieve maximally tolerated dose, it is also important that the understanding when and how to add, switch, and titrate all therapies to maximally tolerated doses and ideally target doses is important to reduce the morbidity and mortality of heart disease patients. However, in some points, this principle might not be applied properly due to several limitations. In this case, physicians may have to consider the balance between patients preferences, healthcare resources, and the risk of adverse outcomes. In conclusion, it should be noted that physician adherence to GDMT has an important role to reduce morbidity and mortality of heart disease patients.

Cardiovascular disease contributes to 48% of deaths in the world. A cohort study at the Harapan Kita National Heart Center and 5 Indonesia hospitals in 2006 showed that the death rate due to heart disease in hospitals was around 6-12%. Rehospitalization rate reached 29% and the all-out expense of INA-CBG claimed for inpatient was Rp 42.4 trillion. The major problem causing rehospitalization was poor compliance to medication in coronary artery disease (CAD) patients. Education to improve compliance has been known not only reduced rehospitalization rate but also improve quality of life. In these review the author discussed the efficacy of community based cardiac rehabilitation for rehospitalisation reduction dan quality of life improvement

Background : Angiotensin-converting enzyme inhibitors (ACEI) should be titrated to the optimal dose for adequate inhibition of the Renin-Angiotensin-Aldosterone system (RAAS). The up-titration of ACEI to the optimal doses during in-hospital treatment is challenging. Objectives : This study aimed to investigate whether the use of optimal dose of ACEI during in-hospital treatment could give more benefit to the outcome of heart failure (HF) patients. Methods : We involved 171 HF patients in this prospective cohort study. 29 and 142 HF patients were treated with optimal dose and suboptimal dose of ACEI during in-hospital treatment, respectively. The primary endpoint was in-hospital and 30 days post-discharge mortality. The secondary endpoint was 30 days post-discharge rehospitalization due to worsening of HF. Results: Only 17% of HF patients treated with optimal dose of ACEI during in-hospital treatment. In-hospital mortality in optimal dose of ACEI group was lower than in suboptimal dose of ACEI group (0% vs. 19.7%; p = 0.009). The 30 days post-discharge mortality (0% vs 2.7%; p = 0.375) and rehospitalization (6.9% vs 16.7%; p = 0.184) between both groups were not significantly different. Conclusion: The use of optimal dose of ACEI during in-hospital treatment reduced in-hospital mortality in HF patients.

Cardiovascular disease contributes to 48% of deaths in the world. A cohort study at the Harapan Kita National Heart Center and 5 Indonesia hospitals in 2006 showed that the death rate due to heart disease in hospitals was around 6-12%. Rehospitalization rate reached 29% and the all-out expense of INA-CBG claimed for inpatient was Rp 42.4 trillion. The major problem causing rehospitalization was poor compliance to medication in coronary artery disease (CAD) patients. Education to improve compliance has been known not only reduced rehospitalization rate but also improve quality of life. In these review the author discussed the efficacy of community based cardiac rehabilitation for rehospitalisation reduction dan quality of life improvement

Background : Rheumatic heart disease (RHD) contributed to a large number of proportion amoung cardiovascular problems in developing county, especially Indonesia. Secondary prophylaxis method using intramuscular injection of Benzathin Penicillin-G (BPG) has been known as the most effective strategy in the prevention of RHD. However, whether this prevention method also resulting in prevention of disease severity in Indonesian patients remained to be examined. Objectives : This study aimed to assess the difference of rheumatic valve severity in Indonesian pediatric patients between adequate and poor adherence to secondary prophylaxis by using intramuscular BPG injection. Methods : This cross-sectional study was conducted at Pediatric Cardiology Department of Saiful Anwar General Hospital from November 2018 to June 2019. Patients with documented history of RHD were included. Frequency of intramuscular BPG injection during the last one year was recorded. Adherence was measured using the proportion of days covered (PDC) and adequate adherence was defined as PDC =0.90. The severity of RHD was assessed based on the severity of the mitral and / or aortic valve using echocardiography. Bivariate analysis and multivariate logistic regression analysis was used to identify characteristics associated with rheumatic valve severity. Results : A significant difference of rheumatic mitral and/or aortic valve severity was observed between adequate adherence compared to poor adherence group (p = 0.016). Rheumatic mitral and/or aortic valve were found to be more severe in patients who has one or more episode of ARF recurrence (p = 0.003). Multivariate logistic regression analysis demonstrated that adherence to secondary prophylaxis within the last 1 year has the strongest influence on the severity of rheumatic mitral and/or aortic valve (p = 0.049; OR 7.20). Conclusion : The adherence to secondary prophylaxis has the strongest related the rheumatic valve severity compared to other factors.

Background : Rheumatic heart disease (RHD) contributed to a large number of proportion amoung cardiovascular problems in developing county, especially Indonesia. Secondary prophylaxis method using intramuscular injection of Benzathin Penicillin-G (BPG) has been known as the most effective strategy in the prevention of RHD. However, whether this prevention method also resulting in prevention of disease severity in Indonesian patients remained to be examined. Objectives : This study aimed to assess the difference of rheumatic valve severity in Indonesian pediatric patients between adequate and poor adherence to secondary prophylaxis by using intramuscular BPG injection. Methods : This cross-sectional study was conducted at Pediatric Cardiology Department of Saiful Anwar General Hospital from November 2018 to June 2019. Patients with documented history of RHD were included. Frequency of intramuscular BPG injection during the last one year was recorded. Adherence was measured using the proportion of days covered (PDC) and adequate adherence was defined as PDC =0.90. The severity of RHD was assessed based on the severity of the mitral and / or aortic valve using echocardiography. Bivariate analysis and multivariate logistic regression analysis was used to identify characteristics associated with rheumatic valve severity. Results : A significant difference of rheumatic mitral and/or aortic valve severity was observed between adequate adherence compared to poor adherence group (p = 0.016). Rheumatic mitral and/or aortic valve were found to be more severe in patients who has one or more episode of ARF recurrence (p = 0.003). Multivariate logistic regression analysis demonstrated that adherence to secondary prophylaxis within the last 1 year has the strongest influence on the severity of rheumatic mitral and/or aortic valve (p = 0.049; OR 7.20). Conclusion : The adherence to secondary prophylaxis has the strongest related the rheumatic valve severity compared to other factors.

Background : Garcinia mangostana L. has been extensively used for years as antioxidant and anti-inflammation. However, its role in the context of endothelial disease was lacking. Objectives : To assess the effect of add-on G. mangostana L. extracts on endothelial dysfunction in type 2 diabetes subjects with high-risk Framingham score, compared to placebo. Methods : This was a prospective cohort study conducted in type 2 diabetes subjects with high-risk Framingham score. Subjects were randomized into two groups. The first group received 2,520 mg/day of G. mangostana L. extract. The second group was given a placebo for 90 days. The outcome measure of our study was the levels of endothelial progenitor cell (EPC), circulating endothelial cell (CEC), nitric oxide (NO), tumor necrosis factor-a (TNF-a), interleukin-1 (IL-1), IL-6, hemoglobin A1c (HbA1c), high-sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), Superoxide dismutase (SOD) and fasting blood glucose. Multiple linear regression was used to determine the correlation and effect estimate. Results: A total of 49 patients were included in our study. Of those, elevated levels of EPC and SOD were observed in treatment group compared to placebo. On the other hand, the level of CEC, IL-1, Il-6, NO, MDA, TNF-a, fasting blood glucose and HbA1c was found significantly lower than placebo. Conclusion: Garcinia mangostana L. extract is associated with an increased levels of EPC and SOD, and it is also correlated with a decreased levels of CEC, IL-1, Il-6, NO, MDA, TNF-a, fasting blood glucose and HbA1c.

We presented a case of Wolff-Parkinson-White (WPW) Syndrome. A 69-year-old man was admitted for evaluation of frequent episodes of palpitation. The diagnosis of WPW syndrome was established based on the 12-lead surface electrocardiogram (ECG) and electrophysiology (EP) study. We conducted the radiofrequency ablation (RFA) to the accessory pathway (AP). The challenging point of this case was the accessory pathway located just below to the bundle of His, which is related to the risk of complete atrioventricular (AV) block. In summary, we conclude that anatomical consideration, EP study, and the ablation strategy were important to improve the safety and success rate of RFA procedure.

BACKGROUND: Critical limb ischemia (CLI) is a terminal stage of peripheral arterial disease (PAD), in the absence of intervention, may lead to lower extremity amputation or death. In cases where medical management is not effective or severe cases of PAD, endovascular and surgical interventions are indicated.2 Endovascular interventions become a first-line approach of CLI management and have advanced considerably within the past decade.1,3 CASE DESCRIPTION: A 73-year old female with complain of left leg pain, accompanied with necrotic wound since 6 months ago. Duplex ultrasound showed no-flow from proximal to distal left superficial femoral artery (SFA). From CT-Angiography showed total occlusion from proximal left SFA to proximal poplitea artery about 7,2cm with collateral vessels. She was diagnosed with CLI left inferior extremity Fontaine IV Rutherford III. Angiography inferior extrimities was performed with total occlusion from proximal to distal left SFA with collateral vessels run to distal. We deployed a self-expanding stent with size 6mmx100mmx120cm at proximal-mid SFA. The patient showed improvement and was discharged after 5-days observation DISCUSSION: Patients with CLI have high risk of limb-loss without revascularization and high short term risk of cardiovascular events. Endovascular revascularization of femoro-popliteal occlusive offers lower initial risks than open surgery, with grade IIB-recommendation for lesion less than 25cm. Clinical success of endovascular stenting on CLI usually synonymous to limb salvage CONCLUSION:Favorable results can be achieved with endovascular stenting approach in patients with CLI, where close follow-up treatment afterwards can save limb loss.

While the guidelines for the managements of heart diseases have been well-developed and updated periodically, they do not guarantee to reduce the number of heart disease morbidity and mortality. Since the holistic approach is not carefully applied, this morbidity rate may not be significantly reduced. The holistic approach to managing heart disease has broad aspects, but the most important aspect is regarding physician adherence to Guideline-Directed Medical Therapy (GDMT). This paper aimed to discuss the physician adherence to GDMT, and its role in reducing morbidity and in-hospitalization in heart disease patients. Several large scale studies have revealed that good adherence to heart failure treatment guidelines among physicians improved not only quality of life but also resulted in a better prognosis. On other hands, because the main target of physicians adherence to GDMT is to achieve maximally tolerated dose, it is also important that the understanding when and how to add, switch, and titrate all therapies to maximally tolerated doses and ideally target doses is important to reduce the morbidity and mortality of heart disease patients. However, in some points, this principle might not be applied properly due to several limitations. In this case, physicians may have to consider the balance between patients preferences, healthcare resources, and the risk of adverse outcomes. In conclusion, it should be noted that physician adherence to GDMT has an important role to reduce morbidity and mortality of heart disease patients.