Penyakit Jantung Tiroid,Penyakit Jantung Rematik, Dan Penyakit Jantung Anemi (PD)

8/18/2019 Penyakit Jantung Tiroid,Penyakit Jantung Rematik, Dan Penyakit Jantung Anemi (PD)

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Peny. Jantung REUMATIK dan

Peny. Jantung TIROID

Dr. Zainal Safri, SpPD, SpJPDr. Zainal Safri, SpPD, SpJP

Dr. Dede Moe!ir, SpPDDr. Dede Moe!ir, SpPD


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PendahuluanDemam RematikDemam Rematik proses radang akut tenggorokan yangproses radang akut tenggorokan yangdidahului oleh infeksi kuman streptokokusdidahului oleh infeksi kuman streptokokus

beta hemolitikus grup Abeta hemolitikus grup A

penyakit multi-organ, hanya kecacatanpenyakit multi-organ, hanya kecacatanpada jantung yang permanenpada jantung yang permanen

mayoritas penyakit jantung yang diperolehmayoritas penyakit jantung yang diperolehpada anak-anak, yang berdampak besarpada anak-anak, yang berdampak besarterhadap morbiditas dan mortalitas.terhadap morbiditas dan mortalitas.


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Penyakit Jantung RematikPenyakit Jantung Rematik kronikPenyakit Jantung Rematik kronik

merupakan residual sequele darimerupakan residual sequele dari

demamdemam rematik akut, dan diperkirakanrematik akut, dan diperkirakan

!."""!.""" penderita demam rematik akanpenderita demam rematik akan

menderitamenderita PJRPJR setiap tahunnyasetiap tahunnya

#eski banyak penderita PJR yang tidak#eski banyak penderita PJR yang tidakdapat mengingat$mengetahui ri%ayatdapat mengingat$mengetahui ri%ayat

demam rematik sebelumnyademam rematik sebelumnya


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&pidemiologi

'(()*'(()* ' juta penderi' juta penderitata penpenyakiyakit jantungt jantung

rematikrematik ))

""+*""+* '+ hingga '( juta penderi'+ hingga '( juta penderitata,,

ndonesia*ndonesia* ",-",! diantara '""" anak",-",! diantara '""" anak

sekolahsekolah ndonesia menderita demamndonesia menderita demam

rematikrematik

2.4 juta berusia 5-14 tahun

79% diantaranya dari negara berkembang


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DEMAM REUMATIK "DEMAM REUMATIK "

# $$ % & '% T().# $$ % & '% T().

# DA) JARA)* + % T().# DA) JARA)* + % T().

MA)IESTASI K-I)IS "MA)IESTASI K-I)IS "

# ARTRITIS /012# ARTRITIS /012

# KARDITIS %012# KARDITIS %012

# K(OREA '%12# K(OREA '%12

# )ODU-US SU3KUTA) 4 ERITEM# )ODU-US SU3KUTA) 4 ERITEM

MAR*I)ATUM %12MAR*I)ATUM %12

3


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DIA*)OSIS PJR DIA*)OSIS PJR

RI5. DEMAM REUMATIK RI5. DEMAM REUMATIK

KRITERIA JO)ESKRITERIA JO)ES

6 MA7OR ATAU ' MA7OR 8 6 MI)OR26 MA7OR ATAU ' MA7OR 8 6 MI)OR2

4


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TA3. '. KRITERIA JO)ES

KRITERIA MA7OR KRITERIA MA7OR KRITERIA MI)OR KRITERIA MI)OR -KARDITISKARDITIS

-PO-IARTRITISPO-IARTRITIS

-K(OREAK(OREA

-)OD. SU3KUTA))OD. SU3KUTA)

-ERIT. MAR*I)ATUMERIT. MAR*I)ATUM

-DEMAMDEMAM

-ART(A-*IART(A-*I

-I)T. P#RI)T. P#R

MEMA)JA)*MEMA)JA)*

REAKTA) ASEREAKTA) ASE

AKUTAKUT

DITAM3A( 3UKTIDITAM3A( 3UKTI I). STREPTOKOKUS "I). STREPTOKOKUS "

-3IAKA) ARI)* 82 STREPT.3IAKA) ARI)* 82 STREPT.

-ASTOASTO

5


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Diagosis karditis :. Perubahan sifat bising jantung organik. kuran jantung bertambah

. /ising gesek perikardial$efusi perikardial

. 0anda gagal jantung kongestif

Nodul subkutan : nodul kecil, seukuran kacang,

lokasi pada tendo ekstensor tangan, kaki, siku, tepipatela, kulit kepala.

Khorea : gangguan sistim syaraf pusat yang ditandaigerakan tiba-tiba, tanpa tujuan, tidak teratur,kelemahan otot, emosi tak stabil.

Eritem marginatum * ruam merah bersifatsementara, berpindah-pindah, tidak gatal, tidakindurasi, memucat pada tekanan.

Test antibodi streptokokus * standarisasi

palingluas digunakan Pasien DR titer 1 "" unit$ ml.


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OTO T(ORA9OTO T(ORA9 UKURA) JA)TU)*UKURA) JA)TU)*

EK*EK* PEMA)JA)*A) I)T. P &R PEMA)JA)*A) I)T. P &R

EKOKARDIO*RAI & DOPP-EREKOKARDIO*RAI & DOPP-ER ""

# RUA)*A) JA)TU)*# RUA)*A) JA)TU)*

# U)*SI :E)TRIKE-# U)*SI :E)TRIKE-# DERAJAT RE*UR*ITASI KATUP# DERAJAT RE*UR*ITASI KATUP

6


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PE)ATA-AKSA)AA) "PE)ATA-AKSA)AA) "

'. ISTIRA(AT'. ISTIRA(AT

6. ERADIKASI KUMA)6. ERADIKASI KUMA)

;. A)TI RADA)*;. A)TI RADA)*


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TER!"

1 #a$isi$at1 #a$isi$at

2. !enisi$in T& '()2. !enisi$in T& '()

nak anak) *en+athin ,enii$$ine 6.-9. /nak anak) *en+athin ,enii$$ine 6.-9. /

0easa) *en+athin ,enii$$ine 12 juta /0easa) *en+athin ,enii$$ine 12 juta /

taau ) ra$ !enii$$ine 4 & 25 mg hari 1 hari(taau ) ra$ !enii$$ine 4 & 25 mg hari 1 hari(

atau kmbinasi " daan ra$ 1 hari(atau kmbinasi " daan ra$ 1 hari(

*i$a a$ergi ,enii$ine*i$a a$ergi ,enii$ine eritrmisin 4 & 25 mg 1 hari(eritrmisin 4 & 25 mg 1 hari(

3. rtiksterid3. rtiksterid

4. *ed rest4. *ed rest

5. TT!5. TT!

6. !enenang untuk hrea6. !enenang untuk hrea


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!R8"#"# TER'0!

E*/':

1.1. ;auhi ,enderita /R";auhi ,enderita /R"

2.2. !enisi$in!enisi$in

!ada nn R'0) min 3-5 tahun!ada nn R'0) min 3-5 tahun

!ada R'0 resik tinggi) se$ama mungkin!ada R'0 resik tinggi) se$ama mungkin

3. #u$


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:T"*"T" !0 0E R'E/

/T

!enisi$in diberikan se$ama ,erja$anan!enisi$in diberikan se$ama ,erja$anan ,enyakit untuk eradikasi stre,tkkus. ,enyakit untuk eradikasi stre,tkkus.

"njeksi *en+athin !enisi$in = 12 juta unit"njeksi *en+athin !enisi$in = 12 juta unit

seka$i. !i$ihan bat ,er ra$ ada$ah ,enisi$inseka$i. !i$ihan bat ,er ra$ ada$ah ,enisi$in= 2.-25. unit 4 ka$i shari= 2.-25. unit 4 ka$i shari

*agi ,enderita yang a$ergi terhada,*agi ,enderita yang a$ergi terhada,

,enisi$in da,at diberi eritrmisin 25 mg 4 ,enisi$in da,at diberi eritrmisin 25 mg 4ka$i seharika$i sehari

ama ,engbatan 1 hari.ama ,engbatan 1 hari.


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Report of a WHO Expert Consultation Geneva 10 October – 1 November 2001

World Healt Or!ani"ation# Geneva 200$


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Pre2ensi Primer




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Pro3laksis 4ekunder




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Durasi Pro3laksis




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!eny. ;antung Thyrid


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ACTION OF THYROID HORMONE

T ati>e hrmnes are sereted by theT ati>e hrmnes are sereted by the

thyrid) thyr&ine T4( and triidthyrninethyrid) thyr&ine T4( and triidthyrnine

T3(.T3(. st studies su,,rt the hy,thesis that T3st studies su,,rt the hy,thesis that T3

is the


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Thyrid hrmne?s e


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Thyroid E/ran"c#ear Acion$

T3 inreases bth g$use and @a u,take byT3 inreases bth g$use and @a u,take by

the heart.the heart.

E&tranu$ear e


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RE0ATION1HI' 2ET3EEN THE THYROID AND

THE 1YM'ATHETIC NER4O51 1Y1TEM The effec$ of TH on he hear are indirec and $econdary oThe effec$ of TH on he hear are indirec and $econdary o

chan!e$ in aciviy of he $ym%aheic nervo"$ $y$em&chan!e$ in aciviy of he $ym%aheic nervo"$ $y$em&

The cardiova$c"#ar effec$ of hy%erhyroidi$m i&e&The cardiova$c"#ar effec$ of hy%erhyroidi$m i&e&achycardia $y$o#ic hy%eren$ion increa$ed cardiac o"%"achycardia $y$o#ic hy%eren$ion increa$ed cardiac o"%"

and myocardia# conraci#iy can ,e a,o#i$hed or red"ced ,yand myocardia# conraci#iy can ,e a,o#i$hed or red"ced ,y

,#oc6in! he aciviy of he $ym%aheic nervo"$ $y$em&,#oc6in! he aciviy of he $ym%aheic nervo"$ $y$em&

TH i$ increa$in! he aciviy of he $ym%ahoadrena# $y$emTH i$ increa$in! he aciviy of he $ym%ahoadrena# $y$emor ,y enhancin! he re$%on$e of cardiac i$$"e o norma#or ,y enhancin! he re$%on$e of cardiac i$$"e o norma#$ym%aheic $im"#aion&$ym%aheic $im"#aion&


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THE 1YM'ATHETIC NER4O51 1Y1TEM TH7$ effec in hree area$ ha$ ,een e/%#ored adrener!icTH7$ effec in hree area$ ha$ ,een e/%#ored adrener!ic

o"%" adrener!ic rece%or$ and adrener!ic ran$d"ciono"%" adrener!ic rece%or$ and adrener!ic ran$d"cionmechani$m$&mechani$m$&

Admini$raion of TH ca"$e$ an increa$e in ,oh he n"m,erAdmini$raion of TH ca"$e$ an increa$e in ,oh he n"m,erof rece%or$ and heir affiniy for heir #i!and 8hi#eof rece%or$ and heir affiniy for heir #i!and 8hi#ehy%ohyroidi$m ind"ce$ he o%%o$ie effec&hy%ohyroidi$m ind"ce$ he o%%o$ie effec&

TH a#$o increa$e$ mRNA #eve#$ for he ,ea-adrener!icTH a#$o increa$e$ mRNA #eve#$ for he ,ea-adrener!icrece%or&rece%or&


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THE 1YM'ATHETIC NER4O51 1Y1TEM Chan!e$ in rece%or n"m,er and affiniy hen #ead oChan!e$ in rece%or n"m,er and affiniy hen #ead o

chan!e$ in $en$iiviy of he myocardi"m o ,eachan!e$ in $en$iiviy of he myocardi"m o ,eaadrenoce%or a!oni$$& For e/am%#e $im"#aion ofadrenoce%or a!oni$$& For e/am%#e $im"#aion of

adeny#ae cyc#a$e aciviy ,y i$o%roereno# i$ increa$ed inadeny#ae cyc#a$e aciviy ,y i$o%roereno# i$ increa$ed inhy%erhyroidi$m and red"ced in hy%ohyroidi$m&hy%erhyroidi$m and red"ced in hy%ohyroidi$m&

Chan!e$ are a#$o $een in he force of conracion&Chan!e$ are a#$o $een in he force of conracion&

The$e effec$ 8ere a#$o o,$erved in vivo in do!$ inThe$e effec$ 8ere a#$o o,$erved in vivo in do!$ in 8hich %ro%rano#o#-ind"ced red"cion$ in hear rae and 8hich %ro%rano#o#-ind"ced red"cion$ in hear rae andmyocardia# conraci#iy 8ere !reaer in hy%erhyroid hanmyocardia# conraci#iy 8ere !reaer in hy%erhyroid hane"hyroid anima#$&e"hyroid anima#$&


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Effec of Thyroid Hormone on he Hear

T9 enhance$ he rae of conracion of cardiacT9 enhance$ he rae of conracion of cardiac

m"$c#e even in he %re$ence of adrener!icm"$c#e even in he %re$ence of adrener!ic

,#oc6ade&,#oc6ade& The ma:or acion$ of T9 on he #ef venric#e areThe ma:or acion$ of T9 on he #ef venric#e are

() a direc (+) inoro%ic effec and (*) an() a direc (+) inoro%ic effec and (*) an

increa$e in he $i;e of he venric"#ar caviyincrea$e in he $i;e of he venric"#ar caviy 8iho" a chan!e in end-dia$o#ic %re$$"re or 8iho" a chan!e in end-dia$o#ic %re$$"re or

#en!h of he $arcomere in dia$o#een!h of he $arcomere in dia$o#e&


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Effec of Thyroid Hormone on he Hear

The diret e


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E


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E


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(ypert>yroidi?

Hy%erhyroidi$m i$ a re#aive#y common di$ea$e ha occ"r$ more ofen inHy%erhyroidi$m i$ a re#aive#y common di$ea$e ha occ"r$ more ofen in 8omen han men 8ih a %ea6 incidence in he hird and fo"rh decade$& 8omen han men 8ih a %ea6 incidence in he hird and fo"rh decade$& 1i!n$ and $ym%om$ fai!"e hy%eraciviy in$omnia hea ino#erance1i!n$ and $ym%om$ fai!"e hy%eraciviy in$omnia hea ino#erance

%a#%iaion$ dy$%nea increa$ed a%%eie 8ih 8ei!h #o$$ noc"ria%a#%iaion$ dy$%nea increa$ed a%%eie 8ih 8ei!h #o$$ noc"riadiarrhea o#i!omenorrhea m"$c#e 8ea6ne$$ remor emoiona# #a,i#iydiarrhea o#i!omenorrhea m"$c#e 8ea6ne$$ remor emoiona# #a,i#iy

increa$ed hear rae $y$o#ic hy%eren$ion hy%erhermia 8arm moi$ $6in&increa$ed hear rae $y$o#ic hy%eren$ion hy%erhermia 8arm moi$ $6in& Hy%erhyroidi$m i$ he c#inica# $ae re$"#in! from e/ce$$ %rod"cion of T9Hy%erhyroidi$m i$ he c#inica# $ae re$"#in! from e/ce$$ %rod"cion of T9

T= or ,oh&T= or ,oh&

The mo$ common ca"$e i$ a diff"$e o/ic !oierThe mo$ common ca"$e i$ a diff"$e o/ic !oier

The $econd mo$ common form of hy%erhyroidi$m i$ nod"#ar o/ic !oierThe $econd mo$ common form of hy%erhyroidi$m i$ nod"#ar o/ic !oier 1er"m T9 #eve#$ are increa$ed and $er"m T1H i$ $"%%re$$ed&1er"m T9 #eve#$ are increa$ed and $er"m T1H i$ $"%%re$$ed&


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CARDIO4A1C50AR MANIFE1TATION1

Cardiova$c"#ar $i!n$ and $ym%om$ are hereforeCardiova$c"#ar $i!n$ and $ym%om$ are hereforeim%oran c#inica# fea"re$ of hy%erhyroidi$m&im%oran c#inica# fea"re$ of hy%erhyroidi$m&

'a#%iaion$ dy$%nea achycardia and $y$o#ic'a#%iaion$ dy$%nea achycardia and $y$o#ichy%eren$ion are common findin!$&hy%eren$ion are common findin!$&

Dia$o#ic hy%eren$ion can a#$o occ"r& Ty%ica##y noedDia$o#ic hy%eren$ion can a#$o occ"r& Ty%ica##y noedare a hy%eracive %recordi"m 8ih a #o"d fir$ hearare a hy%eracive %recordi"m 8ih a #o"d fir$ hear$o"nd a hird hear $o"nd> occa$iona##y a $y$o#ic$o"nd a hird hear $o"nd> occa$iona##y a $y$o#ic

e:ecion c#ic6 i$ heard&e:ecion c#ic6 i$ heard&


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Coronary ,#ood f#o8 are increa$ed $y$o#icCoronary ,#ood f#o8 are increa$ed $y$o#ic

e:ecion and %ree:ecion %eriod are a,,reviaede:ecion and %ree:ecion %eriod are a,,reviaed

%"#$e %re$$"re i$ 8idened $y$emic va$c"#ar%"#$e %re$$"re i$ 8idened $y$emic va$c"#arre$i$ance i$ red"ced&re$i$ance i$ red"ced&


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The chan!e$ in cardiac f"ncion are $econdary o heThe chan!e$ in cardiac f"ncion are $econdary o heincrea$ed mea,o#ic demand$ of %eri%hera# i$$"e&increa$ed mea,o#ic demand$ of %eri%hera# i$$"e&

TH e/er$ a direc cardiac $im"#an acion inde%enden ofTH e/er$ a direc cardiac $im"#an acion inde%enden ofi$ effec on !enera# i$$"e mea,o#i$m&i$ effec on !enera# i$$"e mea,o#i$m&

Norma#i;aion of he myocardia# conraci#e may no occ"rNorma#i;aion of he myocardia# conraci#e may no occ"r"ni# $evera# monh$ afer norma#i;aion of hyroid f"ncion&"ni# $evera# monh$ afer norma#i;aion of hyroid f"ncion&

The overa## %aho#o!ica# con$e?"ence$ a$$ociaed 8ihThe overa## %aho#o!ica# con$e?"ence$ a$$ociaed 8ihhyroo/ico$i$ re$"# from an ineracion ,e8een he effechyroo/ico$i$ re$"# from an ineracion ,e8een he effecof TH on he hear and i$ effec on he %eri%hera#of TH on he hear and i$ effec on he %eri%hera#circ"#aion&circ"#aion&


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@ardi>asu$ar e


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C-@R and EC. chan!e$ are common ," non$%ecific inC-@R and EC. chan!e$ are common ," non$%ecific inhy%erhyroidi$m&hy%erhyroidi$m&

On che$ /-ray he #ef venric#e aora and %"#monaryOn che$ /-ray he #ef venric#e aora and %"#monary

arery are %rominen and !enera#i;ed cardiac en#ar!emenarery are %rominen and !enera#i;ed cardiac en#ar!emencan ,e noed&can ,e noed&

In '/ $in"$ rhyhm he ma!ni"de of he achycardia inIn '/ $in"$ rhyhm he ma!ni"de of he achycardia in!enera# %ara##e#$ he $everiy of he di$ea$e&!enera# %ara##e#$ he $everiy of he di$ea$e&

1in"$ achycardia i$ %re$en in 9 B of %aien$ 8ih1in"$ achycardia i$ %re$en in 9 B of %aien$ 8ihhy%erhyroidi$m and occ"r$ mo$ fre?"en#y&hy%erhyroidi$m and occ"r$ mo$ fre?"en#y& Ten o %ercen of %aien$ 8ih hy%erhyroidi$m haveTen o %ercen of %aien$ 8ih hy%erhyroidi$m have

%er$i$en AF&%er$i$en AF&


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Inraaria# cond"cion di$"r,ance$ manife$edInraaria# cond"cion di$"r,ance$ manife$ed

,y %ro#on!aion or nochin! of he ' 8ave and,y %ro#on!aion or nochin! of he ' 8ave and

%ro#on!aion of he 'R inerva# in %aien$ 8ih%ro#on!aion of he 'R inerva# in %aien$ 8ihhy%erhyroidi$m&hy%erhyroidi$m&

1econd - or hird-de!ree hear ,#oc6 may re$"#&1econd - or hird-de!ree hear ,#oc6 may re$"#&

The ca"$e of he A4 cond"cion di$"r,ance i$The ca"$e of he A4 cond"cion di$"r,ance i$no c#ear&no c#ear&


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Inravenric"#ar cond"cion di$"r,ance$ common#yInravenric"#ar cond"cion di$"r,ance$ common#yR222 occ"r in B of %aien$ 8ih hy%erhyroidi$mR222 occ"r in B of %aien$ 8ih hy%erhyroidi$m 8iho" a$$ociaed hear di$ea$e of oher eio#o!y& 8iho" a$$ociaed hear di$ea$e of oher eio#o!y&

'aro/y$ma# 14Tand f#"er are rare in hy%erhyroidi$m&'aro/y$ma# 14Tand f#"er are rare in hy%erhyroidi$m&

Occ"# hyroo/ico$i$ may "nder#ie eiher chronic orOcc"# hyroo/ico$i$ may "nder#ie eiher chronic or%aro/y$ma# i$o#aed AF%aro/y$ma# i$o#aed AF


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An!ina and CHF occ"r in %aien$ 8ih hy%erhyroidi$m&An!ina and CHF occ"r in %aien$ 8ih hy%erhyroidi$m&

Five #ine$ of evidence have $"!!e$edFive #ine$ of evidence have $"!!e$ed

() CHF ha$ ,een %rod"ced in anima#$ ,y admini$erin! T9&() CHF ha$ ,een %rod"ced in anima#$ ,y admini$erin! T9&

(*) CHF in chi#dren 8ih hyroo/ico$i$ and no "nder#yin! cardiac(*) CHF in chi#dren 8ih hyroo/ico$i$ and no "nder#yin! cardiacdi$ea$e&di$ea$e&

(=) An!ina re%ored in a hy%erhyroid '/ 8ih norma# coronary arerie$(=) An!ina re%ored in a hy%erhyroid '/ 8ih norma# coronary arerie$%re$"ma,#y $econdary o hyroid-ind"ced coronary arery $%a$m&%re$"ma,#y $econdary o hyroid-ind"ced coronary arery $%a$m&

(9) The a,norma# #ef venric"#ar f"ncion o,$erved in hy%erhyroid '/(9) The a,norma# #ef venric"#ar f"ncion o,$erved in hy%erhyroid '/

i$ no rever$ed ,y ,ea ,#oc6ade ," i$ rever$ed ,y reain! hei$ no rever$ed ,y ,ea ,#oc6ade ," i$ rever$ed ,y reain! hehy%erhyroidi$m&hy%erhyroidi$m&

() The cardiomyo%ahy in %aien$ 8ih hyroo/ico$i$ may ,e() The cardiomyo%ahy in %aien$ 8ih hyroo/ico$i$ may ,eirrever$i,#e&irrever$i,#e&


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DIA.NO1I1 OF HY'ERTHYROIDI1M

Hy%erhyroidi$m in mo$ %aien$ i$ c#inica##yHy%erhyroidi$m in mo$ %aien$ i$ c#inica##y

manife$ed a$ de$cri,ed a,ove&manife$ed a$ de$cri,ed a,ove&

The dia!no$i$ i$ confirmed 8ih a #o8 T1H #eve#The dia!no$i$ i$ confirmed 8ih a #o8 T1H #eve# 8hich ref#ec$ an e#evaed #eve# of TH in he ,#ood& 8hich ref#ec$ an e#evaed #eve# of TH in he ,#ood&

In e#der#y %aien$ 8ih a%aheic hy%erhyroidi$mIn e#der#y %aien$ 8ih a%aheic hy%erhyroidi$m

cardiova$c"#ar manife$aion$ %redominaecardiova$c"#ar manife$aion$ %redominae$%ecifica##y AF and


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TREATMENT OF CARDIO4A1C50AR

MANIFE1TATION1 OFHY'ERTHYROIDI1M 2ea ,#oc6er$ can ,e admini$ered 8ih ca"ion in2ea ,#oc6er$ can ,e admini$ered 8ih ca"ion in%aien$ 8ih CHF&%aien$ 8ih CHF&

The hear fai#"re 8ih achycardia ,ea ,#oc6ade may ,eThe hear fai#"re 8ih achycardia ,ea ,#oc6ade may ,e,eneficia#& 2ea-,#oc6in! dr"!$ a#$o $#o8 he venric"#ar,eneficia#& 2ea-,#oc6in! dr"!$ a#$o $#o8 he venric"#arrae in AF&rae in AF&

The a!en$ for correcin! he f"ndamena# defec areThe a!en$ for correcin! he f"ndamena# defec arehionamide$&hionamide$&

Iodine inhi,i$ he re#ea$e of TH from he hyroo/ic !#and&Iodine inhi,i$ he re#ea$e of TH from he hyroo/ic !#and&I i$ herefore "$ef"# for ra%id ame#ioraion of heI i$ herefore "$ef"# for ra%id ame#ioraion of hehy%erhyroid $ae in %aien$ 8ih hyroid hear di$ea$e&hy%erhyroid $ae in %aien$ 8ih hyroid hear di$ea$e&


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Penyakit Jantung Tiroid,Penyakit Jantung Rematik, Dan Penyakit Jantung Anemi (PD)