DECREASED CORRECTED T-WAVE DURATION IS A BETTER PREDICTOR OF

HYPERKALEMIA IN END-STAGE RENAL DISEASE PATIENTS

ON REGULAR HEMODIALYSIS

N.R.C. Sari1, P.A.R. Raharja1, K.A. Yudistira2, I.N. Sutarka3

1
Internship Doctor, Bhayangkara Hospital, Denpasar, Indonesia; 2 Internship Doctor, Puri
Raharja Hospital, Denpasar, Indonesia; 3 Division of Nephrology, Department of Internal
Medicine, Tabanan General Hospital, Tabanan, Indonesia.

ABSTRACT

Background
There are variable conclusions regarding the reliability of electrocardiogram (ECG) as a rapid
method to detect hyperkalemia in end-stage renal disease (ESRD) patients. This study aimed to
determine whether any ECG parameter is reliable to predict hyperkalemia in ESRD patients on
regular hemodialysis.
Methods
One hundred and thirty-nine patients on regular hemodialysis were enrolled in this cross-
sectional study. Routine laboratory results including serum potassium and a standard 12-lead
resting ECG were obtained before hemodialysis session.
Results
The mean age was 51.7 ± 12.2 years and 59% were males. Mean pre-dialysis serum potassium
concentration was 4.5 ± 0.9 mEq/L (range 2.6–7.5). There was no significant mean difference
of the ECG parameters between quartiles of the serum potassium concentration (p>0.05).
Prevalence of hyperkalemia (K>5.5 mEq/L) was 13.7%. Patients with hyperkalemia had a
significantly shorter T-wave duration (Tdur; p=0.02) and corrected T-wave duration (Tdc;
p=0.02). Patients with hyperkalemia had a significantly higher risk of having Tdur ≤170 ms
(OR=3.101; p=0.03) and Tdc ≤170 ms (OR=3.495; p=0.02). Multiple logistic regression
showed that hyperkalemia had a significant relationship with Tdur and Tdc ≤170 ms
(OR=3.101, p=0.035 and OR=3.49, p=0.034) after adjustment for other factors. Bivariate
correlation analysis found a significant inverse correlation between both Tdur and Tdc with
serum potassium concentration (r=-0.168, p=0.048 and r=-0.203, p=0.017). Multiple linear
regression showed that inverse correlation between Tdc and serum potassium concentration
was still significant after adjustment for other factors (p=0.035).
Conclusions
ESRD patients on regular hemodialysis with serum potassium >5.5 mEq/L do not exhibit
typical ECG manifestations of hyperkalemia. Both decreased Td and Tdc can be used to predict
hyperkalemia in ESRD patients on regular hemodialysis, but decreased Tdc has a stronger
association and inverse correlation with hyperkalemia.

Keywords: corrected T-wave duration, ECG, ESRD, hemodialysis, hyperkalemia.

Stable Atrial Fibrilation : Distribution, Risk Factor, and Management Therapy in Koja
General Hospital
A. A. Hartono1, G. C. Massie2, N. Y. Nasser3, R. S. D. Gill4
1 2
Koja General Hospital, Jakarta, Indonesia; Kembangan District Hospital, Jakarta,
Indonesia; 3Faculty of Medicine, University of Airlangga, Surabaya, Indonesia; 4Subang
General Hospital, West Java, Indonesia

Background
Atrial fibrillation (AF) is an irregular heartbeat (arrhythmia) that can lead to many other heart-
related complications..The treatment goals of AF start with a proper diagnosis through an in-
depth examination from a physician based on the patient’s history, physical examination, ECG,
and also risk factors. Rhythm control, rate control, prevention of thromboembolism, are
recommended for therapy in AF based on its pathophysiology mechanisms. In what follows,
we conclude some of these risk factors and the underlying mechanisms by which these
conditions may contribute to the development of AF. These underlying factors also may alter
the prognosis. Adequate treatment of reduction of these risk factors possibly may reduce the
prevalence of AF and improve prognosis.
Methods
A cross-sectional study was done from January – May 2016 to 26 patients with stable atrial
fibrillation at Koja General Hospital, Jakarta.
Results
There were 26 patients included in the study, with mean age 59.79 ± 13.22 and male: female
ratio 1: 1.17. CHF (80.8%) shows the biggest proportion as risk factor followed by hypertension
(76.9%) , coronary arterial disease (42.3%), valvular disease (7.7%). Most of patients (38.5%)
are given digoxin followed by beta blockers (34.5%), ca-channel blockers (17.5%) and
amiodarone (7.7%) as a first line therapy . 34.6% of patients gets simvastatin and 30.8% gets
anticoagulant as additional therapy.
Conclusion
Most patients are man and mostly aged above 50 years old. Many patients have CHF followed
by hypertension and coronary arterial disease as the risk factor. Digoxin is the most used
medicine followed by beta blockers. Some patients get simvastatin and anticoagulant as
preventive therapy.
Keyword
Atrial fibrillation, Koja General Hospital, Cardiac arrhythmia
 HYPERTENSION RISK FACTORS IN THE POPULATION AT
BANJAR BENAWAH KANGIN, PETAK VILLAGE, GIANYAR REGENCY 2015
(By: dr. Ayu Putu Harina Ferdiyanthi, S.Ked., 2016)

Abstract

Hypertension is one of the cardiovascular diseases which has a high national incidence, even
every region in Indonesia has a relatively high prevalence of hypertension, for example is in
the population at Banjar Benawah Kangin, Petak Village, Gianyar Regency. The aim of this
research is to determine the risk factors of hypertension and the correlation with the incidence
of hypertension in target community. The design of this research is a descriptive correlative
with Cross Sectional study, utilizing primary data through observation and instantaneous
measurement. Samples taken via consecutive sampling technique, with prior informed consent.
Data are presented by single frequencies and cross tabulations, and then analyzed by Chi Square
and T Independent. From 75 research subjects: 58.7% hypertension; 82.7% female; 25.3% body
mass index >25.0; 60% central obesity; 8% blood sugar levels >200 mg/dL, with an average
age of 57.75 years, and mean basal metabolic rate 1152.64. The result showed a significant
correlation between the incidence of hypertension with risk factors of age (p=0,001), body mass
index (p=0,009), abdominal circumference (p=0,028), and blood sugar levels (p=0,032).
However, there are no significant correlation between the incidence of hypertension with risk
factors of gender (p=0,104) and basal metabolic rate (p=1,000). The conclusion is the incidence
of hypertension rised by increasing age, as well as the high value of the body mass index,
abdominal circumference, and blood sugar levels.

Key Words : Risk Factors, Hypertension, Population of Banjar Benawah Kangin

Clinical Efficacy of Sublingual Captopril in The Treatment of Hypertensive Urgency in
Primary Care
A Case Report
Dedy Kristofer Simangunsong
General Practitioner, Puskesmas Mananga, Central Sumba, East Nusa Tenggara, Indonesia.

Background
Patients with poorly controlled hypertension may present to the emergency room with
“hypertensive crisis”. Hypertensive crisis is classified in emergency and urgency. In an
hypertensive urgency blood pressure should be decreased within 24-48 hours.
Case Illustration
A man, 56 years old, came to the primary care with chief complaint worsening headache for 3
days. There was no associated with dyspnea, chest or back pain, nausea and vomit, or visual
disturbances. This was the first such episode. He was diagnosed with essential hypertension 2
years ago but poorly controlled. There were no co-morbidities.
On arrival, he was conscious and well oriented. His blood pressure was 200/120 mmHg, pulse
was 105 bpm, respiratory rate was 20/min, and afebrile. On physical examination, there was no
neurological sign. There were no abnormalities on heart, lungs, and abdominal.
The patient was admitted to the ward and started on 25 mg sublingual captopril. After 3 hours,
an ideal decrease (20.45% of Mean Arterial Pressure) was detected. Blood pressure decreased
to 170/90 mmHg over the first 3 hours. No serious side effect was recorded during the
administration of 25 mg sublingual captopril. The blood pressure was still measured during a
follow-up period of first 48 hours.
Discussion
Hypertensive urgency can be managed with an oral or sublingual drugs medical regimen 1 and
gradual BP control over 12 to 24 to 48 hours.2 Mean arterial pressure (MAP) should be reduced
by no more than 25% within the first 24 hours.3
Antihypertensive agents used to treat hypertensive urgency are captopril, nicardipine, labetalol,
clonidine.3 Captopril has also been suggested as a first-line agent in the treatment of
hypertensive urgency, but it needs to be used with caution.2 Significant adverse effects include
cough, hypotension, hyperkalemia, angioedema, renal failure, and teratogenic.3
Oral and sublingual usage of captopril is quite common in emergency services.4 The
antihypertensive effects of sublingual captopril occur at five minutes and persist for about 240
minutes.5
In the study of 101 patients with hypertensive urgency, sublingual captopril (25 mg) was
administered. After 120 minutes, 30% of the patients’ MAP showed only a 5% drop, while the
remaining 70% registered a proper MAP decline ranging from 5% to 25%.6
But, in the study of 71 patients with hypertensive urgency, in the first hour there was no
significant difference between sublingual and oral captopril to reduce the blood pressure. But
if the patient cannot tolerate the oral way, sublingual captopril is still effective despite its bad
taste.4
In this case, there was significant gradual reduce of BP over 3 hours with no serious side effect.
Conclusions
Prompt recognition and early treatment is crucial in hypertensive urgency. The administration
of sublingual captopril can be considered in the management of hypertensive urgency.
Key Words: hypertension, hypertensive urgency, sublingual captopril.
Comparison Of Intravascular Ultrasound (IVUS)-Guided Versus Angiography-Guided
Drug Eluting Stents (DES) Implantation For Coronary Artery Lesions : A Meta-
Analysis In East Asian Population

F Alzahra’1, I Maghfirah2, R Maulana3, AD Putrinarita2, F Nugraha4

1
Faculty of Medicine Gadjah Mada University, 2Faculty of Medicine Airlangga University,
3
Faculty of Medicine Muhammadiyah Jakarta University, 4Faculty of Medicine Taruma
Negara University

BACKGROUND
The preceding meta-analysis concluded that in world populations, patients who underwent
intravascular ultrasound (IVUS) in guiding PCI with drug eluting stents (DES) implantation
would have better outcomes compared to those with angiography-guided PCI. Still, the efficacy
of IVUS-guided DES implantation compared to angiography-guided in East Asian population
remains undetermined.
OBJECTIVES
Inasmuch as numerous differences in patient characteristics and demographics between East
Asian and the other world population, the comparison of outcomes between IVUS-guided and
angiography-guided DES implantation were analyzed.
METHODS
We systematically searched Pubmed, Science Direct, Clinical Key, EBSCO, ProQuest,
Cochrane, and Google Scholar database up to November 2015 for RCT and observational
studies to evaluate clinical outcomes of IVUS-guided PCI with DES implantation compared to
angiography-guided PCI. The primary outcome measures were the major adverse cardiac
events (MACE; a composite of death, myocardial infarction, target lesion revascularization and
target vessel revascularization) and definite or probable stent thrombosis. Comparison of all
outcomes was performed by RevMan 5.3 (random-effects model) and expressed by odds ratio
(ORs) with 95% Confidence Interval (CIs).
RESULTS
A total of 4 randomized and 12 observational studies met the criteria for this meta-analysis.
These studies included 10,137 IVUS-guided and 14,210 angiography-guided patients. The
comparison of IVUS-guided versus angiography-guided stated that odds ratios for major
adverse cardiovascular events was 0.75 (95% confidence interval [CI]: 0.57 to 0.98; p = 0.04;
I2 = 66%). Other than that, IVUS-guided associated with markedly diminished rates of all-cause
mortality (OR: 0.63; CI: 0.46 to 0.86; p = 0.004; I2 = 16%), cardiovascular death (OR: 0.46; CI:
0.28 to 0.74; p = 0.001; I2 = 0%), myocardial infarction (OR: 0.59; CI: 0.36 to 0.96; p = 0.03;
I2 = 49%) and definite or probable stent thrombosis (OR: 0.46; CI: 0.23 to 0.91; p = 0.03; I2 =
0%). Meanwhile, this study did not show superiority of IVUS-guided compared with
angiography-guided in reducing the risk of TLR and TVR.
CONCLUSION
Our meta-analysis demonstrated that IVUS-guided DES implantation associated with
significantly lower risks of adverse clinical events compared with angiography guidance in East
Asian patients.

Keywords : intravascular ultrasound, angiography, coronary artery lesion, percutaneous

coronary intervention, drug eluting stent, East Asian
 The cAMP Responsive Element Binding Protein H Regulates Genes Involved in Lipid
Metabolism: Implication for Atherosclerosis Plaque Formation
G. A. R. Pertiwi1, H. Shimano2
1
Faculty of Meidicine, Udayana University, Bali, Indonesia, 2Department of Endocrinology
and Metabolism, University of Tsukuba, Ibaraki, Japan

Background: Hyperlipidemia state tightly correlates with atherosclerosis formation. The

cAMP-responsive-element-binding protein H (CREBH) is a bZip transcription factor expressed
primarily in the liver, which is activated by atherogenic diet, ER or inflammatory stress. Upon
activation, CREBH regulates lipogenesis, lipolysis, fatty acid oxidation, and overall maintain
lipid metabolism homeostasis. Our preliminary study found that mice with down regulation of
CREBH expression exhibited more extensive atherosclerosis lesion area compared to mice with
normal CREBH expression. This study would investigate the role of CREBH in atherosclerosis
through regulation of some genes involved in lipid metabolism.
Method: The CREBH-deficient mice were crossed with low density lipoprotein receptor
(LDLR)-deficient mice to produce LDLR-/-CREBH-/- mice. After 10 weeks old, all mice
(LDLR-/-CREBH-/- and LDLR-/-) were feed with standard high fat diet for 5 weeks. Mice then
were euthanized and liver tissues were harvested. RNA extraction and quantitative real time
PCR assay were performed to analyze relative expression of genes involved in lipid metabolism
such as SREBP1c, Elovl6, SREBP2, HMGCR, DGAT1, DGAT2, ApoB, and also FGF21.
Results: Double knockdown mice successfully expressed no CREBH genes (p=0.001).
Absence of hepatic CREBH in LDLR-/- CREBH-/- mice caused relatively higher expression of
genes involve in fatty acid synthesis (SREBP1c, SREBP2), cholesterol synthesis (higher
SREBP2, but lower HMGCR), triglyceride synthesis (DGAT1 only), and ApoB, but lower level
of FGF21, compared to LDLR-/- mice only. FGF21 has positive impact on lipid dysregulation.
These results were statistically significant for SREBP1c, DGAT1, and FGF21 genes expression
(p<0.05).
Conclusion: CREBH involves in lipid metabolism especially through regulation of genes
needed for fatty acid and triglyceride synthesis and protective gene such as FGF21. Down-
regulation of CREBH causes hyperlipidemia state and therefore induces atherosclerosis plaque
formation.

Key words: CREBH, hyperlipidemia, atherosclerosis

 Chitosan Protects Against High Fat Diet-Induced Atherosclerosis in Rats through
Reduction of CD36 Expression and Intimal Thickness
G. A. R. Pertiwi1, N. M. Linawati2
1
Faculty of Medicine, Udayana University, Bali, Indonesia; 2Department of Histology Faculty
of Medicine, Udayana University, Bali, Indonesia

Background: CD36 is considered to play pivotal role in atherosclerosis formation, beside lipid
accumulation itself. CD36 which is expressed on membrane surface of macrophage facilitates
macrophage in binding and uptake oxidized LDL (oxLDL) and promotes foam cell formation
and plaque development. Chitosan, cationic polymer obtained by deacetylation of chitin, has
been demonstrated to lower cholesterol level and inhibit plaque progression in animal models
of atherosclerosis. This study aimed to analyze possible effect of chitosan on atherosclerosis
through reduction of CD36 expression and its effects on intimal thickness.
Methods: Adult male Wistar rats were injected by epinephrine 0.006 mg once before
intervention. Rats then were fed with high fat diet while receiving (1) chitosan of various
concentrations (5%, 10%, 25%, or 50%), or no treatment (control group) (n= 5 per group). After
30 days of treatment, rats were sacrificed and abdominal aorta was taken approximately 3 cm
in length. The expression of CD36 receptor was evaluated by immunohistochemistry staining
using rabbit anti-CD36/PAS-4 polyclonal antibody and the neointimal thickness was also
measured using HE staining.
Results: The expression of CD36 on intima was significantly lowered in dose dependent
manner upon chitosan treatment, compared to control group (p<0.000). In parallel with the
reduction of CD36, chitosan caused gradual decline of intimal thickness with the lowest intimal
thickness mean was seen in 50% group (mean: 1.30 ± 8.82 nm). However, those findings were
not statistically significant.
Conclusion: These findings supported therapeutic role of chitosan on atherosclerosis plaque
formation through reduction of CD36 expression and decrease intimal thickening.

Keywords: chitosan, CD36, intimal thickness, atherosclerosis

 INTERACTION BETWEEN CHRONIC NEUROINFLAMMATION AND
PAROXYSMAL SYMPHATETIC HYPERACTIVITY IN HYPERTENSION
Michael Jonatan[1], Ricardo Adrian Nugraha[1], Yogi Agung Prima Wardhana[1], Radityo
Bagus Wicaksono[1], Rina Judiwati[2]
[1]
Faculty of Medicine, Universitas Airlangga – Surabaya
[2]
Department of Biomedics, Faculty of Medicine, Universitas Airlangga – Surabaya

Introduction. There is a strong relationship between autonomic nervous system and immune
systems playing a prominent role in the initiation and maintenance of hypertension and
significantly contributes to cardiovascular mortality. Hypertension is associated with
neuroinflammation and increased sympathetic tone. Studies have shown consistent association
between hypertension, proinflammatory cytokines and the cells of the innate and adaptive
immune systems. Overactivity of the renin-angiotensin system, oxidative stress, and
cyclooxygenases (COX) in the brain are implicated in the pathogenesis of hypertension.
Methods. We appraised several trials from Pubmed and Cochrane database to examine sources
of heterogeneity, including difference in clinical outcomes and exposure measurements. For
studies that used similar sources of data over concurrent periods and similar age range, only the
study with the largest data set was included in the meta-analysis.
Results. Hypertensive stimuli, such as angiotensin II, DOCA-salt, and norepinephrine, cause T
cells and monocytes/macrophages to accumulate in the brain and their vascularization. These
cells release inflammatory cytokines, such as IL-6, interferon-γ, and IL-17, that promote
vascular hypertrophy. In rat models, hypertension exhibited significantly higher levels of TLR4
in the hypothalamus, especially in Paraventricular Nuclei (PVN). TLR4 inhibition within the
PVN attenuated MAP, improved cardiac hypertrophy, reduced TNF-α, IL-1β, iNOS levels, and
NFκB activity in SHR but not in WKY rats. These results were associated with a reduction in
plasma NE and HMGB1 levels and an increase in IL-10 levels in SHR. We also found that
hypertension, induced by either angiotensin II or l-NG-nitro-l-arginine methyl ester, is
accompanied by microglial activation as manifested by microgliosis and proinflammatory
cytokine upregulation.
Discussion. Inflammation of forebrain and hindbrain nuclei controlling the sympathetic
nervous system (SNS) outflow from the brain to the periphery represents an emerging concept
of the pathogenesis of neurogenic hypertension. Angiotensin II (Ang-II) and prorenin were
shown to increase production of reactive oxygen species and pro-inflammatory cytokines
(interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α)) while
simultaneously decreasing production of interleukin-10 (IL-10) in the paraventricular nucleus
of the hypothalamus and the rostral ventral lateral medulla. Peripheral chronic inflammation
and Ang-II activity seem to share a common central mechanism contributing to an increase in
sympathetic neurogenic vasomotor tone and entailing neurogenic hypertension.
Both hypertension and obesity facilitate the penetration of peripheral immune cells in the brain
parenchyma. We suggest that renin-angiotensin-driven hypertension encompasses feedback
and feedforward mechanisms in the development of neurogenic hypertension while low-
intensity, chronic peripheral inflammation of any origin may serve as a model of a feedforward
mechanism in this condition.
Conclusion. Hypertension alone can facilitate the penetration of peripheral immune cells in the
brain parenchym. We suggest that renin-angiotensin-driven hypertension encompasses
feedback and feedforward mechanisms in the development of neurogenic hypertension while
low-intensity, chronic peripheral inflammation of any origin may serve as a model of a
feedforward mechanism in this condition.

Keywords: Angiotensinogen, Hypertension, Neuroinflammation, Hypothalamus

 ELEVATED RED BLOOD CELL DISTRIBUTION WIDTH AS A PREDICTIVE
FACTOR FOR THROMBOEMBOLIC STROKE IN NON-VALVULAR ATRIAL
FIBRILLATION

Radityo Bagus Wicaksono1, Ricardo Adrian Nugraha1, Michael Jonatan1, Timotius

Jonathan2
1Airlangga School of Medicine - Dr. Soetomo General Hospital, Surabaya
2Department of Neurology, Abdoer Rahem General Hospital, Situbondo

Introduction. Red cell distribution width (RDW) has been shown to be helpful in
predicting adverse long-term events in patients with cardiovascular diseases.
However, at present, no study has been conducted on the relationship between RDW
and thromboembolism risk in non-valvular atrial fibrillation (AF).
Objective. We aimed to (1) review the average RDW value in non-valvular atrial
fibrillation and the association with ischemic stroke; (2) assess prognostication by
reviewing the relationship between RDW value on admission with length of hospital
stay in ischemic stroke non-valvular atrial fibrillation subjects.
Methods. In this literature review, we analyzed the current scientific literature about the
putative role and the potential epidemiologic association between RDW and
cerebrovascular accidents. 12 relevant studies were searched and identified in the
MEDLINE and EMBASE databases.
Results. RDW was significantly higher in the stroke group (16.3 ± 2.7 vs 14.1 ± 1.8,
p=0.0002) as compared to healthy group, with pooled risk ratio (RR) 2.20 (95% CI,
1.42-3.39; p=0.0004).. In multivariate regression analysis, 1 % increment in RDW
yielded a 23 % higher risk of stroke (multivariable HR: 1.33, 95 % CI: 1.07-1.60). RDW
was a significant marker for length of hospital stay >7 days (p=0.003, RR: 1.13, CI:
1.04-1.24) and retained its prognostic significance even when corrected for Hb values
(Pooled RR: 1.17, CI: 1.05-1.31, p=0.0001). Heterogeneity was moderately present;
however, sensitivity analyses for follow-up duration, infarct area, RDW as dichotomous
values showed similar results.
Conclusions. Stroke patients had significantly higher average RDW value than healthy
subjects. Higher RDW value also significantly and independently predicts adverse
outcomes in stroke patients with longer length of hospital stay. Our findings suggested
that RDW is directly associated with the risk of stroke regardless of anemia status and
improves the predictive accuracy for stroke in patients with non-valvular atrial
fibrillation.
Keywords: Anisocytosis, Non-Valvular Atrial Fibrillation, Red Blood Cell Distribution
Width, and Thromboembolic Stroke
 Reducing No-Reflow Phenomenon in STEMI Patients Undergoing Primary
Percutaneous Coronary Intervention: Scientific Evidence of GPIIb/IIIa Inhibitor
Ricardo Adrian Nugraha1, Michael Jonatan1, Tan Nicko Octora1, Rina Yudiwati2
1
Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
2
Department of Biomedics, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
Correspondence Email: ricardo.unair@gmail.com

Introduction. Primary percutaneous coronary intervention (PCI) is the best available

reperfusion strategy for acute ST-segment elevation myocardial infarction (STEMI). Despite
optimal coronary artery reperfusion has been done, No-Reflow Phenomenon (NR) and distal
embolization of intracoronary thrombus are still major problems even after successful
interventions. NR during primary PCI may fail to restore optimal myocardial salvage and
reperfusion rate. Strategy may be pharmacologicy based or device based. Among
pharmacologic based, Glycoprotein ΙΙb/ΙΙΙa inhibitors (abciximab or tirofiban) as vasorelaxants
and antiplatelets are indicated by European Society of Cardiology (ESC) guidelines for
prevention of no-reflow (class of recommendation IIa and level of evidence B).
Objective. We carried out a literature search aimed at identifying all randomized clinical trials
of Intracoronary Glycoprotein ΙΙb/ΙΙΙa inhibitors (GPI) administration in the setting of primary
PCI. The outcomes examined were post-procedure rates of TIMI 3 flow, TIMI myocardial
perfusion grade 3, ST segment resolution >= 50%, No-Reflow Phenomenon (NR), distal
embolization, and composite endpoint of death. For each outcome, we fit a Bayesian
hierarchical meta-analytic model.
Methods. Literature search was done from PubMed, Cochrane, EMBASE, Google Scholar,
EBSCO, Springer and Ovid databases without language or time limitation. Randomized
controlled trials were enrolled for analyzing if they investigated the treatment of intracoronary
administration of Glycoprotein ΙΙb/ΙΙΙa inhibitors (GPI) versus standard treatment for NR
during primary PCI.
Results and Findings. Ten studies with 702 patients were included. Significantly, the treatment
of Glycoprotein ΙΙb/ΙΙΙa inhibitors was more effective in improving the thrombolysis in
myocardial infarction (TIMI) flow (OR 0.24, 95% CI 0.15-0.37, P < 0.00001) and reducing
major adverse cardiovascular events (MACE) (OR 0.09, 95% CI 0.05-0.18, P < 0.00001). There
was a trend to increase the risk of bleeding, but the data of the result did not reach the statistical
significance (OR 1.44, 95% CI 0.69-3.00, P = 0.32). In a small randomized study of abciximab
versus tirofiban for patients undergoing Primary PCI, there are similar rates of final TIMI flow
grade 3 (86% vs. 88%).
Discussion. There are four mechanisms play role in NR: Distal atherotrombosis embolization,
ischemic injury, reperfusion injury, and individual susceptibility for microcirculatory injury.
Other phenomenon are known to contribute to complexity of NR, including large lipid rupture,
leukocyte infiltration, vascular damage, vasoconstriction, activation of inflammatory pathways
and cellular edema. Glycoprotein ΙΙb/ΙΙΙa inhibitors (GPI) can block the final pathway of
platelet aggregation and distal atherotrombosis embolization, which results better outcome in
TIMI flow and improving myocardial viability.
Conclusion. Adjunctive intracoronary administration of Glycoprotein ΙΙb/ΙΙΙa inhibitors may
improve recanalization therapy and reduces the incidence of No-Reflow Phenomenon during
Primary PCI. Further studies for clinical endpoints are needed. It suggested that intracoronary
administration of Glycoprotein ΙΙb/ΙΙΙa inhibitors during Primary PCI should be fully
considered the individuation of patients and balanced the efficacy and the potential hazard.
KEYWORDS: GP ΙΙb/ΙΙΙa inhibitors, No-Reflow Phenomenon, Primary PCI, TIMI Flow
 Gestational Hypertension is Associated with Supraventricular Tachyarrhythmias in
Women during Pregnancy

Ricardo Adrian Nugraha1, Radityo Bagus Wicaksono1, Michael Jonatan1, Ilham Aldika
Akbar2, Rina Yudiwati3
1
Faculty of Medicine, Universitas Airlangga, Indonesia
2
Department of Obstetrics, Faculty of Medicine, Universitas Airlangga, Indonesia
3
Department of Biomedics, Faculty of Medicine, Universitas Airlangga, Indonesia
Correspondence Email: ricardo.unair@gmail.com

ABSTRACT

Introduction. Pregnancy may be associated with various types of supraventricular

tachyarrhythmias, even without any pre-existing arrhythmias or identifiable structural heart
disease. The exact etiology of arrhythmias in pregnancy is still unknown but hormonal,
haemodynamic and autonomic alterations are postulated to play a part. Pre-eclampsia and
gestational hypertensive disorder are belived to be associated with elevated maternal risk for
supraventricular tachyarrhythmias.
Methods. Analytic observational studies using case control design from 54 pregnant women
with supraventricular tachyarrhythmias (53.7% atriall fibrillation, 20.4% atrial flutter, 7.4%
focal atrial tachycardia, 3.7% AVRT, 13% AVNRT, 1.8% IART), and 54 healthy pregnant
women. Cardiac arrhythmias were identified from medical records. Mean age and pregnancy
age weren’t statistically significant in both groups (27.63 vs 28.74 years old, p=0.41).
Result. The association of gestational hypertension with supraventricular tachyarrhythmias was
substantially attenuated on adjustment for any identifiable structural heart diseases. Gestational
hypertension were found among 29 women in supraventricular tachyarrhythmias group and 13
women in control group. Analysis revealed that gestational hypertension (OR 3.658; 95% CI,
1.705-6.394) could be the risk factor for pregnant women in getting supraventricular
tachyarrhythmias. History of palpitations (OR 5.95; 95% CI, 2.52-8.81) and consuming over-
the-counter influenza drugs during pregnancy (OR 1.68; 95% CI, 1.04-3.12) also have
significant association with prevalence of supraventricular tachyarrhythmias in pregnant
women.
Conclusion. High blood pressure during pregnancy could be a risk factor of getting
supraventricular tachyarrhythmias. In general, supraventricular tachyarrhythmias during
pregnancy can be safely managed medically. Drugs should be avoided in first trimester, but in
second or third semester, management of supraventricular tachyarrhythmias in pregnant women
is similar to non-pregnant women. Despite most cases of arrhythmias are rarely require therapy,
fetus may suffer haemodynamic disruption, leading to intrauterine fetal death or delay in growth
and development.

Keywords: atrial fibrillation, gestational hypertension, pregnancy, supraventricular

tachyarrhythmias, symphatetic overstimulation
 LARGE ABDOMINAL AORTIC ANEURYSM: A CASE OF
INTRALUMINAL THROMBUS
Prayoga Setiawan, Putu Gede Budiana*
*Cardiology and Vascular Medicine Department, Badung District Hospital

Abstract
Abdominal aortic aneurysm is a complex and challenging disease which has significant clinical
practice variability. A 70-year-old man, came to ER of Badung District Hospital with chief
complaint pulsatile abdominal pain since 2 days before admission. History of hypertension was
admitted. The patient is a heavy smoker (1 pack per day) since he was young. Abdominal USG
on private hospital result showed abdominal aorta dilatation with thrombus. Abdominal CT
Scan revealed abdominal aorta caliber enlargement (6,38 cm) with intraluminal thrombus (3,20
cm). Patient was diagnosed with abdominal aortic aneurysm (AAA). Medical therapy was given
and patient was reffered to vascular surgeon. AAA primarily affects elder men. Smoking is a
strong risk factor for the development of AAAs due to its promoting effects on inflammation,
proteolysis, and smooth muscle cell (SMC) apoptosis. Other risk factors comprise coronary
artery disease, atherosclerosis, and hypertension. Besides that, these factors also have been
associated with an increased risk of AAA rupture across several studies. A systematic review
suggests that statins may reduce aneurysm growth rates by about 50%. Smoking cessation
appears to reduce growth rate by 20%-30%. Management of AAA depends on size of the
aneurysm and growth rate. Rapid aneurysm growth with more than 10 mm per year represents
another indication for early repair. This aneurysm size is 6,38 cm, patient must be referred to
vascular surgeon for assessing aneurysm morphology and fitness for operative repair.

Keywords: AAA, intraluminal thrombus, smoking, hypertension

 ST ELEVATION ACUTE CORONARY SYNDROME (STEACS) IN ISCHEMIC
DILATED CARDIOMYOPATHY PATIENT: A CASE REPORT
Prayoga Setiawan, Putu Gede Budiana*
*Cardiology and Vascular Medicine Department, Badung District Hospital

Abstract
The dilated cardiomyopathy constitutes a severe clinical manifestation of the disease. A 59-
year-old man, came to ER of Badung District Hospital with chest pain (angina typical) since 4
hours before admission. He was diagnosed with ischemic dilated cardiomyopathy at Sanglah
Hospital since 2 years ago. Echocardiography result in Sanglah Hospital showed in accordance
with CAD, LV dilatation, mild MR, moderately decreased LV systolic function, severely
decreased diastolic function, and decreased RV systolic function. He had denied undergoing
invasive coronary angiography. In 6 month, he had stopped the medication without supervision
because he felt any better. The initial ECG revealed ST elevation on lead I, aVL, V1 to V4.
Chest radiography showed cardiomegaly. Cardiac marker of Troponin I was <0,01 and 5,57
respectively, CKMB was 10 and 50 respectively. Patient was diagnosed with STEMI anterior
extensive/Killip I with history of ischemic dilated cardiomyopathy. Standard initial treatment
was given and thrombolytic procedure has been done. Echocardiography result in Badung
District Hospital was severe LV dilatation, LVH eccentric hypertrophy, RWMA, mild AR,
moderate MR, mild TR, severely decreased LV systolic function, moderately decreased LV
diastolic function, and decreased RV systolic function. After few days, ECG showed the result
of STEMI in evolution. There are two possibilities that suggest the cause of STEACS in this
patient, plaque rupture and coronary artery embolism. We suggest patient with ischemic dilated
cardiomyopathy undergoing a coronary angiography to confirm the etiology of cardiomyopathy
and to prevent any complication in the future.

Keywords: STEACS, ischemic dilated cardiomyopathy, coronary angiography, CAD,

coronary artery embolism
TYPE 2 MYOCARDIAL INFARCTION WITH RESPIRATORY FAILURE : A CASE
REPORT
Ida Ayu Tri Wedari, Putu Gede Budiana*
*Cardiology and Vascular Medicine Departement, Badung District Hospital

Abstract
Type 2 myocardial infarction (T2MI) is a commonly encountered clinical challenge. T2MI is
diagnose in instance in which a supply/demand imbalance leads to myocardial injury with
necrosis that is not caused by ACS. A 75 years old man was evaluated in the emergency
department for shortness of breath since one day before admitted to hospital, and get
worsened 1 hour before admitted to hospital. About 1 hour evaluation in emergency
department the symptoms got worsened. Abruptly, he got unconscious, and got intubation.
Electrocardiography shows P Pulmonal and ST depresion in precordial lead. Chest radiograph
shows emphysematous lung. Laboratory show respiratory acidosis (pH 7.23, pCO2 70.3
mmHg) and significant increased of cardiac markers troponin I (5.21 µg/L) and CKMB (79.5
µg/mL). Echocardiography shows that there is mild TR, LVEF 60%. Patient was diagnosed
with T2MI with respiratory failure et causa acute exarcebation of chronic obstructive
pulmonary disease (COPD). The patient was treated with standard initial therapy. 2 Days after
admission to ICCU patient got extubated and in stable condition (BP 110/70, RR 18x/min,
SpO2 96-98%). There are no formal guideline available regarding the management of T2MI.
Despite its incidence and association with worse outcomes, there are no guidelines adressing
the acute or long term management of this entity. This absence of guide is likely to result in
variable clinical decision making when dealing with T2MI, which could lead to wide
variation in cost-effectiveness and resource utilization.
Keywords : T2MI, supply/demand imbalance, respiratory failure, COPD
RENAL SUPPORTIVE THERAPY IN STEMI PATIENT WITH
ACUTE KIDNEY INJURY : A CASE REPORT
Ida Ayu Tri Wedari, Putu Gede Budiana*, Ida Bagus Mahendra**
*Cardiology and Valcular Medicine Departement, Badung District Hospital
**Internal Medicine Departement, Badung Disctrict Hospital

Acute kidney injury (AKI) is an important issue in the management of acute cardiovascular
care. AKI may occur following rapid hemodynamic changes due to acute coronary syndromes.
A 61 years old woman was evaluated in the emergency departement for dizzines and chest
discomfort since 13 hours before admitted to the hospital. Chest discomfort felt substernal and
described undigestion-liked sensation. Chest radiograph shows cardiomegali 60% with
increased lung vascularity. Electrocardiography shows ST elevation with Q wave in Inferior
and RV region. Laboratory show increased in blood glucose, cardiac troponin and CKMB, with
anuria and progressive worsening renal function. Patient was diagnosed with STEMI Inferior
and RV Infarct with Acute Kidney Injury. She refused to reffer for PCI and did not suitable for
trombolytic because of late onset presentation. The patient was treated with standard initial
therapy and got dialysis done twice. This patient shows good respons with stable hemodynamic
and serum creatinine return to baseline on day 10 of admission.The optimal timing of dialysis
for AKI and when to stop is not defined clearly. Clinical practice gudeline consider initiate
renal supportive therapy emergently when life threatening change in fluid, electrolite and acide
base balance, and consider to stop dialysis if there is an improvement in kidney function that
adequate to meet patient demand.
Keywords : STEMI, AKI, dialysis
Case Report

A Woman, 43 years old Presenting with Congestive Heart Failure (CHF) as The
Valvular Involvement of Systemic Lupus Erythematosus (SLE)
I Gst Agung Raka Mahasadu, Agus Aprianta
Kertha Usada Hospital, Singaraja, Indonesia

Abstract
Background
Valvular involvement is the most frequent cardiac manifestation in SLE. It has been shown that
the prevalence of valvular disease in SLE can be up to 60-74% by transesophageal
echocardiography (TEE).
Case Illustration
A 43-year-old woman complained sudden onset of dyspnea on effort, arthritis and pain on the
left chest. SBP was 90/70 mmHg, RR 32x/min; temperature 38,50C and SaO2 90% on room air.
The chest examination and x-ray revealed systolic murmur at the left lower sternal border and
the apex, left pleural effusion and pulmonary edema. ECG showed sinus tachycardia. The
laboratory examination showed leukocytosis, mild hyponatremia, eGFR of 57,26
ml/minute/1,73m2 and proteinuria. Thoracentesis revealed non specific inflammation without
any sign of malignancy cells with no evidence of tuberculosis from PCR. In addition,
Pseudomonas aeruginosa colony was isolated from pleural fluid. Lupus work-up showed that
there was ANA IF positive with a positive anti SS-A native and anti dsDNA antibody. The
patient was initially treated with ARB and diuretic until SLE was diagnosed, when high-dose
steroid was added. A transthoracic echocardiogram was repeated 1 month later showing
moderate mitral regurgitation, moderate level LVH, decrease of diastolic function grade I and
normal left ventricle systolic (EF biplane 69 %).
Discussion
The diagnosis of SLE was based on 4 of the American College of Rheumatology (ACR) criteria:
serositis, arthritis, positive ANA, and positive double-stranded DNA. The patient presented
with symptoms of CHF, which was the sequelae of mitral regurgitation. Valvular regurgitation
has been reported to occur in up to 74% of patients. The mechanism for the development of
valvular damage in SLE related to immune complex deposition and complement activation that
can lead to valvular regurgitation, stenosis or both. However, several studies have suggested
that antiphospholipid antibodies can also contribute to the pathogenesis of the valvular disease.
Treatment of valvular manifestations of SLE depends on the type and severity of involvement.
Some investigators have suggested that the introduction of corticosteroids as treatment of SLE
may have decreased.
Conclusion
Valvular heart disease is the most important cardiac manifestation of systemic lupus
erythematosus (SLE). In our patient, four of the ACR diagnostic criteria for SLE were present.
It serves as a reminder that SLE may be an underlying cause for the development of mitral
valve regurgitation.
Key words: Systemic Lupus Erythematosus, Valvular heart disease
 Correlation between Betel Nut Chewing with Systolic and Diastolic Blood Pressure
Y.E. Budiman1, F.M.S.Ringgo2, M.A. Abia3
1
Faculty of Medicine University of Indonesia, Jakarta, Indonesia; 2Ba’a General Hospital,
Rote, Indonesia; 3Sotimori Health Center, Rote, Indonesia

Background : Over the years, Betel nut (Areca catechu) chewing is widely believed to bring
oral and gastrointestinal benefits. However, recent studies suggest that Betel nut chewing is
associated with hypertension. This paper was designed to further find the correlation between
the Betel nut chewing with systolic and diastolic blood pressure.

Objectives : to find correlation between Betel nut chewing with SBP and DBP

Methods : This was a case control study, 77 subjects were included. We exclude subjects with
other chronic diseases (chronic kidney disease, chronic liver disease, COPD, etc.). The subjects
of each group was then assessed with history of hypertension and its treatment, history of Betel
nut chewing (as well as duration and nuts/day), physical activity level, smoking history, and
systolic/diastolic blood pressure. BP was measured two times, before assessment and after
assessment, in a relaxed environment. Unpaired T-test were performed to compare the mean of
systolic and diastolic BP between (A) group of Betel nut chewers and (B) non-chewer group.

Results : From 42 subjects with history of HT, 14 were non-chewers. From 35 subjects with
no history of HT, only 2 were chewers. The OR for hypertension in chewing group was
significantly low (OR < 0.05). There was a significant difference in both mean systolic (p<
0.005; 95% CI; CI is from 23.9 – 39.1) and diastolic (p< 0.005; 95% CI; CI is from 12.5 – 22.3)
blood pressure between Betel-nut chewers and non-chewers; with mean difference between
chewers and non-chewers for 21.5 mmHg for SBP and 17.4 mmHg for DBP. There was,
however, no significant correlation between both chewing duration (< 10 years, >= 10 years)
and amount consumed with either systolic or diastolic blood pressure.

Conclusion : The activity of Betel nut chewing was significantly associated with hypertension;
no correlation was found between chewing duration and amount with blood pressure.
 Left Ventricular Non-Compaction Cardiomyopathy

Thengker A2, Lim H1,2, Hadi MW2, Lukito AA1,2

1
Cardiovascular Dept, Pelita Harapan University, 2 Siloam Hospital Lippo Village, Tangerang, Indonesia

Background
Left ventricular non-compaction or "spongy myocardium", is a rare congenital cardiomyopathy
that can be diagnosed at any age. It is characterised by a thin, compacted epicardial layer and
an extensive non-compacted endocardial layer, with prominent trabeculation and deep recesses
that communicate with the left ventricular cavity but not with the coronary circulation, probably
due to an arrest of compaction during intrauterine life. Its potential complications which are
heart failure, ventricular arrhythmias, and embolic events. Echocardiography is the standard
diagnostic tool, and cardio-magnetic resonance can confirm or rule out this disease when the
apex is difficult to visualize.

Methods
A 60 yo female with hypertension has been complaining of intermitent shortness of breath,
weakness, dyspnea on effort, orthopnea and chest discomfort since 10 years ago, which driven
her to visit hospital frequently, yet it never been completely relieved and she has been treated
as ischemic heart failure complicated with arrythmias (bigeminy PVCs). Coro-angiogram in
2011 in another hospital revealed 30% stenosis in mid RCA and anomaly coronary origin. On
February 2016, she came to our hospital, physical examination was normal and only
extrasystole in auscultation, the ECG showed intraventricular conduction delay and PVCs and
the echocardiogram showed rounded apical with LVEF of 46%. Laboratory result found NT-
proBNP of 984 mg/L. Coronary CT angiogram revealed LCX ostium anomaly which originated
from right aortic cuspid next to RCA ostium, and the proximal of LCX go through between
aorta and left atrium and also a 30-50% stenosis of LM- proximal LAD. Rounded LV apex
also noted. Then Cardiac MRI was done and showed LV trabeculation non-compacted vs
compacted myocardial thickness ratio of 2.85, which was abnormal, and thinning of basal
anterior and basal anteroseptal wall with LVEF of 34%. Since the LV non-compaction
cardiomyopathy is related to arrhythmic death, the 7-day holter monitor was performed, but
found no AF nor ventricular arrhythmias.

Results
The LV non-compaction cardiomyopathy was finally confirmed as the diagnosis of this patient
after prolonged and extensive investigations.

Conclusion
The prevalence of LV non-compaction cardiomyopathy is rare, and need extended
investigation to confirm the diagnosis. Cardiac MRI may help for further confirmation if
echocardiography alone is not clearly showed non-compacted trabeculae.
WPW LOCATION PREDICTION ALGORITHM WITH ACCESSORY PATHWAYS
ARRUDA AND D’AVILA : A Case Report

I.G.A Made Adnyana Putra1, B. Setia2

1
General Practitioners, Emergency Departement of Mataram General Hospital, Lombok, West
Nusa Tenggara, Indonesia
2
Cardiologyst, Departement of Cardiology and Vascular Medicine of Mataram General
Hospital, Lombok, West Nusa Tenggara, Indonesia

Background :
Wolff-Parkinson-White syndrome (WPW ) is a syndrome of pre-excitation of the ventricles of
the heart due to an accessory pathway (AP). While the vast majority of WPW syndrome remain
symptomatic, there is a risk of sudden death, the incidence of less than 0.6%, due to
tachyarrhythmias. Determination of AP location mostly uses Arruda’s and D’Avila algorithm.
Different methods could produce different results.

Case illustration
A-27-year-old man came to emergency unit with chief complaint palpitation, the hemodynamic
are stable with BP 120/80 mmHg, HR 92 beat per minute, axilla temperature 36.6 0C. ECG
showed VES Bigemini. After therapy with amiodaron ECG showed WPW.

Case Discussion :
Pre-excitation complete the WPW ECG pattern, obtained the following elements: (1) The PR
interval is less than 0.12 seconds, with normal P waves. (2) Abnormal QRS complexes with a
duration of 0.11 seconds or more. (3) There are ramps on the initial deflection of the QRS
complex (delta waves) (4) Secondary changes ST segmen and T wave.

Conclusion :
After trying to compare these two algorithms we obtain different results. In Arruda algorithm
AP locations found on AS (anteroseptal) and D'avila AP location could be found on the RA
(right lateral).

Keywords :
Wolff-Parkinson-White syndrome, Arruda, D’Avila
Case Report : The Role of Modified Jones Criteria in Diagnosing Rheumatoid Heart
Disease in Rural Hospital
R.S.Djamal1, K.Wijaya2, C.A.Effendy3, S.N.O.Diputra4
Subang General Hospital, Jawa Barat, Indonesia1,2, Gatot Soebroto Central Army Hospital,
Jakarta, Indonesial3, Penta Medika Clinic, Bali, Indonesia4
Introduction
Rheumatoid Fever (RF) and Rheumatoid Heart Disease (RHD) remain significant causes of
cardiovascular diseases in the world today. Currently, clinical examination remains the basis of
a diagnosis of RF and carditis, and the role of echo-Doppler should be considered supportive.
Such recommendations are in keeping with the original intent of the Jones Criteria (JC), which
were established as a universal standard for the diagnosis of RF.
Case Description
A 10 years old boy patient admitted for dyspnea which he complain for 1 week. There was
history of chronic Pharyngitis since 2 weeks prior to admission. Patient was alert with
respiratory distress, blood pressure 100/70, good pulse with rate 120 bpm, respiratory rate
30/minute, the temperature was 38.9C. From Physical examination of patient there was rales in
both of lungs base, mitral valve murmur, and lower extremities oedema. From ECG there was
right axis deviation, and Cardiomegaly was foundin the thorax x-ray. From laboratory study,
ASTO and CRP was possitve. The patient was diagnosed with RHD and treated with diuretics,
high dose anti-inflamatory agent, antibiotics such as Eryhtromicyn. However he had significant
improvement and discharged one week later.
Discussion
The presence two of major criteria, or one of major and two minor criteria, indicates a high
probability of RF, if supported by evidence of a prior Group A streptococcal infection. The
presence modified JC in this case were one major and two minor such as carditis, fever and
positive CRP. Therefore these patients can be diagnosed as Rheumatoid Heart Disease.
Conclusion
Delayed of diagnostic could decrease patients survival rate. In hospital with limited facilities,
JC could be useful to diagnose RHD. This case report was made to increase the alertness of
RHD cases upon patients and to ensure the use of Jones Criteria in order to diagnose RHD in
limited facilities settings.
 Total AV Block in Intoxication Methanol : A Case Report
W.Gotama 1, B.Setia 2
1
General Practitioner, Kayangan Public Health, Mataram, Indonesia
2
SMF Cardiology and Vascular Medicine, RSUD Kota ,Mataram, Indonesia
Introduction:
Acute methanol ingestion can prolong the PR interval, but searching Medline, we haven’t found report
of Total atrioventricular block in methanol poisoning. We present a Third-degree atrioventricular (AV)
block in a methanol poisoned patient.

Background:
Methanol is a common commercial compound that can lead to significant morbidity and mortality
with high levels of exposure. The purpose of this case is to reported electrocardiographic (ECG)
changes associated with methanol intoxication.

Case presentation:
A 53-year-old man with a non-contributory medical history ingested 4dL of vodka and was found
comatose. patient was referred consult from neurology department due to dyspnea and abnormal ECG.
On arrival she was somnolent with nausea, temperature 36.0°C, pulse 40 counts/min, blood pressure 60
mmHg palpation , respiratory rate 14 counts/min and SpO2 95% on room air. Her blood methanol level
was 1.51 mg/dL. ECG revealed sinus rhythm, Third-degree atrioventricular block and Old myocard
infarct anteroseptal. He was given dopamine and sulfas atropine. ECG 4 hours after admission revealed
a Old myocard infarct without TAVB.

Discussion:
Methanol intoxication and its possible effects on the cardiac conduction system have been scarcely
reported in the literature. ECG changes associated with methanol intoxication have been attributed to
formic acid, a metabolite of methanol. There are few hypotheses that attempt to explain the ECG
changes observed during methanol intoxication. Methanol and formic acid can decrease the heart rate
and the contractility of the myocardium.

Conclusion:
Acute methanol poisoning has the potential in adults with third-degree atrioventricular block, possibly
by its direct inhibitory action on the conduction system

Keywords:
Methanol intoxication, Total atrioventricular (AV) block.