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UvA-DARE (Digital Academic Repository) Etiology, management, and outcomes of patients with coronary artery disease in a resource-poor Indonesian setting Learning from the local evidence Qanitha, A. Publication date 2019 Document Version Final published version License Other Link to publication Citation for published version (APA): Qanitha, A. (2019). Etiology, management, and outcomes of patients with coronary artery disease in a resource-poor Indonesian setting: Learning from the local evidence. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. 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UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:09 Oct 2021 Etiology, management, and outcomes of patients with coronary artery with coronary of patients and outcomes disease in a resource-poor Indonesian setting management, Etiology, Etiology, management, and outcomes of patients with coronary artery disease in a resource-poor Indonesian setting Learning f�om the local evidence Andriany Qanitha Andriany Andriany Qanitha ETIOLOGY, MANAGEMENT, AND OUTCOMES OF PATIENTS WITH CORONARY ARTERY DISEASE IN A RESOURCE-POOR INDONESIAN SETTING LEARNING FROM THE LOCAL EVIDENCE ANDRIANY QANITHA Etiology, management, and outcomes of patients with coronary artery disease in a resource- poor Indonesian setting: Learning from the local evidence AMC Heart Center, Amsterdam University Medical Center. Thesis. Faculty of Medicine, University of Amsterdam, The Netherlands, with a summary in Dutch. ISBN 978-94-6361-210-4 Author Andriany Qanitha Cover design Iliana Boshoven-Gkini (www.AgileColor.com) Layout Redpastel Graphic, The Hague, The Netherlands (www.redpastel.nl) Printed by Optima, Rotterdam, The Netherlands (www.ogc.nl) Copyright © 2018 by Andriany Qanitha, Amsterdam, The Netherlands. This thesis was accomplished with financial support from Directorate General of Higher Education/ Direktorat Jenderal Pendidikan Tinggi (DIKTI), Ministry of National Education Republic of Indonesia and Faculty of Medicine, University of Hasanuddin. Financial supports by the Dutch Heart Foundation and Academic Medical Center, University of Amsterdam for the publication of this thesis are gratefully acknowledged. ETIOLOGY, MANAGEMENT, AND OUTCOMES OF PATIENTS WITH CORONARY ARTERY DISEASE IN A RESOURCE-POOR INDONESIAN SETTING LEARNING FROM THE LOCAL EVIDENCE ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. ir. K.I.J. Maex ten overstaan van een door het College voor Promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op dinsdag 19 maart 2019, te 14.00 uur door Andriany Qanitha geboren te Ujung Pandang PROMOTIECOMMISIE Promotores : Prof. mr. dr. B.A.J.M. de Mol AMC-UvA Prof. dr. J.P.S. Henriques AMC-UvA Copromotor : Dr. C.S.P.M. Uiterwaal Universiteit Utrecht Overige leden: Prof. dr. A.C. van der Wal AMC-UvA Prof. dr. B.J.M. Mulder AMC-UvA Prof. dr. R.J.G. Peters AMC-UvA Prof. dr. J.J. Piek AMC-UvA Prof. dr. H.M. Verkooijen Universiteit Utrecht Dr. M.J.M. Cramer Universitair Medisch Centrum Utrecht Faculteit der Geneeskunde So which of the favors of your Lord would you deny? TABLE OF CONTENTS Chapter 1 General introduction 9 PART I Early-life determinants as cardiovascular risk factors Chapter 2 Infections in early life and premature acute coronary syndrome: 17 A case-control study Eur J Prev Cardiol, 2016 Chapter 3 Pregnancy-related conditions and premature coronary heart 31 disease in adult offspring Heart Asia, 2017 PART II Coronary artery disease: characteristics, management, and outcomes Chapter 4 Characteristics and the average 30-day and 6-month clinical 51 outcomes of patients with coronary artery disease: The first cohort from Makassar Cardiac Center, Indonesia BMJ Open, 2018 Chapter 5 Predictors of medium-term mortality in patients hospitalized 73 with coronary artery disease in a resource-limited South-East Asian setting Open Heart, 2018 Chapter 6 Adherence to guideline recommendations for coronary 93 angiography in a poor South-East Asian setting: Impact on short- and medium-term clinical outcomes Under review PART III Organizing challenges and affordable technology Chapter 7 Tele-ECG consulting and outcomes on primary care patients in 113 a low-to-middle income population: The first experience from Makassar Telemedicine Program Submitted Chapter 8 General discussion 137 Position paper : Clinical cardiology in a poor South-East Asian setting – Lessons from the present towards improvement Submitted Chapter 9 Summary and final remarks 159 Samenvatting Rangkuman Chapter 10 Appendix 175 Press release of publications Manuscripts presented in this thesis Contributing authors PhD portfolio Acknowledgment Curriculum vitae Chapter 1 General Introduction Chapter 1 BACKGROUND AND OBJECTIVES Worldwide, many people die from cardiovascular disease (CVD) each year. In 2015, there were approximately 422 million prevalent cases and over 17 million premature deaths due to CVD globally.1,2 Around 75% of coronary heart disease and stroke-related deaths occur in the low- and middle-income countries (LMICs),3 and half of the world’s cardiovascular burden is estimated to occur in Asia.4 South-East Asia is a sub-region of Asia and comprised geographically of southern China, eastern India, western New Guinea, northern Australia and the states of the Association of South-East Asian Nations (ASEAN), i.e. Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam.5 Almost a quarter of the world’s population lives in the South-East Asia Region (SEAR) where lifestyle changes and epidemiological transition have occurred very rapidly.6 For these reasons, the burden of cardiovascular disease is growing fast in SEAR,7 and CVD manifests at a younger age in these populations.7,8 Most likely as a consequence, this region has high rates of premature CVD death (<60 years of age).5,7 Despite the high cardiovascular burden, there is a lack of reliable data and current estimates of CVD prevalence are poor. Indeed, data on patients’ clinical outcomes related to the quality of care in these resource-poor settings are also limited, and virtually unavailable in Indonesia. This thesis aims to capture a general picture of the current state of atherosclerotic CVD in the low-to- middle income South-East Asian population, particularly in Indonesia. As relatively little investigation has been done in this area, this thesis is dedicated to the exploration and study of the unmet needs of cardiovascular practices in eastern Indonesia by identifying the risk factors, patient characteristics, management strategies, and outcomes that may be of considerable importance to the organization of local healthcare systems in the future. OUTLINE OF THE THESIS This thesis consists of three parts. The first part focuses mainly on assessing those local factors that may potentially act in the etiology of the development of premature coronary artery disease in a low- to-middle income population. We begin the first part by showing the association between exposure to infection from early childhood to adolescence and the occurrence of coronary artery disease (CAD) in adulthood (Chapter 2). In Chapter 3, we step back into the intrauterine period. We study if unfavourable conditions suffered by the participants’ mothers during pregnancy could impact the vulnerable in utero environment adversely. We hypothesize that an adverse intrauterine environment could potentially be associated with – or even trigger – the atherosclerotic process during the vasculature development of the fetus, and later in life develop into clinically manifest CAD. Chapters 2 and 3 are based on a population- based, case-control study conducted at Makassar Cardiac Center, Dr. Wahidin Sudirohusodo Hospital, Indonesia from 2013 to 2014. We enrolled 153 newly-diagnosed patients with premature acute coronary syndrome (ACS) and 153 sex- and age-matched controls of healthy subjects living in the same neighborhood as the cases. 10 General introduction 1 . Outline of the thesis Figure 1 Figure 11 Chapter 1 In the second part of the thesis, we focus specifically on patients hospitalized with CAD, both on acute and chronic events. We cross-sectionally quantified the clinical profiles, management, quality of care, prognostic factors, and adherence to guideline recommendations and assessed their rela- tionship with the short- and mid-term clinical outcomes. The primary endpoints were all-cause mor- tality and major adverse cardiovascular events (MACE). In Chapters 4, 5 and 6, we describe a cohort of 477 patients hospitalized with ACS and stable CAD at Makassar Cardiac Center, Indonesia, enrolled from February 2013 to December 2014. Follow-up was