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Abstrak :
[ABSTRAK
Latar belakang. Angka kejadian akut kardiovaskular diperkirakan akan semakin meningkat. Pasien dengan Angina APS dapat berkembang menjadi Sindroma Koroner Akut (SKA). Konsep proses inflamasi dan stress oksidatif berperan terhadap patogenesis atherosklerosis. Radikal bebas seperti reactive oxygen atau nitrogen species, dan HOCL (hypochlorous acid) dapat mengakibatkan kerapuhan plak. HOCL merupakan Reactive Oxygen Species (ROS) kuat yang menyebabkan ketidakstabilan plak sehingga mudah ruptur. Plak yang mudah ruptur disebut plak vulnerable. HOCL adalah substrat yang dihasilkan oleh myeloperoxidase (MPO). Studi histopatologi plak vulnerablemenilai ukuran pusat nekrotik adalah prediktor kuat terjadinya ruptur plak (OR 0.35; P <0.05), dan (OR 2.0; P <0.02).CT angiografi koroner adalah suatu modalitas pencitraan non invasif yang mampu memvisualisasi morfologi plak vulnerable salah satunya dengan mengidentifikasi adanya Napkin Ring Sign (NRS). NRS sangat spesifik untuk menilai pusat nekrotik. Studi ini bertujuan melihat hubungan MPO dengan plak vulnerableyang dinilai dengan Napkin Ring Sign pada pasien angina pektoris stabil. Metode. Penelitian ini adalah studi potong lintang yang dilakukan di Pusat Jantung Nasional Harapan Kita dari periode Juni ? November 2014. Studi dilakukan pada 41 subyek, pada pasien dengan angina pektoris stabil, jumlah laki ? laki sebanyak 32 orang ( 78%) dan perempuan 9 orang (22%), Pengambilan sampel secara konsekutif. Pengukuran kadar MPO dilakukan dengan menggunakan colorimetri assay. Pemeriksaan CT angiografi koroner dilakukan untuk mengidentifikasi NRS.Analisa statistik untuk mencari hubungan antara kadar MPO dengan plak vulnerable yang ditandai dengan NRSpada pemeriksaan CT angiografi koroner. Hasil.Kadar MPO (nmol) pada pasien dengan positif NRS lebih tinggi dibandingkan yang negatif 124,371 + 15,324 vs 105,206 + 18,335, aktivitas MPO (milliunit/mL) 829,136 + 102,157 vs701,371 + 122,235. Analisa bivariat erdapat hubungan yang bermakna antara kadar MPO dengan NRS p 0,002, IK 95%2.3,0 - 39,9. Dari multivariat regresi logistik didapatkan kadar MPO > 117,2 (median), memiliki OR 9,6 (IK 95% 2,3 -39) dengan p 0,002. Setelah dilakukan penyesuaian dengan faktor resiko, pada analisa multivariat regresi logistik, didapatkan OR 20,3 (IK 95% 3,1-31,7) dengan p 0,002. Kesimpulan. Kadar MPO memiliki hubungan yang bermakna dengan plak vulnerable yang ditandai dengan temuan NRS pada CT angiografi koroner pada pasien dengan APS. Kata kunci : atherosklerosis, plak vulnerable, myeloperoxidase, napkin ring sign.

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ABSTRACT
Background.Coronary Heart Disease ( CHD) is still the major health problem in worldwide. Atherosclerosis is a chronic inflammatory process where oxidative damage play a role in atherosclerosis. Overexpression of Reactive Oxygen Species ( ROS) could be detrimental and weaken the plaque. This type of plaque is often referred to as vulnerable plaque. Reactive oxygen or nitrogen species, and HOCL (hypochlorous acid) responsible for plaque vulnerability leading to Acute Coronary Syndrome. HOCL is a substrat of Myeloperoxidase (MPO). MPO is a member of the heme peroxidase superfamily, generates reactive oxidants contributes to plaque vulnerability. Coronary Computed Tomography Angiography (CCTA) is a non invasive modality which able to identify morphology of vulnerable plaque. Napkin- Ring Sign (NRS) has been associated with high-risk plaques in several studies. Methods. A cross sectional study in 41 patients stable angina pectoris was done.The subjects was taken blood sample and underwent CCTA to evaluate NRS in National Cardiovascular Center Harapan Kita from June to November 2014. Statistical analysis is done to explore the association between MPO and vulnerable plaque marked with NRS in stable angina pectoris. Results. There was association between MPO level with vulnerable plaque marked with Napkin Ring Sign, p value 0,002 , CI 95%2.3,0 - 39.9. Level of MPO is higher in positif NRS vs non NRS (nmol) 124,371 + 15,324 vs 105,206 + 18,335, activity of MPO (milliunit/mL) 829,136 + 102,157 vs701,371 + 122,235. Logistic regression analysis showed level of MPO ≥ 117,2 nmol (median), OR 9,6 (CI95% 2,3 -39) p value0,002. After adjustment with confounding factor MPO level ≥ 117,2 nmol (median), OR 20,3 (IK 95% 3,1-31,7) , p value 0,002. Conclusion.There was association between Myeloperoxidase level with vulnerable plaque marked with Napkin Ring Sign;Background.Coronary Heart Disease ( CHD) is still the major health problem in worldwide. Atherosclerosis is a chronic inflammatory process where oxidative damage play a role in atherosclerosis. Overexpression of Reactive Oxygen Species ( ROS) could be detrimental and weaken the plaque. This type of plaque is often referred to as vulnerable plaque. Reactive oxygen or nitrogen species, and HOCL (hypochlorous acid) responsible for plaque vulnerability leading to Acute Coronary Syndrome. HOCL is a substrat of Myeloperoxidase (MPO). MPO is a member of the heme peroxidase superfamily, generates reactive oxidants contributes to plaque vulnerability. Coronary Computed Tomography Angiography (CCTA) is a non invasive modality which able to identify morphology of vulnerable plaque. Napkin- Ring Sign (NRS) has been associated with high-risk plaques in several studies. Methods. A cross sectional study in 41 patients stable angina pectoris was done.The subjects was taken blood sample and underwent CCTA to evaluate NRS in National Cardiovascular Center Harapan Kita from June to November 2014. Statistical analysis is done to explore the association between MPO and vulnerable plaque marked with NRS in stable angina pectoris. Results. There was association between MPO level with vulnerable plaque marked with Napkin Ring Sign, p value 0,002 , CI 95%2.3,0 - 39.9. Level of MPO is higher in positif NRS vs non NRS (nmol) 124,371 + 15,324 vs 105,206 + 18,335, activity of MPO (milliunit/mL) 829,136 + 102,157 vs701,371 + 122,235. Logistic regression analysis showed level of MPO ≥ 117,2 nmol (median), OR 9,6 (CI95% 2,3 -39) p value0,002. After adjustment with confounding factor MPO level ≥ 117,2 nmol (median), OR 20,3 (IK 95% 3,1-31,7) , p value 0,002. Conclusion.There was association between Myeloperoxidase level with vulnerable plaque marked with Napkin Ring Sign, Background.Coronary Heart Disease ( CHD) is still the major health problem in worldwide. Atherosclerosis is a chronic inflammatory process where oxidative damage play a role in atherosclerosis. Overexpression of Reactive Oxygen Species ( ROS) could be detrimental and weaken the plaque. This type of plaque is often referred to as vulnerable plaque. Reactive oxygen or nitrogen species, and HOCL (hypochlorous acid) responsible for plaque vulnerability leading to Acute Coronary Syndrome. HOCL is a substrat of Myeloperoxidase (MPO). MPO is a member of the heme peroxidase superfamily, generates reactive oxidants contributes to plaque vulnerability. Coronary Computed Tomography Angiography (CCTA) is a non invasive modality which able to identify morphology of vulnerable plaque. Napkin- Ring Sign (NRS) has been associated with high-risk plaques in several studies. Methods. A cross sectional study in 41 patients stable angina pectoris was done.The subjects was taken blood sample and underwent CCTA to evaluate NRS in National Cardiovascular Center Harapan Kita from June to November 2014. Statistical analysis is done to explore the association between MPO and vulnerable plaque marked with NRS in stable angina pectoris. Results. There was association between MPO level with vulnerable plaque marked with Napkin Ring Sign, p value 0,002 , CI 95%2.3,0 - 39.9. Level of MPO is higher in positif NRS vs non NRS (nmol) 124,371 + 15,324 vs 105,206 + 18,335, activity of MPO (milliunit/mL) 829,136 + 102,157 vs701,371 + 122,235. Logistic regression analysis showed level of MPO ≥ 117,2 nmol (median), OR 9,6 (CI95% 2,3 -39) p value0,002. After adjustment with confounding factor MPO level ≥ 117,2 nmol (median), OR 20,3 (IK 95% 3,1-31,7) , p value 0,002. Conclusion.There was association between Myeloperoxidase level with vulnerable plaque marked with Napkin Ring Sign]

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Latar Belakang. Diabetes dapat mempengaruhi struktur dan fungsi jantung tanpa adanya hipertensi dan aterosklerosis.Dengan meningkatnya risiko gagal jantung dan kejadian kardiovaskular pada pasien diabetes, maka mengetahui penyebab dan mekanisme utama yang mendasari terjadinya disfungsi diastolik menjadi penting dalam upaya mencari strategi pengobatan yang potensial.Studi pre-klinik menunjukkan bahwa Endothelin-1 (ET-1) berperan penting dalam patofisiologi kardiomiopati diabetes. Namun, hubungan antara kadar ET-1 plasma dengan kejadian disfungsi diastolik serta mekanisme yang mendasari belum diketahui dengan pasti. Tujuan. Mengetahui hubungan antara kadar ET-1 plasma dengan disfungsi diastolik dan mekanisme yang mendasarinya. Metode. Sejumlah empat puluh satu pasien diabetes dan non diabetes yang memenuhi kriteria inklusi dan eksklusi di poliklinik Pusat Jantung Nasional Harapan Kita direkrut secara konsekutif pada bulan Oktober 2012. Fungsi diastolik ventrikel kiri diperiksa dengan echocardiography, sampel darah diambil untuk pemeriksaan ET-1 plasma dengan radioimmunoassay. Pemeriksaan cardiac magnetic resonance imaging (CMRI) dengan kontras gadolinium dilakukan untuk menilai fibrosis diffuse pada miokardium serta MRI spektroskopi untuk menilai kadar trigliserida (steatosismiokardium). Hasil. Kadar ET-1 plasma lebih tinggi pada kelompok diabetes dibandingkan dengan non diabetes (1.48±0.50 vs. 1.08±0.22 pg/ml, p<0.05). Seluruh pasien diabetes mengalami disfungsi diastolik dengan 17 (85%) pasien mengalami disfungsi diastolik derajat 2 dan 3, sementara 13 (61.9%) pasien non diabetes menunjukkan fungsi diastolik normal. Tekanan atrium kiri yang meningkat juga didapatkan pada 16 (80%) pasien diabetes. Pada pasien dengan derajat disfungsi diastolik derajat 3 didapatkan kadar ET-1 yang lebih tinggi dibandingkan dengan pasien dengan fungsi diastolik normal (1.78±0.50 vs. 1.09±0.19 pg/ml, p<0.05). Sejumlah 17 (85%) pasien diabetes mengalami fibrosis, steatosis ataupun keduanya, sementara 16 (76%) pasien non diabetes yang tidak mengalami keduanya. Kadar ET-1 plasma berkorelasi dengan fibrosis miokardium (Speaman koef. R = -0.394, p<0.05), namun tidak berkorelasi dengan steatosis miokardium (Pearson koef R = 0.259, p=NS). Pasien dengan fibrosis dan steatosis mengalami derajat disfungsi diastolik yang lebih berat, dan menunjukkan kadar ET-1 plasma yang lebih tinggi (1.44±0.53 vs. 1.14±0.25, p<0.05). Kesimpulan. Kadar ET-1 plasma yang lebih tinggi pada diabetes berhubungan dengan tekanan atrium kiri yang meningkat dan derajat disfungsi diastolik yang lebih berat, serta berkorelasi dengan terjadinya fibrosis miokardium, namun tidak berkorelasi dengan steatosis miokardium. ...... Background. Diabetes may affect cardiac structure and function independent to atherosclerosis and hypertension. Considering the increased risk of heart failure and cardiovascular event in diabetic cardiomyopathy, investigation of etiology and mechanism of this unique entity is important for developing potential therapy. Endothelin-1 (ET-1) has been associated with development of diabetic cardiomyopathy in pre-clinical study. Objective. This study aims to investigate correlation of plasma ET-1 with development of myocardial fibrosis and diastolic dysfunction diabetes patient. Methods. Fourty-one diabetes and non diabetes patient with no history of myocardial infarction and left ventricular hyperthrophy were recruited in this cross sectional study. Plasma ET-1 level were measured with radioimmunoassay, diastolic function were evaluated by Doppler echocardiography, and diffuse myocardial fibrosis were evaluated by post-contrast myocardial T1 relaxation time using cardiac MRI. Results. Plasma ET-1 level is higher in diabetes group as compare to non diabetes (1.48±0.50 vs. 1.08±0.22 pg/ml, p<0.05). All diabetes subjects developed diastolic dysfunction, with 17 (85%) had grade 2 and 3 diastolic dysfunction, compare to 13 (61,9%) non diabetes patient which showed normal diastolic function. We also observed the increased of left atrial pressure (LAp) in 16 (80%) of diabetes patient. Patient with grade 3 (severe) diastolic dysfunction showed higher plasma ET-1 level as compare to patient with normal diastolic function (1.78±0.50 vs. 1.09±0.19 pg/ml, p<0.05). Diabetes subject had shorter post-contrast T1 relaxation time - reflecting diffuse myocardial fibrosis (440.97±16.97 vs. 489.41±6.73 ms, p<.005), and correlates inversely to plasma ET-1 level (Spearman Coeff R = -0.394, p<0.05). Conclusion. In conclusion, higher plasma endothelin-1 level is associated with diffuse myocardial fibrosis and diastolic dysfunction in diabetes patient. This may provide additional evidence for the potential clinical use of endothelin receptor blockade in preventing diabetic cardiomyopathy.

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ABSTRAK
Latar Belakang. Stenosis Mitral (SM) tinggi prevalensinya di negara berkembang karena erat terkait dengan prevalensi penyakit jantung demam rematik (PJR). Pasien SM sedang-berat terdapat peningkatan regio turbulensi dan shear stress mengakibatkan kerusakan endotel pembuluh darah sehingga meningkatkan resiko tromboemboli. P-selectin merupakan molekul adhesi berperan dalam proses inflamasi dan sebagai faktor protrombotik yang diekspresikan secara cepat. Indeks volume atrium kiri (IVAK) merupakan parameter superior untuk mengukur fungsi atrium kiri dengan ekokardiografi. Metode. Penelitian potong lintang melibatkan 20 pasien SM sedang-berat dengan MVA <1.5 cm2 yang menjalani Komisuratomi Mitral Transvena Perkutan (KMTP) yang diambil secara konsekutif pada bulan Mei 2013 sampai Oktober 2013 di Pusat Jantung Nasional Harapan Kita Jakarta. Pasien diambil sampel darah pra dan pasca KMTP untuk diperiksa kadar P-Selectin. Kemudian hasilnya dianalisa secara statistik. Hasil. Dalam studi ini, tidak didapatkan asosiasi antara IVAK dengan ekspresi kadar P-selectin pra dan pasca KMTP. Hal ini ditunjukkan dengan nilai pra KMTP β= -0.103 (95% CI -0.251,0.045) p=0.16 dan pasca KMTP β= 0.009 (95% CI -0.155,0.172) p=0.91. Setelah dilakukan regresi linier dengan penyesuaian (adjusted) terhadap variabel perancu yakni usia, jenis kelamin, dan atrial fibrilasi tetap tidak didapatkan asosiasi antara IVAK dengan kadar P-selectin dengan nilai pra KMTP β= -0.154 (95% CI -0.340,0.032) p=0.09 dan pasca KMTP β= -0.049 (95% CI -0.250,0.152) p=0.61. Kesimpulan. Tidak ada perbedaan nilai P-selectin pra dan pasca KMTP. Nilai IVAK yang sudah jelek tidak berhubungan dengan kadar P-selectin pra dan pasca KMTP pada pasien SM.

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ABSTRACT
Background. The prevalence of Mitral stenosis (MS) remains significant in developing countries related to prevalence of Rheumatic Heart Disease (RHD).In moderate-severe MS patients enormous increase in turbulent region and shear stress causing dysfunction of vascular endothelial, as consequence it increase the risk of thromboembolic complication. Pselectin is an adhesion molecule that play role in inflammation process, it express rapidly in minutes. Left Atrial Volume Index (LAVI) is superior parameter compare with other echocardiography two dimension method to assess left atrial function. Methods. Study was designed as cross-sectional study involving 20 MS moderate-severe patients with MVA< 1.5 cm2 who performed successful Percutaneous transvenous Balloon Mitral Valvulotomy (PBMV). Samples were taken consecutively from May 2013 to October 2013 at the National Cardiovascular Center Harapan Kita Jakarta. Blood samples of Pselectin were collected pre and post PBMV. The result was statistically analyzed by using echocardiography data of LAVI prior PBMV to describe any association between expression of P-selectin and atrial function. Result. In our study, we found no association between LAVI and expression of P-selectin level pre and post PBMV MS patient. This data describe in each of value of pre PBMV β= - 0.103 (95% CI -0.251,0.045) p=0.16 and post PBMV β= 0.009 (95% CI -0.155,0.172) p=0.91 After we performed linear regression with adjusted confounding variable including sex, age, and atrial fibrillation, still we found no association between LAVI and P-selectin level. This data describe in each of value of pre PBMV β= -0.154 (95% CI -0.340,0.032) p=0.09 and post PBMV β= -0.049 (95% CI -0.250,0.152) p=0.61. Conclusion. We found there is no difference in P-selectin level pre and post PBMV. There is no association between poor LAVI value and expression of P-selectin pre and post PBMV in MS.

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Tujuan : Mendapatkan perbandingan reaktifitas platelet jam pertama (dengan alat Multiplate) antara ticagrelor dan clopidogrel. Latar Belakang : Ticagrelor memiliki kemampuan inhibisi platelet lebih baik dibandingkan clopidogrel. Penelitian PLATO atau substudi PLATO-platelet, dosis clopidogrel hanya 300 mg, dibandingkan dengan ticagrelor 180 mg pada pasien STEMI. Penelitian ini dilakukan untuk menilai reaktifitas platelet pada jam-1,4 dan 8 antara ticagrelor 180 mg atau clopidogrel 600 mg pada pasien STEMI. Metode : Penelitian random clinical trial, double blind, pasien STEMI dengan naive clopidogrel atau ticagrelor, dilanjutkan tindakan intervensi perkutan primer (PPCI) di RS Jantung Harapan Kita dari April-Juni 2013. Aktifitas platelet diukur jam pertama, jam keempat dan kedelapan dengan alat Multiplate. Hasil : Didapat 22 pasien STEMI nave clopidogrel/ticagrelor, dengan 11 pasien tiap kelompok. Tidak terdapat perbedaan terhadap usia, onset iskemik, BMI, penyakit penyerta Diabetes Melitus serta waktu pengambilan sampel pemeriksaan antara 2 kelompok obat. Didapat nilai reaktifitas platelet tetap tinggi pada kelompok obat clopidogrel dibandingkan ticagrelor pada jam pertama. Hasil kelompok ticagrelor tetap konstan hingga jam ke-8. Dan penurunan rekatifitas platelet kelompok clopidogrel menurun mendekati nilai yang diharapkan hingga jam 8. Kesimpulan : Reaktifitas platelet ticagrelor lebih rendah dibandingkan clopidogrel saat jam pertama pasca loading obat. Terdapat 45% (5 pasien) pada kelompok clopidogrel yang tetap memiliki reaktifitas platelet tinggi pada pemeriksaan jam pertama, keempat dan kedelapan, serta 9% (1 pasien) pada ticagrelor yang memiliki kenaikan nilai reaktifitas platelet pada jam keempat dan kedelapan ......Objectives : This study sought to compare platelet reactivity by180 mg ticagrelor and 600 mg clopidogrel in primary PCI STEMI patients. Background: The ability of ticagrelor in inhibiting platelet functions was more potent than clopidogrel in stable CAD and UAP/NonSTEMI patients. According to the PLATO trial or PLATO-platelet substudy, patients treated with 180 mg ticagrelor had better clinical endpoint and more platelet inhibition compared to 300 mg clopidogrel. The study we conducted was to see the platelet reactivity at 1st, 4th, and 8th hour after ingestion of 180 mg ticagrelor compared to 300 mg clopidogrel in STEMI patients Methods: This is a randomized double blind clinical trial carried out in Department of Cardiology and Vascular Medicine Universitas Indonesia/ National Cardiovascular Center Harapan Kita in April - June 2013. As many as 22 clopidogrel or ticagrelor nave STEMI patients undergoing primary PCI with were recruited. Platelet reactivity (PRU) was assessed by Multiplate at 1,4,8 h after LD. Result : Both nave ticagrelor and clopidogrel goups had 11 patients each. About 45% patients in clopidogrel group have high reactivity platelet at 1h, 4h and 8 h MEA analysis, and 9% patients in ticagrelor group have high reactivity platelet at 4h and 8 h MEA analysis. Conclusion: The action of Ticagrelor in platelet reactivity was lower compared to Clopidogrel in STEMI patients. 45 % patients in clopidogrel group maintained high platelet reactivity at 1st, 4th and 8th hour after LD, while 9% patients in ticagrelor group had high platelet reactivity started at 4th up 8th hour after LD.

Abstrak :
Latar Belakang. Pemacuan ventrikel kanan merupakan hal yang tidak dapat dipisahkan dari tatalaksana bradikardi simptomatik, bradiaritmia, dan kelainan konduksi lainnya. Sayangnya terdapat efek buruk pemacuan ventrikel kanan terhadap disinkroni dan penurunan fungsi ventrikel kiri. Penelitian ini mencoba melihat secara potong lintang hubungan pemacuan ventrikel kanan terhadap kejadian disinkroni dan penurunan fungsi ventrikel kiri. Metode. Seratus delapan belas pasien dengan disfungsi nodal AV diambil secara konsekutif untuk studi potong lintang, mulai bulan Maret hingga Mei 2013 didapat dari registri divisi Aritmia Pusat Jantung Nasional Harapan Kita, Jakarta. Pasien menjalani pemeriksaan disinkroni dan fungsi ventrikel kiri dengan ekokardiografi. Dilakukan penilaian terhadap interval elektromekanikal dengan doppler jaringan, kemudian dinilai variabel nilai awal yang didapat dari rekam medis pasien. Hasil. Dalam studi kami, 70 dari 118 (59.3%) pasien mengalami disinkroni dalam rerata durasi pemacuan 4.7 tahun. Terdapat perbedaan signifikan terhadap durasi waktu di kelompok pasien yang mengalami disinkroni intraventrikel dengan yang tidak mengalami disinkroni intraventrikel (5.29 vs 3.27 tahun). Setelah pemacuan ventrikel kanan 6.1 tahun, pasien paska pacu-jantung berisiko untuk mengalami disinkroni intraventrikel dengan OR 4.07 kali. Tidak didapatkan perbedaan bermakna antara pemacuan di apeks RV ataupun RVOT terhadap kejadian disinkroni. Terdapat kecenderungan kejadian disinkroni intraventrikel, disinkroni interventrikel, dan penurunan fraksi ejeksi ventrikel kiri pada pasien-pasien yang mendapatkan pemacuan apeks RV. Kesimpulan. Semakin lama durasi pemacuan ventrikel kanan, semakin tinggi risiko kejadian disinkroni intraventrikel pada pasien pacu-jantung permanen dengan OR di atas 6.1 tahun adalah 4.07 kali. ......Background. Right ventricular pacing is an established therapy from the management of symptomatic bradycardia, brady-arrhytmias, and other conduction disturbances. Unfortunately there are deleterious effects of right ventricular pacing on cardiac synchrony and left ventricular function. This study tried to look cross sectionaly the variable of pacing duration, lead locations to the occurrence of dyssynchrony and decrease left ventricular ejection fraction. Method. One hundred and eighteen patients with AV nodal dysfunction (SND with AVN dysfunction, AF slow response, Total AV-Block, and AF post AVJ ablation) taken consecutively for this cross-sectional study, from March to May 2013 obtained from the registry division of the National Cardiac Arrhythmia Center Harapan Kita, Jakarta. Patients then undergone echocardiography assessment for cardiac dyssynchrony and left ventricular function. After we assessed of the electromechanical interval with tissue Doppler, we then assessed the value of the basic variables that was obtained from patient medical records. Results. In our study, 70 of 118 (59.3%) patients had dyssynchrony at a mean duration of pacing disinkroni in 4.7 years. There are significant differences in the duration of time under pacing in the group of patients who experienced intraventricular dyssynchrony (5.29 vs. 3.27 years). In post-cardiac pacemaker patients, there were increased risk by year with peak after 6.1 years of OR 4.07 times. There were no significant differences between pacing lead at the RV apex or RVOT. There is a downward trend in intraventricular and interventricular dyssynchrony, also with poor left ventricular ejection fraction in patients receiving RV apical pacing. Conclusion. The longer the duration of right ventricular pacing, the higher the risk of intraventricular dyssynchrony in patients with permanent cardiac pacemaker (OR for patients with RV pacing more than 6.1 years is 4.07x).