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MUHMMAD DIAH
SD, SMP, SMA Bireuen Dokter Umum: FK UNSRI Palembang Internist : FK UNSRI, Palembang Konsultan Kardiovaskuler: RCSM-RSMH Kolegium Intervensi Jantung: - Angiografi : 2011 (RSCM) - Fellow Intervention Clinical Cardiologi (FCIC) Institut Jantung Negara (IJN). Kuala Lumpur - Sertifikasi Intervensi Cardiologi Tk III (Koleguim) Pekerjaan: Staf Departemen Kardiologi RSUZA/FK UNSYIAH Staf Subdivisi Kardiologi Bag Penyakit Dalam RSUZA.FK UNSYIAH Ka Instalasi Kateterisasi Jantung RSUZA Banda Aceh Staf SP2 Kardiologi, Bagian Peny Dalam RSMH/FK UNSRI
DEFINISI
Suatu sindroma klinik yang menandakan adanya iskemia miokard akut, terdiri dari : Infark miokard akut Q wave (STEMI) Infark miokard akut non-Q (NSTEMI) Angina pektoris tidak stabil (UAP)
Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis.
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PATOGENESIS
Umumnya disebabkan oleh aterosklerosis koroner Plak aterosklerosis ruptur terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koroner Apabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan nekrosis
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Risk Factors
Uncontrollable
Sex Hereditary Race Age
Controllable
High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Stress and anger
The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance
Myocardial Ischemia
CAD
plaque
Atherosclerosis
Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)
CAD
Atherosclerosis
Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)
CAD
Atherosclerosis
Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)
ST Segment Elevation
STEMI NSTEMI
Unstable Angina
Non occlusive thrombus
NSTEMI
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/T wave inversion on ECG Elevated cardiac enzymes
STEMI
Complete thrombus occlusion ST elevations on ECG or new LBBB
Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
HISTORY
PRODROMAL SYMPTOMS History very valuable to establish D/. Prodoma : chest discomfort unstable angina 1/3 symptoms for 1 4 wks 20% symptoms for < 24 hrs Malaise, exhaustion NATURE OF PAIN Most patients severe prolonged, 30 minutes - hours Constricting, crushing, oppressing, compressing heavy weight or squeezing in chest Choking, vise-like, heavy pain or stabbing, knife-like, boring or burning discomfort Location : retrosternal, spreading frequently to both sides of the chest with predilection to the left side Often pain radiates down ulnar aspect of left arm, producing 14 tingling sensation in left wrist, hand and fingers
NATURE OF PAIN SOME INSTANCES : pain begins in epigastrium, and simulates abdominal disorder Sometimes pain radiates to shoulders, upper extremities, neck, jaw and interscapular region favoring the left side
Elderly : no chest pain but acute left ventricular failure and chest tightness or marked weakness or syncope
Pain arises from nerve endings in ischemic or injured, but not necrotic, myocardium OTHER SYMPTOMS 50% nausea or vomiting in transmural infarcts Occasionally diarrhea, profound weakness, dizziness, palpitation, cold perspiration, sense of impending doom Occasionally : cerebral embolism or systemic arterial embolism
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atau
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PHYSICAL EXAMINATION
GENERAL APPEARANCE Anxious, considerable distress, restless, Levine sign (fist sign: costricting, pressing pain typical of angina pectoris) LV failure & symp. stimulation : cold perspiration, pallor, dyspnea, cough with frothy pink or blood-streaked sputum. Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientation
HEART RATE Variable depending on underlying rhythm and degree or ventr. failure Most commonly, HR 100 110/min; > 95% patients : VPBs within first 4 hours 18
BLOOD PRESSURE Majority normotensive, but syst. BP may decline and diast. BP may rise Half of pts with inferior MI parasympathetic stimulation : hypotension, bradycardia or both (Bezold Jarisch reflex) half of pts with anterior MI, sympathetic excess : hypertension, tachycardia or both TEMPERATURE AND RESPIRATION Most pts with extensive MI fever within 24-48 hrs, fever resolves by 4th or 5th day Respiration due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure
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CHEST LV failure and/or LV compliance : moist rales Severe failure : diffuse wheezing, cough + hemopthysis 1967 : Killip & Kimball : prognostic classification Class I II : patients free of rales or S3 : rales < 50% lung fields +/- S3 pulm. edema IV : cardiogenic shock
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Pemeriksaan Penunjang
Pemeriksaan EKG
Gambaran EKG infark miokard akut Q-wave (STEMI) : Elevasi segmen ST 1 mm pada 2 sadapan extremitas Atau 2 mm pada 2 sadapan prekordial yang berurutan Atau gambaran LBBB baru atau diduga baru
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ST-segment elevation
Gambaran EKG infark miokard akut non-Qwave (NSTEMI) atau angina pektoris tidak stabil (UAP) : Depresi segment ST atau gelombang T terbalik pada 2 sadapan berurutan Inversi gelombang T minimal 1 mm pada 2 sadapan atau lebih yang berurutan. Perubahan segment ST saat keluhan dan kembali normal saat keluhan hilang sangat menyokong UAP
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ST-segment depression
T-wave inversion
ELEKTROKARDIOGRAM
Current-of-injury patterns with acute ischemia
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Plot of the appearance of cardiac markers in blood versus time after onset of symptoms
A myoglobin B troponin
C CK-MB D troponin in UA
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Diagnosis Banding
1. Diseksi aorta 2. Perikarditis 3. Nyeri angina hipertrofi atipikal pada kardiomiopati
7. Gangguan neurogen
8. Psikogen
dinding
dada
muskuloskeletal,
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Kasus 1
Laki-laki, usia 50 tahun Nyeri dada semakin memberat sejak 7 jam sebelum masuk rumah sakit Riwayat nyeri sebelumnya (-) FR : merokok, HT dan DM tidak diketahui Riw Keluarga : PJK (+) PF : CM, TD=140/90 mmHg
Cor dan Pulmo : dalam batas normal Abdomen : dalam batas normal Ekstremitas : edema -/-
Kasus 1
Interpretasi EKG ?
a. STEMI Anterior dan NSTEMI Inferior b. STEMI Anteroseptal dan OMI Inferior c. STEMI Anteroseptal d. NSTEMI Inferior
STEMI Anteroseptal
Terdapat perubahan pada segmen ST berupa elevasi yang merupakan terjadinya acute injury di anteroseptal ( leads V1-V4) Dengan atau tanpa perubahan resiprokal berupa depresi segmen ST pada sandapan inferolateral Gamb EKG :
Acute Injury pada sandapan V1-V3 :
Elevasi segmen ST upsloping Gel T yang tinggi
Kasus 1
Interpretasi EKG ?
a. STEMI Anterior dan NSTEMI Inferior b. STEMI Anteroseptal dan OMI Inferior c. STEMI Anteroseptal d. NSTEMI Inferior
Kasus 2
Laki-laki, 36 tahun Nyeri dada hebat sejak 40 menit sebelum datang ke IGD rumah sakit FR : tidak jelas. Kadar lipid belum diperiksa PF : CM. TD = 130/90 mmHg Lain-lain dalam batas normal
Kasus 2
Interpretasi EKG ?
a. NSTEMI Anterior dan Inferior b. STEMI Anterior Ekstensif/Luas c. STEMI Anterior Ekstensif/Luas dengan Ventricular ectopic beats d. STEMI Anteroseptal
Kasus 2
Interpretasi EKG ?
a. NSTEMI Anterior dan Inferior b. STEMI Anterior Ekstensif/Luas c. STEMI Anterior Ekstensif/Luas dengan Ventricular ectopic beats d. STEMI Anteroseptal
Kasus 3
Wanita, 67 tahun Nyeri dada semakin memberat sejak 3 jam FR : riw DM (+) PF : CM. TD = 140/90 mmHg Lab :
GDS = 250 mg/dL Troponin T (-), CK dan CK-MB dalam batas normal
Kasus 3
Interpretasi EKG ? a.OMI Anteroseptal b.NSTEMI Inferior c. STEMI Anteroseptal d.STEMI Lateral
STEMI Lateral
Terdapat perubahan pada segmen ST berupa elevasi di sandapan lateral (V4-V6) dan I-aVL Dengan atau tanpa perubahan resiprokal berupa depresi segmen ST pada sandapan inferior Gamb EKG :
Elevasi ST upsloping Gel T yang tinggi
Kasus 3
Interpretasi EKG ? a.OMI Anteroseptal b.NSTEMI Inferior c. STEMI Anteroseptal d.STEMI Lateral
Kasus 4
Laki-laki, usia 60 tahun Nyeri dada beberapa jam sebelum masuk RS (onset tidak jelas) FR : DM (+) PF : CM. TD = 80/50 mmHg
Cor dan Pulmo dalam batas normal Lain-lain tidak ditemukan kelainan Lab : Troponin T (+)
Kasus 4
Interpretasi EKG
a. STEMI Inferior b. STEMI Inferior dan Infark Ventrikel Kanan c. NSTEMI Inferior dan Infark Ventrikel Kanan d. Infark Ventrikel Kanan
Kasus 4 VES
JPB
Interpretasi EKG
a. STEMI Inferior b. STEMI Inferior dan Infark Ventrikel Kanan c. NSTEMI Inferior dan Infark Ventrikel Kanan d. Infark Ventrikel Kanan
Interpretasi EKG :
Curiga iskemi/infark inferior, harus dilakukan pemeriksaan ventrikel kanan dan posterior Gejala klinis tidak khas pada pasien DM dan usia lanjut Komplikasi infark inferior dan infark ventrikel kanan : infark inferior : blok pada AV node
infark ventrikel kanan : gangguan hemodinamik
EVOLUSI EKG
ELECTROCARDIOGRAPHIC HIGHLIGHTS
Anatomic Region
Anterior wall Anteroseptal Anteroseptal Lateral Septal wall Inferior wall Inferior and RV
Coronary Artery
LAD LAD Proximal LAD LAD RCA; LCX Proximal RCA
Descriptive Leads
V3 and V4 V1 to V4 V1-V6, I and aVL V1 and V2 II, III and aVF II, III, aVF, V1, V2 and V3R-V6R II, III, aVF, V1, V2 and V7-V9 V1, V2 and V7-V9 V5, V6, I and aVL V3-V6, I and aVL II, III, aVF, I, aVL, V5 and V6 V1, V2, V7 to V9, V5, V6, I and aVL
RCA; LCX RCA; LCX LAD LAD; LCX LAD; LCX LAD; LCX
Kasus 5
Laki-laki, usia 42 tahun Nyeri dada yang memberat sejak 2 hari sebelum datang ke IGD RPD : infark miokard akut 1 tahun yang lalu, belum dilakukan intervensi selain obat-obatan FR : merokok PF : CM. TD = 130/80 mmHg
Lain-lain dalam batas normal
Kasus 5
Interpretasi EKG ? a. Angina Pektoris Stabil b. Angina Pektoris tidak Stabil (UAP) c. Angina pasca infark d. NSTEMI Anteroseptal
Deep and symmetrical T wave inversion pada sandapan anterior (V1-V5, I-aVL) Inversi gelombang T seringkali merupakan perubahan yang nonspesifik kecuali inversi yang bentuknya dalam dan simetris
Kasus 5
Interpretasi EKG ? a. Angina Pektoris Stabil b. Angina Pektoris tidak Stabil (UAP) c. Angina pasca infark d. NSTEMI Anteroseptal
Manajemen
Myocardial Ischemia
Remodeling
CAD
Atherosclerosis
Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)
DELAY TO THERAPY
2. Out-hospital transport
3. In-hospital evaluation
TYPICAL ANGINA
EQUIVALENT ANGINA
2. LOCATION
3. INDIGESTION 4. UNEXPLAINED WEAKNESS 5. DIAPORESIS 6. SHORTNESS OF BREATH
3. RADIATION
4. UNLIKELINESS
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
study
Portable chest x-ray ( 30 minutes)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 hours of onset - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors -Adrenoreceptor blockers Clopidogrel
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
1. Refractory chest pain 2. Recurrent/persistent ST deviation 3. Ventricular tachycardia 4. Hemodynamic instability 5. Sign of pump failure 6. Shock within 48 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves Develops high or intermediate risk criteria or troponin-positive Monitored bed in ED Develops high or intermediate risk criteria or troponin-positive
Start adjunctive treatment 12 hrs Admit to monitored bed Assess risk status
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