logging in or signing up Sindrom Koroner Akut jantungku Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1693 Category: Education License: All Rights Reserved Like it (4) Dislike it (0) Added: October 19, 2009 This Presentation is Public Favorites: 0 Presentation Description Sindrom Koroner Akut merupakan suatu keadaan atau kejadian yang sangat berbahaya karena tingginya angka kematian dan kesakitan. Comments Posting comment... By: gotelvia (18 month(s) ago) dok,, slide nya boleh di download gak ??? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: Acute Coronary Syndrome Dr.Edial Dr.Edial www.jantunghipertensi.com Slide 2: Spectrum of Acute Coronary Syndromes Unstable Angina Non STEMI STEMI alDr.Edi www.jantunghipertensi.com Slide 3: INCIDENCE Acute Coronary Syndromes 1,57 million Hospital Admission = ACS UAP/NonSTEMI STEMI 1,24 Million per year 0,33 Million per year Dr.Edial www.jantunghipertensi.com Slide 4: ACS - Predisposing Factors Conventional Risk Factors Smoking Hypertenssion Dyslipidemia Metabolic Syndrome Insuline Resistance & DM Obesity Mental Stress & Depression > 20 % ACS No Risk Factors Jama 290(7):891-898,Aug 2003 www.jantunghipertensi.com Slide 5: Novel Risk Factors * hs CRP * Homocystin * Lpa * Fibrinogen * D-Dimer Dr.Edial New Risk Factors : New Risk Factors Cocain/Meth HIV CKD RA SLE NEJM 2003 Nov 20;349 Slide 7: ACS - Presentations Typical Angina Definition Of Typical Angina * Typical : atleast 2 out 0f 3 * Atypical : 1 out of 3 * Non-Anginal Chest pain = 0 * “ Asymptomatic “ = o persent Natural Pain Presipitating Factors Relieving Factors Dr.Edial www.jantunghipertensi.com Slide 8: Response to Nitroglycerin has no diagnostic Role Sensitivity = 35%, specificity = 50% (Am J Card 90;1264,Des 1 2002) Dr.Edial Slide 9: Dr.Edial www.jantunghipertensi.com Slide 10: Differential Diagnosis Acute Aortic Dissection Acute Pericarditis Miocarditis Pulmonary Embolism Atypical Angina Vasospastic Angina Hypertropic Cardiomyopathy Hyperkalemia BBB (Bundle Brunch Block) Early Repolarization WPW(Wolf -Parkinson-White) Bruguda Syndrome www.jantunghipertensi.com Cardiac Dr.Edial Slide 11: Pleuretic Pain Chest wall pain GERD (Gasro-Esophageal reflux and Spasm) Ulcus pepticum Panic attack Psikogenic Dissorder Differential Diagnosis Non Cardiac Dr.Edial Slide 12: Evaluation of patients suspected of having ACS * Clasical Angina at rest or at less than usual activity * Nature of Pain 1. Usually more than 30 min for MI & 20-30 for UAP 2. Squezing, Constricting, Crushing 3. Oppressing, Compressing 4. Retrosternal * Spreading To Both side of anterior chest (more to the left) Ulnar aspect of Arm * In some cases epigastric pain Dr.Edial Slide 13: Evaluation of patients suspected of having ACS Others Symptoms Cold Perspirations Nausea/Vomiting (Vagal Stimulations) Profound weakness Dizziness Palpitation Dr.Edial www.jantunghipertensi.com Slide 14: Silent ACS Due to aotonomic Disturbance Specially See in Diabetic and Hypertensive patients Older patients Women 40.000/yr.. Chest Pain, in US loss ACS Dr.Edial Symptoms ACS – for Women : Symptoms ACS – for Women Heart disease kills more Women than Men every year. Women symptoms of heart disease differently then Men 1. Shortness of breath, often without chest pain of any kind 2. Flu-like symptoms- specifically nausea,clamminess or cold sweats 3. Unexplained fatique,weakness or dizziness 4. Pain in the chest,upper back,shoulder,neck or jaw 5. Feelings of anxiety, loss of appetite, disconfort Dr.Edial www.jantunghipertensi.com Los Aneles-Mey 11,2009Archives of Internal Medicine. : Los Aneles-Mey 11,2009Archives of Internal Medicine. Women chest pain without CAD Elevated risk CV event, heart attack or stroke Cedars-Sinai Heart Institute study, Women with Chest Pain Positive Exercise Normarl Coronary Angiography 5 yr,,, more CV evetns then women no chest pain Cause : microvascular angina, endothelial dysfunction Dr.Edial Sent home without treatment www.jantunghipertensi.com Atypical Presentations of ACS : Atypical Presentations of ACS Classical Angina without severe or prolonged pain Heart failure Atypical location of pain CNS manifestations Apprehension/nervousness Syncope Acute indigestion Dr.Edial www.jantunghipertensi.com Note ..! : Note ..! 1. 46% ACS no Chest pain 2. Elderly pt , Woman only 20% have chest pain 3. Thrombolytic not indicated for pt > 75 (Archives of Internal Medicine 3/2003) 4. An ECG that demonstrated ischemia, abn.Cardiac marker, additional pressence of ST elev. in Lead aVR,aVL and V1 indicates an acute Prox.LAD ,LMCA occlusion. 5. ST elev in lead aVR more than 1,5 mm 70% mortality 6. LMCA or 3 VD rarely respons to medical theraphy,should be referred emergently for invasive theraphy. Dr.Edial www.jantunghipertensi.com Patophysiology : Patophysiology ACS Plaque Rupture not the large clots the small clots tend to cause MI Dr.Edial TIMI Score : TIMI Score 1. Age > 65 2. 3 or more tradiotional Risk Factors (HTN,DM,Hyperchol,FH,Smoking) 3. Known coronary stenosis 0f 50% 0r greater 4. ST-segmen deviation on ECG 5. 2 or more anginal events in past 24 hours 6. ASA use during past week 7. Elevated Cardiac Enzymes Score : 3 or more Increased risk of death or MI Score 0-2 low risk 3-4 moderate risk 5-7 high risk Syndrme X : Syndrme X Chest Pain Positive Exercise Normarl Coronary Angiography Dr.Edial www.jantunghipertensi.com EKG in ACS : EKG in ACS Myocardial Ischemia Non Q Wave Infarction ST Elevation Q Wave infarction Noninfarction Transmural Ischemia (Including Prinzmetal variant angina) Noninfarction subendocardial Ischemia (Including Classic Angina) ST Depretion or T wave Inverted Without Q wave T Inverted / ST Depressions New Q wave, Usually proceded by Hyperacute T, with ST elevation Folowed by T wave Invertions ST Segmen Elevation Myocardial Infarction(STEMI) : ST Segmen Elevation Myocardial Infarction(STEMI) Dr.Edial Slide 24: STEMI Definition ST Elevation (In anterior Leads more than 2 mm, in limb leads more 1 mm) In 2 consecutive EKG leads (except presumably new LBBB) and : Clinical symptoms ( eg : chest pain) Raised markers of Myocardial Injury New wall motion on Echo New perfusion defect on SPECT MPI Dr.Edial www.jantunghipertensi.com Physical Examination In MI : Physical Examination In MI General : Appearance (Anxiety,orthopnoe,Altered sensorium) Fundus Oculi : (HPN,DM,Embolus) Heart : (Tachycardia,Bradicardia, other Arrhytmias) Peripheral : Pulses & Carotid (PAD,HTN,SHOCK) Blood Pressure : (HTN,Hypotension) Temperature : (Due to Shock) Respiration : (Tahypnoea) JVP : (CHF, RVMI,Shock) Chest : Crackless,Bronchospasm, PLEF) Dr.Edial Physical Examination In MI : CVS : Heartsounds : (Soft S1, Loud S2) Murmurs : (MR, VSR) Pericardial Rub Abdomen : (Diaphregmetic Irritation,Liver) Physical Examination In MI Dr.Edial www.jantunghipertensi.com Slide 27: Laboratory Findings Mioglobin Troponin – I CK-MB CK-Nac LDH GOT-GPT Laboratory Findings : Laboratory Findings Dr.Edial EKG : EKG Diagnostic Test To Deferentiating Between STEMI and NON-STEMI ACS Serial Standard 12 Lead EKG is Reccomended RV Leads in Case of Inferior Wall MI aVR, aVL, V1 LMCA , >> Mortality Dr.Edial www.jantunghipertensi.com Slide 30: General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial www.jantunghipertensi.com EKG Sequences in Acute Anterolateral STEMI : EKG Sequences in Acute Anterolateral STEMI Dr.Edial Echocardiography : Echocardiography Useful in emergency as Being Portable Specially in cases where : 1. EKG non-diganostic (LBBB). 2.ACS vs Aortic disection 3.Suspected complications of STEMI (VSR,Free wall rupture, Chordi rupture). 4.Information about arterial territory involveled 5.Information about EF/MR, Pericardial effusion www.jantunghipertensi.com Echocardiography – Territory Identification : Echocardiography – Territory Identification Slide 34: Management of Patient With ST Elevation Myocardial Infarction Dr.Edial www.jantunghipertensi.com Slide 35: General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial Slide 36: General Point of Treatment (Cont) 9. Glycemic controll 10. Hemodinamic Monitoring 11. Physical Activity (Limitation) 12. Compicatios of STEMI & Their Management 13. Early Risk Stratification 14. Planning Discharge 15. Longterm Management & Secondary Prevention Dr.Edial www.jantunghipertensi.com Slide 37: Immediate Management Assess Hemodynamics Strict Bed rest Intranasal Oxygen Aspirin 325mg Uncoated to be chewed Stat Clopidogrel 300mg Stat I/V Betablockers if not containdicated Dr.Edial www.jantunghipertensi.com Slide 38: Control of Pain NTG Oral / IV Morphine Betablockers/ NHP Calcium channel blockers Stop NSADS and Steroids www.jantunghipertensi.com Slide 39: Reperfusion Therapy First one hour is Golden Hour Within initial 3 hours results of Thrombolysis and primary PCI are same Dr.Edial www.jantunghipertensi.com Slide 40: Contraindications & Cautions Absolute Contraindications 1. Any prior intracranial hemorrhage 2. Known structural cerebral vascular lession (eg : arterio- veous malformation) 3. Ischemic Stroke within 3 mo EXCEPT acute ischemic stroke within 3 hr 4. Suspected Aortic dissection 5. Active bleeding or bleeding diathesis (excluding menses) 6. Significant closed head or facial trauma within 3 mo Intracranial neoplasm Active internal bleeding (not menses) Dr.Edial Slide 41: Contraindications & Cautions Relative Contraindications History of Chronic severe poorly controled hypertension Severe uncontrolled hypertension on presentation (SBP > 180 Hg or DBP > 110 Hg) 3. History of prior ischemic stroke > 3 mo dementia, or known intracranial pathology not cavered in contraindications Traumatic or prolonged (> 10 min) CPR or major surgery (< 3wk) Recent ( within 2-4 wk) internal bleeding Noncompressible vascular punctures For streptokinase/Anistreplase : prior exposure (> 3 days ago) or prior allergic reaction to these aggens Pregnancy Active peptic ulcers Current use of antycoagulants : the higher the INR, the higher the risk of bleeding 11. INR > 2 or bleeding diatheses Slide 42: INJURI : Slide 43: EVOLUSI EKG : IMA Dr.Edial Slide 44: Nyeri dada Dugaan SKA ST elevasi Saat datang Diagnosis kerja EKG Biokimiawi Stratifikasi risiko Diagnosis Tatalaksana Abnormalitas ST/T EKG normal/tdk khas Troponin positif Troponin negatif Risiko tinggi Risiko rendah NSTEMI Angina tak stabil STEMI Reperfusi Invasif Non invasif Dr.Edial www.jantunghipertensi.com Slide 45: Biochemical Cardiac Markers for the Evaluation and Management of Patients Suspected of Having an ACS but Without ST-Segment Elevation on 12-Lead ECG Slide 46: Risiko tinggi * Nyeri dada berulang * St Elevalsi persisten * Komplikasi mekanik syok, gagal jantung akut, mur - mur baru Dr.Edial www.jantunghipertensi.com Slide 47: Dr.Edial Slide 48: Stratifikasi sebelum pasien dipulangkan STEMI Invasi primer Fibrinolitik Tanpa reperfusi Kateterisasi (+) Kateterisasi (-) EF > 40% EF < 40% Risiko Tinggi (+) Risiko Tinggi (-) EF > 40% EF < 40% Risiko Tinggi (-) Risiko Tinggi (+) Kateterisasi & revaskularisasi sesuai indikasi Revasikulasi sesuai indikasi Evaluasi fungsional Dr.Edial Slide 49: Evaluasi fungsional EKG dapat dinilai EKG tak dapat dinilai Mampu uji latih Tak mampu uji latih Mampu uji latih Uji latih submak sebelum pulang Uji latih sesuai kemampuan sebelum atau sesudah pulang Ekokardiografi dobutamin Pemeriksaan nuklir Adenosin/dipiridamol Iskemi signifikan (+) Iskemi signifikan (-) Terapi medikamentosa Pemeriksaan nuklir uji latih Ekokardiografi uji latih Kateterisasi & Revaskularisasi sesuia indikasi Dr.Edial Slide 52: Chest pain consistent with coronary ischemia With in 10 mnutes Initial evaluation * 12 leads EKG Establish IV acces * Establish cont EKG monitoring Blood for baseline serum cardiac marker *Aspirin 160-325 mg chewed Therapeutic diagnostic tracking according to 12 leads EKG result Nondiagnostic/normal EKG EKG suggestive of ischemia or T wave inversion or ST segment depression ST segmen elevation or new bundle Continous evaluation monitoring in emergency departement or chet pain unit Serial serum cardiac marker Seria EKG Consider noninvasive evaluation or Consider alternative diagnostic Anti ischemia theraphy Analgesia * Assess suitability for reperfusion Contraindication for fibronolysis Avaiability and appropriate EKG of primery angioplasty inititate . anti ischemia . theraphy Beta-blocker, * Nitroglycerine,Analgesia Adm it to unit of appropriate intensity Admission blood work : -CBC BUN, Electrolyte -Creatinine, -Lipid profile Admission blood work Initiate fibrinolytic if indicated. Goal 30 minutes from entry to ED Primary PTCA if available and suitable (Goal PTCA , 90 +/- 30 minutes Admin it - CCU No evidense of MI or iscehemia Discharge with follw up as appropriate (Goal 8-12 hours MI or demonstrable ischemia Slide 56: Dr.Edial Slide 59: www.jantunghipertensi.com Slide 60: www.jantunghipertensi.com : Dr.Edial Slide 68: Siaran Berita SKA Slide 69: Treadmil... Normal..:1 Slide 70: Kesalahan Treadmil... V0l 2 Slide 71: Treadmil... Senam V0l 2 Slide 72: TERIMAKASIH You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Sindrom Koroner Akut jantungku Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1693 Category: Education License: All Rights Reserved Like it (4) Dislike it (0) Added: October 19, 2009 This Presentation is Public Favorites: 0 Presentation Description Sindrom Koroner Akut merupakan suatu keadaan atau kejadian yang sangat berbahaya karena tingginya angka kematian dan kesakitan. Comments Posting comment... By: gotelvia (18 month(s) ago) dok,, slide nya boleh di download gak ??? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: Acute Coronary Syndrome Dr.Edial Dr.Edial www.jantunghipertensi.com Slide 2: Spectrum of Acute Coronary Syndromes Unstable Angina Non STEMI STEMI alDr.Edi www.jantunghipertensi.com Slide 3: INCIDENCE Acute Coronary Syndromes 1,57 million Hospital Admission = ACS UAP/NonSTEMI STEMI 1,24 Million per year 0,33 Million per year Dr.Edial www.jantunghipertensi.com Slide 4: ACS - Predisposing Factors Conventional Risk Factors Smoking Hypertenssion Dyslipidemia Metabolic Syndrome Insuline Resistance & DM Obesity Mental Stress & Depression > 20 % ACS No Risk Factors Jama 290(7):891-898,Aug 2003 www.jantunghipertensi.com Slide 5: Novel Risk Factors * hs CRP * Homocystin * Lpa * Fibrinogen * D-Dimer Dr.Edial New Risk Factors : New Risk Factors Cocain/Meth HIV CKD RA SLE NEJM 2003 Nov 20;349 Slide 7: ACS - Presentations Typical Angina Definition Of Typical Angina * Typical : atleast 2 out 0f 3 * Atypical : 1 out of 3 * Non-Anginal Chest pain = 0 * “ Asymptomatic “ = o persent Natural Pain Presipitating Factors Relieving Factors Dr.Edial www.jantunghipertensi.com Slide 8: Response to Nitroglycerin has no diagnostic Role Sensitivity = 35%, specificity = 50% (Am J Card 90;1264,Des 1 2002) Dr.Edial Slide 9: Dr.Edial www.jantunghipertensi.com Slide 10: Differential Diagnosis Acute Aortic Dissection Acute Pericarditis Miocarditis Pulmonary Embolism Atypical Angina Vasospastic Angina Hypertropic Cardiomyopathy Hyperkalemia BBB (Bundle Brunch Block) Early Repolarization WPW(Wolf -Parkinson-White) Bruguda Syndrome www.jantunghipertensi.com Cardiac Dr.Edial Slide 11: Pleuretic Pain Chest wall pain GERD (Gasro-Esophageal reflux and Spasm) Ulcus pepticum Panic attack Psikogenic Dissorder Differential Diagnosis Non Cardiac Dr.Edial Slide 12: Evaluation of patients suspected of having ACS * Clasical Angina at rest or at less than usual activity * Nature of Pain 1. Usually more than 30 min for MI & 20-30 for UAP 2. Squezing, Constricting, Crushing 3. Oppressing, Compressing 4. Retrosternal * Spreading To Both side of anterior chest (more to the left) Ulnar aspect of Arm * In some cases epigastric pain Dr.Edial Slide 13: Evaluation of patients suspected of having ACS Others Symptoms Cold Perspirations Nausea/Vomiting (Vagal Stimulations) Profound weakness Dizziness Palpitation Dr.Edial www.jantunghipertensi.com Slide 14: Silent ACS Due to aotonomic Disturbance Specially See in Diabetic and Hypertensive patients Older patients Women 40.000/yr.. Chest Pain, in US loss ACS Dr.Edial Symptoms ACS – for Women : Symptoms ACS – for Women Heart disease kills more Women than Men every year. Women symptoms of heart disease differently then Men 1. Shortness of breath, often without chest pain of any kind 2. Flu-like symptoms- specifically nausea,clamminess or cold sweats 3. Unexplained fatique,weakness or dizziness 4. Pain in the chest,upper back,shoulder,neck or jaw 5. Feelings of anxiety, loss of appetite, disconfort Dr.Edial www.jantunghipertensi.com Los Aneles-Mey 11,2009Archives of Internal Medicine. : Los Aneles-Mey 11,2009Archives of Internal Medicine. Women chest pain without CAD Elevated risk CV event, heart attack or stroke Cedars-Sinai Heart Institute study, Women with Chest Pain Positive Exercise Normarl Coronary Angiography 5 yr,,, more CV evetns then women no chest pain Cause : microvascular angina, endothelial dysfunction Dr.Edial Sent home without treatment www.jantunghipertensi.com Atypical Presentations of ACS : Atypical Presentations of ACS Classical Angina without severe or prolonged pain Heart failure Atypical location of pain CNS manifestations Apprehension/nervousness Syncope Acute indigestion Dr.Edial www.jantunghipertensi.com Note ..! : Note ..! 1. 46% ACS no Chest pain 2. Elderly pt , Woman only 20% have chest pain 3. Thrombolytic not indicated for pt > 75 (Archives of Internal Medicine 3/2003) 4. An ECG that demonstrated ischemia, abn.Cardiac marker, additional pressence of ST elev. in Lead aVR,aVL and V1 indicates an acute Prox.LAD ,LMCA occlusion. 5. ST elev in lead aVR more than 1,5 mm 70% mortality 6. LMCA or 3 VD rarely respons to medical theraphy,should be referred emergently for invasive theraphy. Dr.Edial www.jantunghipertensi.com Patophysiology : Patophysiology ACS Plaque Rupture not the large clots the small clots tend to cause MI Dr.Edial TIMI Score : TIMI Score 1. Age > 65 2. 3 or more tradiotional Risk Factors (HTN,DM,Hyperchol,FH,Smoking) 3. Known coronary stenosis 0f 50% 0r greater 4. ST-segmen deviation on ECG 5. 2 or more anginal events in past 24 hours 6. ASA use during past week 7. Elevated Cardiac Enzymes Score : 3 or more Increased risk of death or MI Score 0-2 low risk 3-4 moderate risk 5-7 high risk Syndrme X : Syndrme X Chest Pain Positive Exercise Normarl Coronary Angiography Dr.Edial www.jantunghipertensi.com EKG in ACS : EKG in ACS Myocardial Ischemia Non Q Wave Infarction ST Elevation Q Wave infarction Noninfarction Transmural Ischemia (Including Prinzmetal variant angina) Noninfarction subendocardial Ischemia (Including Classic Angina) ST Depretion or T wave Inverted Without Q wave T Inverted / ST Depressions New Q wave, Usually proceded by Hyperacute T, with ST elevation Folowed by T wave Invertions ST Segmen Elevation Myocardial Infarction(STEMI) : ST Segmen Elevation Myocardial Infarction(STEMI) Dr.Edial Slide 24: STEMI Definition ST Elevation (In anterior Leads more than 2 mm, in limb leads more 1 mm) In 2 consecutive EKG leads (except presumably new LBBB) and : Clinical symptoms ( eg : chest pain) Raised markers of Myocardial Injury New wall motion on Echo New perfusion defect on SPECT MPI Dr.Edial www.jantunghipertensi.com Physical Examination In MI : Physical Examination In MI General : Appearance (Anxiety,orthopnoe,Altered sensorium) Fundus Oculi : (HPN,DM,Embolus) Heart : (Tachycardia,Bradicardia, other Arrhytmias) Peripheral : Pulses & Carotid (PAD,HTN,SHOCK) Blood Pressure : (HTN,Hypotension) Temperature : (Due to Shock) Respiration : (Tahypnoea) JVP : (CHF, RVMI,Shock) Chest : Crackless,Bronchospasm, PLEF) Dr.Edial Physical Examination In MI : CVS : Heartsounds : (Soft S1, Loud S2) Murmurs : (MR, VSR) Pericardial Rub Abdomen : (Diaphregmetic Irritation,Liver) Physical Examination In MI Dr.Edial www.jantunghipertensi.com Slide 27: Laboratory Findings Mioglobin Troponin – I CK-MB CK-Nac LDH GOT-GPT Laboratory Findings : Laboratory Findings Dr.Edial EKG : EKG Diagnostic Test To Deferentiating Between STEMI and NON-STEMI ACS Serial Standard 12 Lead EKG is Reccomended RV Leads in Case of Inferior Wall MI aVR, aVL, V1 LMCA , >> Mortality Dr.Edial www.jantunghipertensi.com Slide 30: General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial www.jantunghipertensi.com EKG Sequences in Acute Anterolateral STEMI : EKG Sequences in Acute Anterolateral STEMI Dr.Edial Echocardiography : Echocardiography Useful in emergency as Being Portable Specially in cases where : 1. EKG non-diganostic (LBBB). 2.ACS vs Aortic disection 3.Suspected complications of STEMI (VSR,Free wall rupture, Chordi rupture). 4.Information about arterial territory involveled 5.Information about EF/MR, Pericardial effusion www.jantunghipertensi.com Echocardiography – Territory Identification : Echocardiography – Territory Identification Slide 34: Management of Patient With ST Elevation Myocardial Infarction Dr.Edial www.jantunghipertensi.com Slide 35: General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial Slide 36: General Point of Treatment (Cont) 9. Glycemic controll 10. Hemodinamic Monitoring 11. Physical Activity (Limitation) 12. Compicatios of STEMI & Their Management 13. Early Risk Stratification 14. Planning Discharge 15. Longterm Management & Secondary Prevention Dr.Edial www.jantunghipertensi.com Slide 37: Immediate Management Assess Hemodynamics Strict Bed rest Intranasal Oxygen Aspirin 325mg Uncoated to be chewed Stat Clopidogrel 300mg Stat I/V Betablockers if not containdicated Dr.Edial www.jantunghipertensi.com Slide 38: Control of Pain NTG Oral / IV Morphine Betablockers/ NHP Calcium channel blockers Stop NSADS and Steroids www.jantunghipertensi.com Slide 39: Reperfusion Therapy First one hour is Golden Hour Within initial 3 hours results of Thrombolysis and primary PCI are same Dr.Edial www.jantunghipertensi.com Slide 40: Contraindications & Cautions Absolute Contraindications 1. Any prior intracranial hemorrhage 2. Known structural cerebral vascular lession (eg : arterio- veous malformation) 3. Ischemic Stroke within 3 mo EXCEPT acute ischemic stroke within 3 hr 4. Suspected Aortic dissection 5. Active bleeding or bleeding diathesis (excluding menses) 6. Significant closed head or facial trauma within 3 mo Intracranial neoplasm Active internal bleeding (not menses) Dr.Edial Slide 41: Contraindications & Cautions Relative Contraindications History of Chronic severe poorly controled hypertension Severe uncontrolled hypertension on presentation (SBP > 180 Hg or DBP > 110 Hg) 3. History of prior ischemic stroke > 3 mo dementia, or known intracranial pathology not cavered in contraindications Traumatic or prolonged (> 10 min) CPR or major surgery (< 3wk) Recent ( within 2-4 wk) internal bleeding Noncompressible vascular punctures For streptokinase/Anistreplase : prior exposure (> 3 days ago) or prior allergic reaction to these aggens Pregnancy Active peptic ulcers Current use of antycoagulants : the higher the INR, the higher the risk of bleeding 11. INR > 2 or bleeding diatheses Slide 42: INJURI : Slide 43: EVOLUSI EKG : IMA Dr.Edial Slide 44: Nyeri dada Dugaan SKA ST elevasi Saat datang Diagnosis kerja EKG Biokimiawi Stratifikasi risiko Diagnosis Tatalaksana Abnormalitas ST/T EKG normal/tdk khas Troponin positif Troponin negatif Risiko tinggi Risiko rendah NSTEMI Angina tak stabil STEMI Reperfusi Invasif Non invasif Dr.Edial www.jantunghipertensi.com Slide 45: Biochemical Cardiac Markers for the Evaluation and Management of Patients Suspected of Having an ACS but Without ST-Segment Elevation on 12-Lead ECG Slide 46: Risiko tinggi * Nyeri dada berulang * St Elevalsi persisten * Komplikasi mekanik syok, gagal jantung akut, mur - mur baru Dr.Edial www.jantunghipertensi.com Slide 47: Dr.Edial Slide 48: Stratifikasi sebelum pasien dipulangkan STEMI Invasi primer Fibrinolitik Tanpa reperfusi Kateterisasi (+) Kateterisasi (-) EF > 40% EF < 40% Risiko Tinggi (+) Risiko Tinggi (-) EF > 40% EF < 40% Risiko Tinggi (-) Risiko Tinggi (+) Kateterisasi & revaskularisasi sesuai indikasi Revasikulasi sesuai indikasi Evaluasi fungsional Dr.Edial Slide 49: Evaluasi fungsional EKG dapat dinilai EKG tak dapat dinilai Mampu uji latih Tak mampu uji latih Mampu uji latih Uji latih submak sebelum pulang Uji latih sesuai kemampuan sebelum atau sesudah pulang Ekokardiografi dobutamin Pemeriksaan nuklir Adenosin/dipiridamol Iskemi signifikan (+) Iskemi signifikan (-) Terapi medikamentosa Pemeriksaan nuklir uji latih Ekokardiografi uji latih Kateterisasi & Revaskularisasi sesuia indikasi Dr.Edial Slide 52: Chest pain consistent with coronary ischemia With in 10 mnutes Initial evaluation * 12 leads EKG Establish IV acces * Establish cont EKG monitoring Blood for baseline serum cardiac marker *Aspirin 160-325 mg chewed Therapeutic diagnostic tracking according to 12 leads EKG result Nondiagnostic/normal EKG EKG suggestive of ischemia or T wave inversion or ST segment depression ST segmen elevation or new bundle Continous evaluation monitoring in emergency departement or chet pain unit Serial serum cardiac marker Seria EKG Consider noninvasive evaluation or Consider alternative diagnostic Anti ischemia theraphy Analgesia * Assess suitability for reperfusion Contraindication for fibronolysis Avaiability and appropriate EKG of primery angioplasty inititate . anti ischemia . theraphy Beta-blocker, * Nitroglycerine,Analgesia Adm it to unit of appropriate intensity Admission blood work : -CBC BUN, Electrolyte -Creatinine, -Lipid profile Admission blood work Initiate fibrinolytic if indicated. Goal 30 minutes from entry to ED Primary PTCA if available and suitable (Goal PTCA , 90 +/- 30 minutes Admin it - CCU No evidense of MI or iscehemia Discharge with follw up as appropriate (Goal 8-12 hours MI or demonstrable ischemia Slide 56: Dr.Edial Slide 59: www.jantunghipertensi.com Slide 60: www.jantunghipertensi.com : Dr.Edial Slide 68: Siaran Berita SKA Slide 69: Treadmil... Normal..:1 Slide 70: Kesalahan Treadmil... V0l 2 Slide 71: Treadmil... Senam V0l 2 Slide 72: TERIMAKASIH