mengenali acs: cegah dan tangani dg cepat dan benar
Post on 23-Jan-2016
90 Views
Preview:
DESCRIPTION
TRANSCRIPT
Mengenali ACS: Cegah dan tangani dg cepat dan benar
Mohammad Saifur Rohman, dr.SpJP, PhD.FICAMohammad Saifur Rohman, dr.SpJP, PhD.FICA
Mengapa Penting?
Jantung adalah organ yang sangat vitalMenjamin pasokan kebutuhan seluruh organ
tubuhJantung memompa lebih dari 1 juta gallon
pertahunBerhenti ----- DeathPertanda awal Kenali !Terlambat Irreversible (?)
Kegawatdarutan kardiak Cardiac arrestCardiac arrest Acute coronary syndromeAcute coronary syndrome Cardiac dysrhythmiasCardiac dysrhythmias Acute pulmonary oedemaAcute pulmonary oedema Trauma – both blunt & penetratingTrauma – both blunt & penetrating Cardiogenic shockCardiogenic shock Aortic dissectionAortic dissection Valve insufficiencyValve insufficiency
Slide No.Slide No. 33Bgm Keluhan & Tanda ?
Mengapa Harus Cepat?
Serangan Jantung Serangan Jantung Proses adaptasi terhadap perubahan yang Proses adaptasi terhadap perubahan yang
sangat cepatsangat cepat KompensasiKompensasi DekompensasiDekompensasi
Dapat di kenali dan diantisipasi serta dicegah
Diperbaiki? Tidak!, Dicegah? Ya !
Prevalensi SKA
Di Amerika : kejadian Infark miokard Akut Di Amerika : kejadian Infark miokard Akut (IMA) lebih 1 Juta/tahun(IMA) lebih 1 Juta/tahun
200,000 – 300,000 pasien IMA meninggal 200,000 – 300,000 pasien IMA meninggal sebelum sampai RS sebelum sampai RS
Total : Warga negara Amerika mengalami IMA Total : Warga negara Amerika mengalami IMA setiap 29 detik dan meninggal setiap menit.setiap 29 detik dan meninggal setiap menit.
Indonesia ? Indonesia ? Tahun 2008: PJN Harapan Kita 7 pasien SKA , Tahun 2008: PJN Harapan Kita 7 pasien SKA ,
50-60% IMA50-60% IMA !0% IMA < 40 thn!0% IMA < 40 thn
Topol EJ. CV med 2009Data PJN HK 2008
59 patients death cases among 356 patients
The second deadliest diseases
The mortality rate was 16,6% in 2010
SKA DI RSSA MALANG
Apa penyebab KEMATIAN?
keterlambatan pasien datang ke RS
Penanganan di RS
Apa penyebab KEMATIAN?
keterlambatan pasien datang ke RS
Penanganan di RS
Seeking care behaviour pattern
PatientSaiful
Anwar Hospital
Self Medication
PHC
General Practitioner role
Aterosklerosis SKA
Atherogenesis
Progression of Plaque toward Progression of Plaque toward rupturerupture
Progression of Plaque toward rupture
Plaque RupturePlaque Rupture
Platelet aggregation in Platelet aggregation in ruptured plaque ruptured plaque
Adventitia
Lipid core
Platelets aggregate at the site of rupture / erosion
Weissberg, 1999
Thrombus forms and extends into the lumen
Adventitia
Lipid core
Thrombus
Weissberg, 1999
Thrombus formationThrombus formation
Plaque Rupture Toward Plaque Rupture Toward OcclusionOcclusion
Spektrum SKA
Unstable Angina Pectoris :
(EKG normal, Trop T/I (-)) Acute Non ST-Elevation Myocardial Infarction
(NSTEMI) :
(EKG normal/ST depresi/T inversi dan Trop T/I (+))
Acute ST-Elevation Myocardial Infarction (STEMI) :
EKG ST elevasi dan Trop T/I(+)
Bagaimana Diagnosa SKA ?
Membedakan Nyeri dada: SKA?
1. Cardiac or non cardiac1. Cardiac or non cardiac2. Cardiac : Ischemic non Ischemic2. Cardiac : Ischemic non Ischemic3. Ischemic : Coronary non Coronary3. Ischemic : Coronary non Coronary4. Angina pektoris stabil atau SKA4. Angina pektoris stabil atau SKA
Nyeri (tidak enak) dada ….. ?
Sifat :Berat/ tertindih (pressure, tightness, or heaviness, pressure, tightness, or heaviness,
strangling, constricting, or compression),strangling, constricting, or compression), Panas
(burning) burning) ; Masuk angin, Sesak,”maag” Lokasi: Di dada kiri/tengah tidak bisa ditunjuk Penjalaran : ke bahu/lengan, leher, dagu, belakang,epigastrium Lama : 5-30’ Pencetus :aktifitas/stres/dingin Berkurang: Nitrat/Istirahat Tidak khas: Pingsan/kejang/tidak sadar/berdebar
ESC guidelines for SAP 2006ESC AMI ST elevation guidelines 2008
Angina PectorisAngina Pectoris A syndrome resulting from myocardial A syndrome resulting from myocardial
ischemiaischemia Demand and supply imbalanceDemand and supply imbalance Careful history taking; mode of onset, Careful history taking; mode of onset,
location, quality of pain, duration, precipitating location, quality of pain, duration, precipitating factors, pattern of disappearance, risk factor, factors, pattern of disappearance, risk factor, etcetc
Angina PectorisAngina Pectoris A syndrome resulting from myocardial A syndrome resulting from myocardial
ischemiaischemia Demand and supply imbalanceDemand and supply imbalance Careful history taking; mode of onset, Careful history taking; mode of onset,
location, quality of pain, duration, precipitating location, quality of pain, duration, precipitating factors, pattern of disappearance, risk factor, factors, pattern of disappearance, risk factor, etcetc
Hati-hati : Angina Equivalent
Indigestion, belching, dyspneaDM, wanita, manula (post operative)Didapatkan 5% dari ACS2% dipulangkan ternyata ACS
Braunwalds Heart Disease 8th Ed 2008
DD Chest pain
Ischemic Stenosis AortaRegurgitasi AortaHypertrophic CardiomyopathyAngina pada HypertensiHipertensi pulmonal berat
11th ed Hurst’s the heart 2005
DD Chest Pain
Non Ischemic Diseksi AortaPericarditisMitral valve prolaps
11th ed Hurst’s the heart 2005
DD Chest Pain
Gastro intestinalEsophageal spasm/reflux/rupturePeptic Ulcer
NeuromusculoskeletalCostochondritisHerpes zosterChest wall pain dan tenderness etc
11th ed Hurst’s the heart 2005
DD chest pain
PulmonaryPulmonary emboliPneumothoraxPenumonia with pleural involvement
Pleurisy
PsychogenicAxiety/depression/cardiac psychosis etc
11th ed Hurst’s the heart 2005
Non Angina Pain
Hanya terasa pada sebagian kecil dada kiri/kanan (bisa di tunjuk)
Berkahir berjam jam sampai berhari hari. Biasanya tidak berkurang dengan
nitrogliserinMungkin dicetuskan oleh debaran.
ESC guidelines for SAP 2006ESC AMI ST elevation guidelines 2008
Nyeri dada khas SKA
Angina awitan baru derajat 3 menurut klasifikasi kanada kardiovaskuler group
( nyeri dada timbul pada aktifitas ringan sehari-hari)
Angina saat istirahat > 20 menitPerburukan derajat angina menjadi derajat
3 dalam beberapa hari – 1 bln terakhir (Crescendo angina)
Atypical
Pemeriksaan Fisik
Sadar-KomaSadar-Koma TD: Hypertensi-Normal-HypoptensiTD: Hypertensi-Normal-Hypoptensi HR: Regular-irregular/ Bradycardia-TachycardiaHR: Regular-irregular/ Bradycardia-Tachycardia
pulselesspulseless RR: Tachypnea-apneaRR: Tachypnea-apnea Cor: Regular-iregular, murmur, gallopCor: Regular-iregular, murmur, gallop Pulmo: Normal-Rales- wheezingPulmo: Normal-Rales- wheezing Ext: dingin/hangat, edema+/-, etc.Ext: dingin/hangat, edema+/-, etc.
EKGEKG
Secepat mungkin – 10’ setelah pasien tibaSecepat mungkin – 10’ setelah pasien tibaDiulang apabila meragukan adanya Diulang apabila meragukan adanya
kenaikan segmen ST (ST televasi)kenaikan segmen ST (ST televasi)Bandingkan denga EKG sebelumnyaBandingkan denga EKG sebelumnyaPasang monitor EKGPasang monitor EKG
EKG : Gambaran aktifitas listrik jantung
EKG pada SKA
EKG dapat menentukan adanya:Old/Recent/Acute infarctionPericarditisArrhythmiasPembesaran jantung
Gambaran EKG pada Iskemik/IMAGambaran EKG pada Iskemik/IMA
UAP/Acute NSTEMI
Acute NSTEMI
Acute STEMI- Evolution
Acute STEMI-Q wave
Occluded artery
ECG demonstrates large anterior infarction
Anterior STEMI
Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6
with precordial ST depression
Inferior STEMI
Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
Inferior STEMI
EKG
Gangguan IramaGangguan Irama Infark baru atau lamaInfark baru atau lamaPerikarditisPerikarditisPembesaran jantung dllPembesaran jantung dll
2nd degree Type 1
1st degree
3rd degree
2nd degree Type II
Ventricular Tachycardia (VT)
Ventricular Tachycardia (V T)
Unable to determine rhythmUnable to determine rhythmRegularRegular ventricular rate (100-250) ventricular rate (100-250)No P waves presentNo P waves presentQRS complex > 0.10 secQRS complex > 0.10 sec
Ventricular Fibrillation (Ventricular Fibrillation (VF))
Coarse
Fine
Peningkatan Enzym jantung
Troponin T/Troponin ITroponin T/Troponin ICKMBCKMB
Chest x-ray
CTR 62%
Aorta elongation
Po normal
Cardiac Waist (+)
Apex lat downward
Congestion (+)
Non Invasif
Invasif
Universal Definition of Myocardial Infarction
Diagnosa AMI ditegakkan apabila min memenuhi 2 dari kriteria:
Gejala Ischemic Perubahan EKG Kenaikan/penurunan Troponin T/I
Stratifikasi Resiko
High risk Intermediate risk Low risk
Angina saat Istirahat Angina > 20 kurang dengan istirahat
Angina dengan aktivitas
ALO Riwayat CVD
LBBB/RBBB baru Ada Q, ST depresi
ENZYME (+) Sedikit meningkat ENZYM (-)
MR ATAU S3 Baru,
HYPOTENSI, BRADIKARDI, TAKIKARDI. VT
Usia > 70 tahun
ST DEPRESI> 0.5 T inversi EKG TETAP
Prinsip Terapi
Cepat (time responsif), obati penyebab buka sumbatan
Terlambat: FatalMonitor ketat tanda vital sejak awalAntisipasi dini tanda tanda perburukan dan
komplikasi
Terapi Awal SKA
Atasi keadaan kegawat daruratan : Atasi keadaan kegawat daruratan : asistol, apney, syock, lung edema, asistol, apney, syock, lung edema, gagal jantung dll. gagal jantung dll.
Terapi reperfusi : PCI, Fibrinolitik, Terapi reperfusi : PCI, Fibrinolitik, heparinheparin
AntiischemicAntiischemicTerapi komorbid; hipertensi, DM, dllTerapi komorbid; hipertensi, DM, dll
Pentingnya Reperfusi
Sumbatan total15-30 menit tanpa kolateral IMA
Reperfusion selamatkan miorkardKematian1 bulan: 25-30% 4-6% dengan
reperfusi (PCI, fibrinolytic, antithombotic)
ESC AMI ST elevation guidelines 2008
Kerusakan Miokard IrreversibelKerusakan Miokard Irreversibel
Miokard tidak mengalami regenerasi Terlambat/tidak dibuka Miokard mati
Gagal Jantung rawat ulang biaya besar, kualitas hidup kurang baik
Obat gagal Jantung hanya mencegah perburukan, tidak memperbaiki miokard yang mati/infark
Alternatif terapi : Stem cell
The time is muscleThe time is muscle
Terapi NSTEMI
O2O2 Bed restBed rest Pain killerPain killer Nitrate and anti-ischemiaNitrate and anti-ischemia Antiplatelet : Aspirin, ClopidogrelAntiplatelet : Aspirin, Clopidogrel HeparinHeparin HTNHTN Hyperglicemia Hyperglicemia Treat the complication etcTreat the complication etc
Terapi STEMI
O2 Bed rest Pain killer Nitrate and anti-ischemia Antiplatelet : Aspirin, Clopidogrel Fibrinolytic time to neddle : 30 m/PCI HTN Hyperglicemia Treat the complication etc
Fibrinolitik
Manfaat bila onset < 12 jam, optimal bila onset < 3 jam
Bila dikirim ke RS dengan PCI > 90 menit, fibrinolitik
Konsep baru : Fibrinolitik di Ambulan menuju RS Perhatikan kontraindikasi fibrinolitik Awasi ketat komplikasi fibrinolitik seperti
perdarahan, stroke, syok dll Perhatikan tanda tanda keberhasilan: nyeri
hilang, ST elevasi turun >50%, Junctional VES(+), bila gagal rescue PCI
Kontra Indikasi AbsolutKontra Indikasi Absolut
Any prior ICH Known structural cerebral vascular lesion (eg, AVM) Known malignant intracranial neoplasm (primary or
metastatic) Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within 3 months
Kontra Indikasi RelatifKontra Indikasi Relatif
History of chronic severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg
or DBP greater than 110 mm Hg)† History of prior ischemic stroke greater than 3 months, dementia, or known
intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less
than 3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior
allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
Treatment of STEMI Treatment of STEMI
Percutaneous Coronary Intervention
•Primary PCI : Pasien langsung di lakukan tindakan reperfusi dengan membuka sumbatan di arteri koroner tanpa dilakukan fibrinilotik terlebih dahulu•Rescue PCI : Dilakukan PCI setelah gagal dengan terapi fibrinolitik•Facilitated PCI : Pasien dilakukan fibrinolitik terlebih dahulu meskipun sudah ada rencana PCI •Urgent PCI: As soon as possible•Early PCI : Dalam waktu 24 jam pertama
Early/urgent PCI: Resiko tinggi, hemodinamik tidak stabil, aritmia maligna, angina (+) dgn terapi, EF <40%,Gagal jantung, Riwayat PCI, CABG dl 6 bl
Tim PCITim PCI
TargetTarget
1. Time to balloon : 90 m2. Yang dibuka hanya Culprit lesion (pembuluh darah tersumbat yang menyebabkan IMA kali ini) saja3. Aliran darah yang diintervensi kembali lancar
A 53 yo man reffered from a private A 53 yo man reffered from a private hospital for primary PCIhospital for primary PCI
A typical chest after exercise 2 hr prior to A typical chest after exercise 2 hr prior to admission admission
ECG send by faxECG send by faxPCI appointment via phonePCI appointment via phonePatient directly transfer red to cath labPatient directly transfer red to cath lab
Primary PCI Case
Komplikasi MI
MechanicalElectricalIschemiaEmbolicInflammation
Komplikasi Mekanik
Ventricular Septal RuptureMitral RegurgitationCardiac free wall ruptureLarge ventricular aneurysmsLV pump failure and cardiogenic shockDynamic LVOT obstructionRV failure
Gagal Jantung (Kriteria Framingham)
MajorMajor Acute pulmonary edemaAcute pulmonary edema PND or orthopneaPND or orthopnea CracklesCrackles S3 gallopS3 gallop HJR/Increased JVPHJR/Increased JVP CardiomegalyCardiomegaly Wt loss >4.5 kg 5d into Wt loss >4.5 kg 5d into
RxRx
MinorMinor Night coughNight cough Tachycardia >120Tachycardia >120 Pleural effusionPleural effusion HepatomegalyHepatomegaly Ankle edemaAnkle edema Vital capacity decrease Vital capacity decrease
>1/3 from max>1/3 from max
*Two major or one major and two minor*
SA Dysfunction Atrial FibrillationFirst-Second degree AV block Total AV Block Left Bundle Branch BlockRight Bundle Branch BlockVentricular TachycardiaVentricular Fibrillation
Komplikasi Elektrik
Perluasan InfarkPerluasan InfarkAngina Post-infarkAngina Post-infark
Komplikasi IschemikKomplikasi Ischemik
Systemic embolism ;
stroke, limb ischemia, renal infarction, intestinal ischemia
Komplikasi EmboliKomplikasi Emboli
Early PericarditisLate Pericarditis (Dresslers syndrome)
Komplikasi Inflamasi
Primary PCI Case
CASE 2CASE 2
CABGCABG
Failed PCI with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery.
Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, have a significant area of myocardium at risk, and are not candidates for PCI or fibrinolytic therapy.
At the time of surgical repair of postinfarction ventricular septal rupture (VSR) or mitral valve insufficiency.
CABGCABG
Cardiogenic shock in patients less than 75 years old with ST elevation, LBBB, or posterior MI who develop shock within 36 hours of STEMI, have severe multivessel or left main disease, and are suitable for revascularization that can be performed within 18 hours of shock
Life-threatening ventricular arrhythmias in the presence of greater than or equal to 50% left mainstenosis and/or triple-vessel disease.
Tips
Obat anti ischemik atau anti nyeri segera di berikan Anti platelet dan heparin dimasukkan secepatnya
setelah diagnosis ACS-NSTEMI ditegakkan, jangan di tunda
Turunkan kebutuhan/kerja jantung dengan berikan rasa nyaman dan aman pasien dan bed rest total
Setengah duduk pada pasien dengan gagal jantung
Pikirkan immediate/urgent PCI pada pasien resiko tinggi/hemodinamik tidak stabil/nyeri berkepanjangn/aritmia maligna dll
Yang sering di lupakan…..
Edukasi pasien mengenai : Mengapa bisa sampai sakit….. Pola hidup Kepatuhan untuk merubah pola hidup Faktor resiko di kendalikan, rokok, HT, dll Kepatuhan minum obat Mencegah serangan jantung berikutnya
dengan…..merubah pola hidup, atur pola makan, olah raga teratur dan terukur
Reperfusi adalah awal dimulainya hidup baru …agar koroner tetap terbuka
SimpulanSimpulan
Tegakkan diagnosa dengan cepat dan tepat Tegakkan diagnosa dengan cepat dan tepat Terapi dengan cepat dan tepat : ReperfusiTerapi dengan cepat dan tepat : Reperfusi Monitor ketat Monitor ketat Cegah komplikasiCegah komplikasi Edukasi untuk prevensi dan rehabilitasiEdukasi untuk prevensi dan rehabilitasi
……..…….Kerja keras di awal……..…….Kerja keras di awal……
Pesan Penting
Tambah ilmu…..3X ..amalkan…
Semoga menjadi ilmu yang bermanfaat
Pengabdian dengan ilmu dan ikhlas
top related