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Penyakit Jantung KoronerIdentitas Nama : Ny. EUsia : 60 thPekerjaan : IRT Alamat : Tebon

Tanggal masuk : 15 April 2014Tanggal pemeriksaan : 15 April 2014SKU : Nyeri dada kiri Pasien datang dengan keluhan nyeri dada kiri sudah dirasakan sejak 2 hari yll memberat 6 jam SMRS. Nyeri dada dirasa seperti ditekan benda berat dan terasa panas. Nyeri dirasa menjalar hingga bahu kiri, rahang, dan tangan kanan kiri. Nyeri dada dirasakan 1 jam, mendadak saat pasien istirahat belum ada perbaikan hingga dibawa ke IRD (jam 20:00). Sesak (-), mual (-), muntah (-)

RPDKeluhan serupa (nyeri dada) (-)Hipertensi (+) tidak terkontrol > 5 tahun dengan riwayat pengobatan captopril diminum hanya jika ada keluhanDiabetes Melitus (-)Kolestrol (-) RPKKeluhan serupa (nyeri dada) ( -)Hipertensi (-)DM KebiasanPasien mengaku suka konsumsi makanan bersantanJarang melakukan olahragaMerokok (-)OKU : compos mentisGCS : 456Vital Sign :TD : 140/90N : 82 X/ mntR : 20 X/ mntt : 37,1 CKepala : CA -/- SI -/- Leher : pembesaran KGB JVP tidak meningkat (5 + 2)Thorax :Inspeksi :Ictus cordis tidak tampak, tidak terlihat luka, bekas luka dan massaPalpasi : Ictus cordis teraba, tidak kuat angkat, tidak ditemukan massa, krepitasiPerkusi : batas jantung kanan : SIC V parasternalis dekstra batas jantung kiri : SIC VI midklavikula sinistra batas atas jantung : SIC II parasternalis sinistra batas pinggang jantung : SIC III parasternalis sinistraAuskultasi :bunyi jantung S1S2 reguler tunggal suara jantung tambahan (-) rhonki (-/-) wheezing (-/-)

Abdomen :Inspeksi : rongga dada lebih tinggi dibanding rongga perutAuskultasi : BU+, supelPerkusi : timpaniPalpasi : nyeri tekan (-)Ekstremitas Oedem (-)Sianosis (-)Nyeri sendi (-)Hasil pemeriksaan Lab

EKG

APJK STEMI anterior iskemia inferior Hipertensi stage IPPlaning diagnostikFoto thoraxCardiac MarkerLab Kimia darah

Planing terapiCaptopril 3x12,5 mgISDN 3X5mgClopidogrel 1x75mgDiazepam 2x2 mgEnoxaparin sodium 2x 0,4 (lovenox)

PENYAKIT JANTUNG KORONER

PJK adalah penyakit jantung yang disebabkan oleh kelainan pada arteri coronariaModifikasi (-)Jenis kelaminKeturunanRasUmur L>45, P>55Modifikasi (+)HipertensiDislipidemiaPerokokAktifitas FisikObesitasDiabetesStres dan MarahFaktor Resiko

Sign & SymptomAngina Pectoris StabilAcute Coronary Syndrom Angina Pectoris Tidak StabilInfark miokard dengan ST elevasiInfark miokard tanpa ST elevasiSudden Death

Angina : Nyeri dada seperti tertekan pada prekordial (retrosternal) yang sering menjalar ke arah lengan kiri, leher kiri, rahang, hingga telingaPatofisiologi

Angina Stabilmerupakan tipe angina paling umum

Terjadi karena jantung bekerja lebih keras dari biasaanya

Angina stabil bukan serangan jantung, tetapi merupakan tanda adanya ancaman serangan jantung (infark) dimasa yang akan datangEtiologiAktivitas Fisik Stress emosionalSuhu dinginMerokokGejala Terjadi ketika jantung harus bekerja lebih keras, biasanya selama aktivitas fisik nyeri seperti tertindih Biasanya berlangsung singkat 5 menit Menurun atau hilang dengan istirahat atau obat angina Terasa seperti kembung Bisa dirasakan seperti nyeri dada yang menyebar ke lengan, punggung atau tempat lainSINDROM KORONER AKUTSuatu sindroma klinik yang menandakanadanya iskemia miokard akut, terdiri dari : Infark miokard akut (STEMI)Infark miokard akut (NSTEMI)Angina pektoris tidak stabil (UAP)

Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis.30PATOGENESISUmumnya disebabkan oleh aterosklerosis koronerPlak aterosklerosis ruptur terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koronerApabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan nekrosis

CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)The cardiovascular continuum of eventsDYSLIPIDEMIAMyocardial Ischemiaplaque32CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)The cardiovascular continuum of eventsDYSLIPIDEMIAMyocardial IschemiaCoronary Thrombosis33CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)The cardiovascular continuum of eventsDYSLIPIDEMIAMyocardial IschemiaCoronary ThrombosisACS34 Unstable AnginaSTEMI NSTEMINon occlusive thrombus

Non specific ECG

Normal cardiac enzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymesComplete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptomsPEMERIKSAAN FISIKKeadaan Umum: cemas, gelisah, keringat dinginKulit: dingin, pucatKardiovaskuler: S3 dan S4 ada atau tidak ada, aritmia, murmur, distensi vena jugularisParu-paru: dispnea, takipneaGI: Mual, muntahSirkulasi: denyut perifer reguler atau tidak, fibrilasi

PEMERIKSAAN PENUNJANGPemeriksaan EKGST ElevasiST DepresiT InversiST ELEVASI

ST DEPRESIMARKER JANTUNGPemeriksaan Penanda Jantung/Enzim jantung (Cardiac Markers): Yang lazim adalah CKMB, dapat pula troponin T (TnT) atau troponin I (TnI)Peningkatan marka jantung akan terlihat pada infark miokard akut (STEMI) dan (NSTEMI)

Amyoglobin CCK-MBBtroponinDtroponin in UA

Plot of the appearance of cardiac markers in blood versus time after onset of symptomsISCHEMIC CHEST PAIN ALGORYTHMChest pain suggestive of ischemia43Chest discomfort suggestive of ischemiaImmediate ED assessment and immediate ED general treatmentAcute coronary syndrome algorithmChest discomfort suggestive of ischemiaImmediate ED assessment ( 10 min) Vital sign Oxygen saturation Obtain IV access Obtain ECG 12 lead Brief history and physical exam Check contraindication for fibrinolytic Initial serum cardiac markers Initial electrolyte and coagulation study Portable chest x-ray ( 30 minutes)Immediate ED general treatment O2 at 4 L/min (maintain O2 sat 90%) Aspirin 160-325 mg Nitroglycerin SL, spray, or IV Morphine IV 2-4 mg repeated every 5-10 minutes (if pain not relieved with nitroglycerine)

Memory: MONA greets all patientsReview initial 12 lead ECGChest discomfort suggestive of ischemiaImmediate ED assessment and immediate ED general treatmentAcute coronary syndrome algorithmST elevation or new or presumably new LBBB strongly suspicious for injuryAcute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentST-depression or dynamic T-wave inversion strongly suspicious for injuryST elevation or new or presumably new LBBB strongly suspicious for injuryAcute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatment48ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI)ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI)Acute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentNormal or non-diagnostic changes in ST-segment or T-waves (intermediate/ low-risk UA)Start adjunctive treatmentNormal or non-diagnostic changes in ST-segment or T-waves (intermediate/ low-risk UA)ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI)ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI)Acute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentBeta-adrenergic receptor blockerClopidogrelHeparin (UFH or LMWH)ADJUNCTIVE TREATMENT(Do not delay reperfusion)51Start adjunctive treatmentNormal or non-diagnostic changes in ST-segment or T-wavesST-depression or dynamic T-wave inversion strongly suspicious for injuryST elevation or new or presumably new LBBB strongly suspicious for injuryAcute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentTime from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARBStatin 12 hoursTime from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARB within 24 hours of onsetStatin 12 hoursStart adjunctive treatmentNormal or non-diagnostic changes in ST-segment or T-wavesST-depression or dynamic T-wave inversion strongly suspicious for injuryST elevation or new or presumably new LBBB strongly suspicious for injuryAcute coronary syndrome algorithmChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentStart adjunctive treatment Heparin (UFH/LMWH) Glycoprotein IIb/IIIa receptor inhibitors -Adrenoreceptor blockers ClopidogrelAdjunctive treatment54Time from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARB within 24 h of symptom onset)Statin 12 hoursStart adjunctive treatmentNormal or non-diagnostic changes in ST-segment or T-wavesST-depression or dynamic T-wave inversion strongly suspicious for injuryST elevation or new or presumably new LBBB strongly suspicious for injuryChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentStart adjunctive treatment 12 hrsAdmit to monitored bedAssess risk status High risk: early invasive strategy Continue ASA, heparin, ACE-I, statinVERY HIGH-RISK PATIENTRefractory chest painRecurrent/persistent ST deviationVentricular tachycardiaHemodynamic instabilitySign of pump failureShock within 48 hours 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-9056Time from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARB within 24 h of symptom onset)Statin 12 hours 12 hrsStart adjunctive treatmentNormal or non-diagnostic changes in ST-segment or T-wavesST-depression or dynamic T-wave inversion strongly suspicious for injuryST elevation or new or presumably new LBBB strongly suspicious for injuryChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentStart adjunctive treatmentAdmit to monitored bedAssess risk status High risk: early invasive strategy Continue ASA, heparin, ACE-I, statinDevelops high or intermediate risk criteria or troponin-positiveMonitored bed in EDDevelops high or intermediate risk criteria or troponin-positive

59Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkanAspirinBeta-blockerACE inhibitorPengobatan Pasca PerawatanBerhenti merokokPertahankan BB optimalAktivitas fisik sesuai dengan hasil treadmillDietRendah lemak jenuh dengan kolesterol, bila perlu dengan target LDL < 100 mg/dLPengendalian hipertensiPengendalian ketat gula darah pada penderita DMModifikasi Faktor RisikoPreventionGet regular medical checkups.Control your blood pressure.Check your cholesterol.Dont smoke.Exercise regularly.Maintain a healthy weight.Eat a heart-healthy diet.Manage stress.