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Prof. Dr. dr. Idris Idham, SpJP (K), FIHA, FACC, FESC ... · PDF fileProf. Dr. dr. Idris...

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  • Prof. Dr. dr. Idris Idham, SpJP (K),

    FIHA, FACC, FESC, FASCC, FSCAI

    SR Negeri Tabing, Padang, Tahun 1957

    SMPN Kuranji, Padang, Tahun 1960

    SMAN I Padang, Tahun 1963

    Dokter Umum Fakultas Kedokteran Universitas Gadjah Mada; (S1) Tahun 1972

    Dokter Spesialis Jantung dan Pembuluh Darah FK UI; (S2) Tahun1983

    Post Graduate Course on Invasive Cardiology, Nuclear Cardiology Austin Hospital Melbourne, Australia, 1992

    Post Graduate Course on Non-Invasive Cardiology Pacemaker Implantation, Royal Melbourne Hospital, Australia, 1993

    Pendidikan Dokter Universitas Airlangga; (S3) Tahun 2000

    Guru Besar tetap Universitas Indonesia; Tahun 2004

    Education

  • Prof. Dr. dr. Idris Idham, SpJP (K),

    FIHA, FACC, FESC, FASCC, FSCAI

    Staf senior, Dept. Kardiologi & Kedokteran Vaskular FKUI &

    Pusat Jantung Nasional Harapan Kita

    Chief cardiologist, RS Medika BSD

    Sekretaris Kolegium Pengurus Pusat Perhimpunan Dokter

    Spesialis Kardiovaskular (PP PERKI) 2008-sekarang

    Fellow of Indonesian Heart Association (FIHA)

    Fellow of American College of Cardiology (FACC)

    Fellow of European Society of Cardiology (FESC)

    Fellow of ASEAN Federation of Cardiology (FAsCC)

    Fellow of Society of Cardiovascular Angiography and

    Intervention (FSCAI)

    Head of Cardiovascular Devision Medika BSD Hospital

  • Cardiovascular Emergency : Focus On Acute Coronary Syndromes

    Roles of Primary Physicians

    Idris Idham

    RS MEDIKA BSD

  • Spectrum of CV Emergency

    Congenital Heart Diseases

    Acute Coronary Syndrome : UAP, NSTEMI, STEMI

    Acute Lung Edema

    Acute Aortic Dissection

    Acute Limb Ischemia

    Deep Veins Thrombosis

  • Hypertensive Crisis : emergency, urgency

    Arrhythmia : AFRVR, SVT, VT, VF, TAVB

    Cardiomyopathy : PPCM, HCM, DCM.

  • CARDIOVASCULAR SPECIALIST COMPETENCY

    FRONTLINE DOCTORS

    FROM PALPITATION TO CVD

  • Front-line medical practitioners

    Play very important role in fighting cardiovascular diseases (CVD), the no.1 killer in Indonesia1

    Front liners are doctors who first encounter the patient, including family physicians

    Patients will benefit from early diagnosis and prompt treatment

    Competent of recognizing important signs & symptoms of CVD, e.g. chest pain

    1Dept. of Health, RI. 2002.

  • Chest Pain

    One of the most challenging symptoms1

    Diagnosis ranges from benign esophageal reflux to fatal MCI

    Failure to manage fatal conditions lead to complications including death

    Over management of low risk conditions causes unnecessary burden

    Acute or escalating chronic chest discomfort is most challenging.

    1Harrisons principles of internal medicine: McGraw-Hill, 2005.

  • Evaluation Aim

    To assess the general clinical condition of patient

    To determine the working diagnosis

    To initiate immediate management plan

    Should be performed rapidly yet accurately

  • General Clinical Assessment

    Stratify patient : stable vs unstable condition; based on level of consciousness & vital signs.

    Stabilize the patient first! Secure ABC (airway, breathing, circulation)

  • Determining Working Diagnosis

    Largely a clinical work, accurate anamnesis is the key.

    Characteristics of chest pain should be thoroughly explored:

    Quality, duration, location, precipitating & relieving factors, other associated features.

    Based on characteristics, determine the organ(s) or system(s) causing the pain.

  • Determining Working Diagnosis

    Consider anatomical structure of thorax & adjacent abdominal organs ; each organ has typical characteristics

    Important : features may not always present ; several features may occur simultaneously

  • Anatomy of Thoracic Cavity

    I.I. - 09 / PDKI Pekanbaru

  • Features of Major Causes of Chest Pain

    Angina: sensation of pressure, tightness, squeezing, heaviness, burning ; located retrosternal, often radiate (detailed later)

    Aortic dissection : abrupt onset of tearing or ripping sensation, knife-like pain in anterior chest, often radiate to back

    Pleuritis : pleuritic pain, influenced by breathing ; accompanied by cough, fever.

    1Harrisons principles of internal medicine: McGraw-Hill, 2005.

  • Features of Major Causes of Chest Pain

    Esophageal reflux : burning, substernal or epigastric pain, relieved by antacids

    Musculoskeletal : aching, worsened by movement, may be reproduced by localized pressure

    Herpes zoster : sharp, burning, dermatomal distribution, with vesicular rash

  • Differential Diagnosis of

    Chest Pain

    Cardiac ACS: infarct,angina

    MVP

    Aortic Stenosis

    Hypertrophic cardio-

    myopathy

    Pericarditis

    Lungs Lung Emboli

    Pneumonia

    Pneumothorax

    Pleuritis

    Gastrointestinal Esophageal reflux Esophageal rupture Gall bladder disease Peptic Ulcer Pancreatitis

    Vascular Aortic dissection/aneurysm

    Others Musculoskeletal Herpes zoster

  • General Approach for First liners

    Targetted anamnesis and thorough physical exams

    Consider most likely diagnoses

    If more than one, consider the worst one

    Closely monitor vital signs

    Administer essential first-line drugs

    Refer to higher facility if required, after patient is reasonably stabilized

  • Focus on:

    Acute Coronary Syndromes

    I.I. - 09 / PDKI Pekanbaru

  • A spectrum of clinical syndromes due to sudden, significantly compromised coronary circulation ranging from unstable angina to NSTEMI and STEMI.

    Further stages of stable angina pectoris

    Topol EJ, ed. Textbook of cardiovascular medicine 2007.

    DEFINITION

  • PATHOPHYSIOLOGY

  • Foam Cells

    Fatty Streak

    Intermediate Lesion Atheroma

    Fibrous Plaque

    Complicated Lesion/Rupture

    Endothelial Dysfunction

    Smooth muscle and collagen

    From first decade From third decade From fourth decade

    Growth mainly by lipid accumulation Thrombosis, hematoma

    Stary HC et al. Circulation 1995;92:1355-1374.

    Atherosclerosis Timeline

  • DIAGNOSIS

  • Presentation (Clinical, Initial ECG)

    ST-Seg Elevation Myocardial Infarction

    Non-STSeg Elevation Acute Coronary Syndr

    ST-Seg Elevation MCI

    Non-ST-seg- Elevation MCI

    Unstable Angina

    Working diagnosis

    Time

    Evolution of ECG &

    Biomarkers

    Final diagnosis

    National Heart Foundation Australia &The Cardiac Society of Australia and New Zealand, MJA 2006

    Biomarker (-) Biomarker (+)

    I.I. - 09 / PDKI Pekanbaru

  • CHEST PAIN Admission

    Working diagnosis

    Bio- chemistry

    Risk Stratification

    Management

    Secondary prevention

    Suspected ACS

    Persistent ST elevation

    No persistent ST elevation

    Troponin, CKMB (+)

    Risk: high / low

    Algorithm in Acute Coronary Syndrome

    Modified from ESC 2007

    - ACS unlikely - NSTEMI - STEMI

    ECG

    Initial management,

    revascularization

    Medical therapy,

    coronary angiography

    Perform

    ed in 10 min

    {on serial ECG}

    Troponin, CKMB (+)

  • Clinical Classification of Angina

    Typical angina (definite)

    substernal chest discomfort with a characteristic quality and duration that is

    provoked by exertion or emotional stress and

    relieved by rest or nitroglycerin

    Atypical angina (probable)

    meets 2 of the above characteristics

    Noncardiac chest pain

    meets

  • UA/NSTEMI THREE PRINCIPAL PRESENTATIONS

    Rest Angina* Angina occurring at rest and prolonged, usually > 20 minutes

    New-onset Angina New-onset angina of at least CCS Class III severity

    Increasing Angina Previously diagnosed angina that has become distinctly more frequent, Longer in duration, or lower in threshold (i.e., increased by > 1 CCS) class to at least CCS Class III severity

  • CHEST PAIN Admission

    Working diagnosis

    Bio- chemistry

    Risk Stratification

    Management

    Secondary prevention

    Suspected ACS

    Persistent ST elevation

    No persistent ST elevation

    Troponin, CKMB (+)

    Risk: high / low

    Algorithm in Acute Coronary Syndrome

    Modified from ESC 2007

    - ACS unlikely - NSTEMI - STEMI

    ECG

    Initial management,

    revascularization

    Medical therapy,

    coronary angiography

    Perform

    ed in 10 min

    {on serial ECG}

    Troponin, CKMB (+)

  • EVOLVING ECG

    A. Normal ECG

    B. Tall or peaked T waves

    C. ST

    D. & E. ST with inverted T

    waves

    F. Abnormal Q

    ECG pattern

    Ischemia : ST , tall T, inverted T

    Injury : ST

    Infarction : pathologic Q

  • CHEST PAIN Admission

    Working diagnosis

    Bio- chemistry

    Risk Stratification

    Management

    Secondary prevention

    Suspected ACS

    Persistent ST elevation

    No persistent ST elevation

    Troponin, CKMB (+)

    Risk: high / low

    Algorithm in Acute Coronary Syndrome

    Modified from ESC 2007

    - A

of 95/95
Prof. Dr. dr. Idris Idham, SpJP (K), FIHA, FACC, FESC, FASCC, FSCAI SR Negeri Tabing, Padang, Tahun 1957 SMPN Kuranji, Padang, Tahun 1960 SMAN I Padang, Tahun 1963 Dokter Umum Fakultas Kedokteran Universitas Gadjah Mada; (S1) Tahun 1972 Dokter Spesialis Jantung dan Pembuluh Darah FK UI; (S2) Tahun1983 Post Graduate Course on Invasive Cardiology, Nuclear Cardiology Austin Hospital Melbourne, Australia, 1992 Post Graduate Course on Non-Invasive Cardiology Pacemaker Implantation, Royal Melbourne Hospital, Australia, 1993 Pendidikan Dokter Universitas Airlangga; (S3) Tahun 2000 Guru Besar tetap Universitas Indonesia; Tahun 2004 Education
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