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Sasmojo WiditoMalang
2014
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Work experience
1994-1997 Community Health Center of Sumbawa,
West Nusa Tenggara
1998-2005 Cardiovascular Resident,
University of Airlangga, Surabaya
2005-now Cardiovascular Specialist,
Dr. Saiful Anwar Teaching Hospital, Malang
2005-now Cardiovascular Lecturer, School of Medicine,University of Brawijaya, Malang
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Training & studying
1986-1993 University of Sebelas Maret, Surakarta,
Medical Doctor
1998-2004 University of Airlangga, Surabaya,Cardiologist
2007 National Cardiovascular Center Harapan Kita,
Jakarta,
Basic Invasive Training
2011-2012 Binawaluya Cardiac Center, Jakarta
Advanced interventional cardiovascular
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Sequence of Ischemic Heart Disease
Risk Factor
Endothelial dysfunction
CAD
Ischemia
AnginaSilent
MI
ArrythmiasLost of muscle
Remodeling
Progresif dilatation
Heart FailureDeath
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ManagementBefore STEMI
4
1 2 3 4 5 6
Onset of STEMI- Prehospital issues- Initial recognition and management
in the Emergency Department (ED)- Reperfusion
Hospital Management- Medications- Arrhythmias- Complications- Preparation for discharge
Secondary Prevention/Long-Term Management
Modified from Libby. Circulation 2001;104:365,
Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.
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Naghavi et al. Circulation 2003;108:166484
Normal coronary arteryno atherosclerosis, widelumen
Atherosclerotic plaquehas caused 60 - 70 %stenosis
A thrombus is well-established, only 3 smalllumens remain
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capsul
core
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SymptomRecognition
Call toMedical System
ED Cath LabPreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment Denied
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healthcare providers should assist patients,
making anticipatory plans for timely recognition and response toan acute event
taking chew nonenteric-coated aspirin (162 to 325 mg) and 1nitroglycerin in response to chest pain promptly
If symptoms are unimproved or worsening 5 minutes after 1 dose,the patient should be instructed to call EMS immediately
Family members, close friends should be enlisted as reinforcementfor rapid action when the patient experiences symptoms ofpossible STEMI
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preexisting bias that a heart attack should present dramaticallywith severe, crushing chest pain
one third of patients with MI experience symptoms other thanchest pain
reasoning that symptoms will be self-limited or are not serious
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attribution of symptoms to other preexisting conditions
fear of embarrassment should symptoms turn out to be a false
alarm
reluctance to trouble others unless really sick
preconceived stereotypes of who is at risk for a heart attack
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lack of knowledge of the importance of rapid action,
unavailability of EMS
unavailability of reperfusion therapies
attempted self-treatment with prescription and/ornonprescription medications
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STEMI
Clinical syndrome
Symptoms: myocardial ischemia
ECG: ST elevation Lab: release of biomarkers of myocardial necrosis.
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Heart attack warning signs
Chest discomfortpressure, squeezing, fullness, or pain in the center of chest
Discomfort in one or both arms, back, neck, jaw, orstomach
Shortness of breath
often comes with or before chest discomfort
Breaking out in a cold sweat, nausea, or light-headedness
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Heart attack warning signs
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Diagnostic ST elevation
New ST elevation at the J point in at least 2 contiguous leads of 2mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads orthe limb leads.
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RBBB QRS complex durationprolonged
V1Monophasic R, rsr, Rsr, RSr, RSR, rSr,rSR, rsR, qR.ST depression (discordant)
V6Wide S, RS complex
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Diagnostic ST elevation
RBBB, STEMI anterior
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LBBBV1, V2, V3 QS, rS, with ST elevation (discordant)
I,aVL,V5,V6 monophasic R, with ST depression (discordant)
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Diagnostic ST elevationLBBB with STEMI
Sgarbossa criteriaI,aVL,V5,V6 ST elevation 1 mm, concordant QRS complex (score 5)
V1,V2, or V3 ST depression 1 mm (score 3)
V2-V4 ST elevation 5 mm, discordant QRS complex (score 2)
Score of 3 had a specificity of 98% for STEMI, but a score of 0 did
not rule out STEMI
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Diagnostic ST elevation
LBBB with STEMI: Sgarbossa criteria
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Diagnostic ST elevation ST depression in 2 precordial leads (V1V4) may indicate
transmural posterior injury
STEMI Inferoposterior
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Clinical findings:Shock with clear lungs, elevated JVP
Kussmaul sign
Hemodynamics:
Increased RA pressure (y descent)
Square root sign in RV tracing
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
Rx:Maintain RV preload
Lower RV afterload (PA---PCW)
Inotropic support
ReperfusionV4RModified from Wellens. N Engl J Med 1999;340:381.
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Diagnostic ST elevation
Multilead ST depression with coexistent ST elevation in lead aVR:left main or proximal left anterior descending artery occlusion
Hyperacute T-wave changes: early phase of STEMI, before thedevelopment of ST elevation
Baseline ECG abnormalities other than LBBB (e.g., paced rhythm,LV hypertrophy, Brugada syndrome) may obscure interpretation.
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Echocardiography: provide focal wall motion abnormalities,facilitate triage in case with ECG findings that are difficult tointerpret.
If doubt persists, immediate referral for invasive angiography maybe necessary to guide therapy in the appropriate clinical context.
Cardiac troponin: preferred biomarker of MI.
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Some of the independent predictors of early deathfrom STEMI include
Age, Killip class,Time to reperfusion, Cardiac arrest,
Tachycardia, Hypotension,
Anterior infarct location, Prior infarction,
Diabetes Mellitus, Smoking status,
Renal function, Biomarker findings
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Thrombolysis In Myocardial Infarction (TIMI) riskscore
http://www.mdcalc.com/timi-riskscore-for-stemi
GRACEhttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.html
Risk assessment is a continuous process, should be repeatedthroughout hospitalization and at time of discharge.
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http://www.mdcalc.com/timi-riskscore-for-stemihttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.htmlhttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.htmlhttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemi -
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Regional systems of stemi care and goals for reperfusion therapy
Strategies for shortening door-to-device times
Prehospital Fibrinolytic Therapy
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CABG, coronary artery bypass graft; DIDO, door-indoor-out; FMC, first medical contact; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.
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Performance of PCI is dictated by an anatomically appropriateculprit stenosis
Cardiogenic shock or severe heart failure initially seen at a non
PCI-capable hospital should be transferred for cardiaccatheterization and revascularization as soon as possible,irrespective of time delay from MI onset.
Angiography and revascularization should not be performedwithin the first 2 to 3 hours after administration of fibrinolytic
therapy
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Back ground studies:
CAPTIM (Comparaison de lAngioplastie Primaire et de laThrombolyse) trial,
WEST (Which Early ST-Elevation Myocardial Infarction Therapy)
trials USIC (Unit de Soins Intensifs Coronaires) Registry
Swedish Registry of Cardiac Intensive Care
Advantages: lower STEMI mortality rates
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Effort:
Training for EMS officer in rural areas
Funding for necessary equipment.
Prehospital fibrinolysis is more widespread in some regions of Europeand the United Kingdom.
further research into the implementation of prehospital fibrinolytic
strategies to reduce total ischemic time.
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Timing of FibrinolyticTherapy
Benefits are well established,with a time-dependent reductionin both mortality and morbidity
rates during the initial 12 hoursafter symptom onset
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Timing of FibrinolyticTherapy
When interhospital transport timesare short, there may be advantagesto the immediate delivery offibrinolytic therapy versus any
delay to primary PCI for patientswith STEMI and lowbleeding risk who present withinthe first 1 to 2 hours of symptom
onset
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Timing of FibrinolyticTherapy
Benefit from fibrinolytic therapy inpatients who present 12 hours aftersymptom onset has not beenestablished
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Timing of FibrinolyticTherapy
Consensus:consideration should be given toadministering a fibrinolytic agent insymptomatic patients presenting 12 hours
after symptom onset with STEMI and alarge area of myocardium at risk orhemodynamic instability if PCI isunavailable
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Choice of Fibrinolytic Agent
Fibrin-specific agents are preferred when available. Adjunctive antiplatelet and/oranticoagulant therapies are indicated, regardless of the choice of fibrinolytic agent.
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Contraindications andComplications WithFibrinolytic Therapy
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Contraindications andComplications WithFibrinolytic Therapy
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Fibrinolytic Therapy When There Is anAnticipated Delay to PerformingPrimary PCI Within 120 Minutes ofFMC
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Fibrinolytic Therapy When There Is anAnticipated Delay to PerformingPrimary PCI Within 120 Minutes ofFMC
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Indications for fibrinolytic therapy when there is a >120 mindelay from FMC to primary PCI
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Adjunctive AntiplateletTherapy With Fibrinolysis
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Adjunctive AnticoagulantTherapy With Fibrinolysis
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Assessment of ReperfusionAfter Fibrinolysis
The relatively sudden and complete reliefof chest pain coupled with 70% STresolution is highly suggestive ofrestoration of normal myocardial bloodflow.
Complete (or near complete) ST-segmentresolution at 60 or 90 minutes afterfibrinolytic therapy is a useful marker of apatent infarct artery
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Assessment of ReperfusionAfter Fibrinolysis
The combination of 50% ST resolution andthe absence of reperfusion arrhythmias at 2hours after treatment predicts TIMI flow 3in the infarct artery.
Lack of resolution of ST elevation by atleast 50% in the worst lead at 60 to 90minutes should prompt strongconsideration of a decision to proceed withimmediate coronary angiography andrescue PCI.
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Indications for Transfer forAngiography AfterFibrinolysis
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Indications for Transfer forAngiography AfterFibrinolysis
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Indications for Transfer forAngiography AfterFibrinolysis
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.PKB. Malang. 2014
Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.PKB. Malang. 2014
Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
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Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
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Use of Stents in Primary PCI
Balloon angioplasty without stent placement may be used inselected patients.
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Antiplatelet Therapy to SupportPrimary PCI for STEMI
The recommended maintenance dose of aspirin to beused with ticagrelor is 81 mg daily.
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Antiplatelet Therapy to SupportPrimary PCI for STEMI
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Anticoagulant Therapy to SupportPrimary PCI
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Anticoagulant Therapy to SupportPrimary PCI
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Posthospital management
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MedicationsAntithrombotic therapiesBeta blockersACE inhibitors/ARBs/aldosterone antagonistsStatins
Physical activity & cardiac rehabilitationPhysical ActivityCardiorespiratory fitness (MET capacity)
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Risk factor modification & lifestyle interventionsSmoking cessationDiet/nutrition
Management of comorbidities
Overweight/obesityLipidsHypertensionDiabetesHF
Arrhythmia/arrhythmia risk
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Psychosocial factorsSexual activityGender-specific issuesDepression, stress, and anxietyAlcohol use
Culturally sensitive issues
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Provider follow-upCardiologistPrimary care providerAdvanced practice nurse/physician assistantOther relevant medical specialists
Electronic personal health recordsInfluenza vaccination
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Socioeconomic factorsAccess to health insurance coverageAccess to healthcare providersDisabilitySocial servicesCommunity services
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Electro-cardiogram
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StressTest
Electro-cardiogram
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StressTest
CoronaryAngiography
Electro-cardiogram
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PublicHealth
perspectiveof CHD
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients communities:
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PublicHealth
perspectiveof CHD
Patients, communities:Take care of yourselfKnow of treatment optionsSeek treatment early
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Patients, communities:Take care of yourselfKnow of treatment optionsSeek treatment early
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Media:Educate patientsMonitor results & compliance
Patients, communities:Take care of yourselfKnow of treatment optionsSeek treatment early
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Cardiologist:Initiate early treatments: anticoagulants,antiplatelets, -blockers, narcoticsMaster triage, and transfer
Media:Educate patientsMonitor results & compliance
Patients, communities:Take care of yourselfKnow of treatment optionsSeek treatment early
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Cardiologist:Initiate early treatments: anticoagulants,antiplatelets, -blockers, narcoticsMaster triage, and transfer
Media:Educate patientsMonitor results & compliance
Interventional cardiologist:Expert in short D2B interventions
,Take care of yourselfKnow of treatment optionsSeek treatment early
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Cardiologist:Initiate early treatments: anticoagulants,antiplatelets, -blockers, narcoticsMaster triage, and transfer
Media:Educate patientsMonitor results & compliance
Interventional cardiologist:Expert in short D2B interventions
,Take care of yourselfKnow of treatment optionsSeek treatment early
Hospital:Provide exceptional ED, CVL, andCCU services
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6thAsian Interventional Cardiovascular Therapeutics, 2010
Patients, communities:
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PublicHealth
perspectiveof CHD
Family physician:Learn of options that exist for CAD patientsRisk factors modifications
Cardiologist:Initiate early treatments: anticoagulants,antiplatelets, -blockers, narcoticsMaster triage, and transfer
Media:Educate patientsMonitor results & compliance
Interventional cardiologist:Expert in short D2B interventions
,Take care of yourselfKnow of treatment optionsSeek treatment early
Hospital:Provide exceptional ED, CVL, andCCU services
Politicians and Leaders:Allocate appropriate resources the next patient maybe you or yourloved one
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The End