Penyakit Jantung

Koroner

Identitas
Nama

: Ny. E
Usia : 60 th
Pekerjaan : IRT
Alamat : Tebon
Tanggal
Tanggal

masuk : 15 April 2014

pemeriksaan : 15 April 2014

S
KU : 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 (-)

 RPD
Keluhan serupa (nyeri dada) (-)
Hipertensi (+) tidak terkontrol > 5 tahun dengan

riwayat pengobatan captopril diminum hanya

jika ada keluhan
Diabetes Melitus (-)
Kolestrol (-)
RPK
Keluhan serupa (nyeri dada) ( -)
Hipertensi (-)
DM

 Kebiasan
Pasien mengaku suka konsumsi

makanan bersantan
Jarang melakukan olahraga
Merokok (-)

O
KU

: compos mentis
GCS : 456
Vital Sign :
TD : 140/90
N : 82 X/ mnt
R : 20 X/ mnt
t : 37,1 C

 Kepala

: CA -/- SI -/ Leher : pembesaran KGB

JVP tidak meningkat (5 + 2)

 Thorax

Inspeksi :Ictus cordis tidak tampak, tidak terlihat luka,

bekas luka dan massa

Palpasi : Ictus cordis teraba, tidak kuat angkat, tidak
ditemukan massa, krepitasi
Perkusi : 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 sinistra
Auskultasi :bunyi jantung S1S2 reguler tunggal
suara jantung tambahan (-)
rhonki (-/-) wheezing (-/-)

 Abdomen

Inspeksi : rongga dada lebih tinggi

dibanding rongga perut

Auskultasi : BU+, supel
Perkusi : timpani
Palpasi : nyeri tekan (-)

 Ekstremitas
Oedem (-)
Sianosis (-)
Nyeri sendi (-)

Hasil pemeriksaan Lab

EKG

A
PJK STEMI anterior
Hipertensi stage I

iskemia inferior

P
Planing

diagnostik

Foto thorax
Cardiac Marker
Lab Kimia darah

 Planing

terapi

Captopril 3x12,5 mg
ISDN 3X5mg
Clopidogrel 1x75mg
Diazepam 2x2 mg
Enoxaparin sodium 2x 0,4 (lovenox)

PENYAKIT JANTUNG
KORONER

PJK adalah penyakit jantung yang

disebabkan oleh kelainan pada arteri
coronaria

Faktor Resiko
Modifikasi (-)

Modifikasi (+)

Jenis kelamin

Hipertensi

Keturunan

Dislipidemia

Ras

Perokok

Umur L>45, P>55

Aktifitas Fisik
Obesitas
Diabetes
Stres dan Marah

Sign & Symptom

Angina

Pectoris Stabil
Acute Coronary Syndrom
Angina Pectoris Tidak Stabil
Infark miokard dengan ST elevasi
Infark miokard tanpa ST elevasi

Sudden

Death

Angina : Nyeri dada seperti tertekan

pada prekordial (retrosternal) yang
sering menjalar ke arah lengan kiri,
leher kiri, rahang, hingga telinga

Patofisiologi

Angina Stabil
merupakan 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 datang

Etiologi
Aktivitas

Fisik
Stress emosional
Suhu dingin
Merokok

Gejala
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 lain

SINDROM KORONER AKUT

Suatu sindroma klinik yang menandakan
adanya 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.

30

PATOGENESIS

Umumnya
disebabkan
aterosklerosis koroner

oleh

Plak aterosklerosis ruptur terbentuk

trombus diatas ateroma yang secara
akut menyumbat lumen koroner

Apabila sumbatan terjadi secara total

hampir seluruh dinding ventrikel akan
nekrosis

The cardiovascular continuum of

events

Myocardial
Ischemia

CAD

plaque
Atherosclerosis

Risk Factors
(DYSLIPIDEMI
, BP,
DM, Insulin Resistance,
A
Platelets, Fibrinogen, etc)

The cardiovascular continuum of

events
Coronary
Thrombosis
Myocardial
Ischemia

CAD
Atherosclerosis

Risk Factors
(DYSLIPIDEMIA
, BP,
DM, Insulin Resistance,
Platelets, Fibrinogen, etc)

The cardiovascular continuum of

events
ACS

Coronary
Thrombosis
Myocardial
Ischemia

CAD
Atherosclerosis

Risk Factors
(DYSLIPIDEMIA
, BP,
DM, Insulin Resistance,
Platelets, Fibrinogen, etc)

Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes

NSTEMI

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI

Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

PEMERIKSAAN FISIK
Keadaan Umum: cemas, gelisah, keringat dingin
Kulit: dingin, pucat
Kardiovaskuler: S3 dan S4 ada atau tidak ada,
aritmia, murmur, distensi vena jugularis
Paru-paru: dispnea, takipnea
GI: Mual, muntah
Sirkulasi: denyut perifer reguler atau tidak,
fibrilasi

PEMERIKSAAN
PENUNJANG
Pemeriksaan
ST Elevasi
ST Depresi
T Inversi

EKG

ST ELEVASI

ST DEPRESI

MARKER JANTUNG

Pemeriksaan
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)

Plot of the appearance of cardiac markers in

blood versus time after onset of symptoms

A myoglobin
B troponin

C CK-MB
D troponin in UA

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of
ischemia

Acute coronary syndrome

algorithm
Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment

Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10
min)
Vital sign

Immediate ED general
treatment

Oxygen saturation

O2 at 4 L/min (maintain O2 sat

90%)

Obtain IV access

Aspirin 160-325 mg

Obtain ECG 12 lead

Nitroglycerin SL, spray, or IV

Brief history and physical exam

Morphine IV 2-4 mg repeated

every

Check contraindication for

fibrinolytic
Initial serum cardiac markers
Initial electrolyte and coagulation
study
Portable chest x-ray ( 30
minutes)

5-10 minutes (if pain not

relieved
with nitroglycerine)
Memory: MONA greets all
patients

Acute coronary syndrome algorithm

Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG

Acute coronary syndrome algorithm

Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

Acute coronary syndrome algorithm

Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or
dynamic T-wave
inversion
strongly
suspicious for
injury

Acute coronary syndrome algorithm

Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury
(STEMI)

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury
(UA/NSTEMI)

Normal or nondiagnostic
changes in STsegment or Twaves
(intermediate/
low-risk UA)

Acute coronary syndrome algorithm

Chest discomfort suggestive of
ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury
(STEMI)
Start adjunctive
treatment

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury
(UA/NSTEMI)

Normal or nondiagnostic
changes in STsegment or Twaves
(intermediate/
low-risk UA)

ADJUNCTIVE TREATMENT
(Do not delay reperfusion)

1. Beta-adrenergic receptor
blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury
Start adjunctive
treatment
Time from onset
of symptoms
12
- Reperfusion hours
strategy:
PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB
- Statin

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury

Normal or nondiagnostic
changes in STsegment or Twaves

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury

Start adjunctive
treatment

Start adjunctive
treatment

Time from onset

of symptoms
12
- Reperfusion hours
strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of
onset
- Statin

Normal or nondiagnostic
changes in STsegment or Twaves

Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor
inhibitors
-Adrenoreceptor blockers
Clopidogrel

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury

Start adjunctive
treatment

Start adjunctive
treatment

Time from onset

of symptoms

12 hrs Admit to monitored

bed
Assess risk status

12
- Reperfusion hours
strategy:
PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin

- High risk: early

invasive
strategy
- Continue ASA,
heparin,
ACE-I,
statin

Normal or nondiagnostic
changes in STsegment or Twaves

VERY HIGH-RISK PATIENT

1. Refractory chest pain
2. Recurrent/persistent ST
deviation
3. Ventricular tachycardia
4. Hemodynamic instability
5. Sign of pump failure
6. Shock within 48 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST elevation or new
or presumably new
LBBB strongly
suspicious for injury

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury

Normal or nondiagnostic
changes in STsegment or Twaves

Start adjunctive
treatment

Start adjunctive
treatment

Develops high or
intermediate risk
criteria or troponinpositive

Time from onset

of symptoms

12 hrs Admit to monitored

bed
Assess risk status

12
hours
- Reperfusion strategy:
PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin

- High risk: early

invasive
strategy
- Continue ASA,
heparin,
ACE-I,
statin

Monitored bed in ED
Develops high or
intermediate risk
criteria or troponinpositive

Pengobatan Pasca Perawatan

Obat-obat untuk mengontrol keluhan iskemia
harus dilanjutkan
Aspirin
Beta-blocker
ACE inhibitor

Modifikasi Faktor Risiko

Berhenti merokok
Pertahankan BB optimal
Aktivitas fisik sesuai dengan hasil treadmill
Diet
Rendah lemak jenuh dengan kolesterol, bila
perlu dengan target LDL < 100 mg/dL
Pengendalian hipertensi
Pengendalian
ketat
gula
darah
pada
penderita DM

59

Get regular medical checkups.

Control your blood pressure.

Prevention

Check your cholesterol.

Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.