ATRIAL FIBRILLATION

Anthony Setiawan
Internsip RS Hermina Sukabumi
2018
https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 RISK FACTOR & CONCOMITANT CVD
• Heart failure
• Hypertension
• Valvular heart disease
• Diabetes mellitus
• Obesity and weight loss
• Chronic obstructive pulmonary disease, sleep
apnoea, and other respiratory diseases
• Chronic kidney disease
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Symptoms and Functional Status of Patients With Atrial Fibrillation, Volume: 125, Issue: 23, Pages: 2933-2943, DOI: (10.1161/CIRCULATIONAHA.111.069450)
 SILENT AF

15-30%
Asymptomatic
Symptomatic

70%

Rienstra, M., Lubitz, S. A., Mahida, S., Magnani, J. W., Sinner, M., Fontes, J. D., et al.
(2012). Symptoms and Functional Status of Patients With Atrial Fibrillation.
 SCREENING

Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 DIAGNOSIS
ECG

- Irregular RR interval
- No discernible, distinct P waves

Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 TREATMENT

Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 RATE CONTROL

Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 RHTYM CONTROL

Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
Kirchhof, P., Benussi, S., Kotecha , D., Ahlsson, A., Atar, D., Casadei, B., et al. (2016). 2016 ESC
Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
 Identitas Pasien
▰ Nama : Ny.N
▰ Jenis kelamin : Perempuan
▰ Tgl Lahir / usia : 17 Maret 1962 / 56 tahun
▰ No RM : J 08 89 98
▰ Alamat : KP.Nyalinsung
▰ Agama : Islam
▰ Pekerjaan : Pegawai Swasta
▰ Pendidikan : Tamat SLTA
▰ Jaminan : JKN Non PBI
▰ Masuk RS : 01 Nov 2018
▰ Keluar RS : 04 Nov 2018
 Anamnesis
• KU: Sesak
Pasien datang ke IGD dengan keluhan
sesak saat aktivitas dan tidak hilang dengan
istirahat. Sesak dirasakan memberat sejak
kemarin. Sering terbangun dari tidur karena
sesak. Tidur harus menggunakan 2-3 bantal.
Keluhan disertai dada berdebar. Keluhan lain
terdapat nyeri ulu hati dan mual. Pasien
menyangkal adanya nyeri dada.
RPD:
• AF (+), CHF(+), HT(+) -> Rutin kontrol ke SpJP
• Stroke (-)
• DM (-)
• Dislipidemia (+) -> Rutin mengkonsumsi
Atorvstatin1x20mg
RPO: Rawat inap di RS Hermina pada 2 minggu lalu
dengan AF+CHF
RPK: Penyakit Jantung(-), DM(-), Dislipidemia(-)
Riwayat Merokok: 1-2batang/hari selama ± 5 tahun, saat
ini sudah berhenti
 Pemeriksaan Fisik

Status Generalis Tanda Vital

• Keadaan Umum = Sakit • Tekanan darah = 140/70
berat mmHg
• Nadi = 140 kali permenit,
• Kesadaran = E4M6V5
ireguler, teraba kuat
(GCS 15), Kompos mentis
Kooperatif • Napas = 36 kali permenit
• Suhu = 37 derajat Celcius
Kepala :
▰ Mata : Konjungtiva anemis -/-, sklera ikterik-/-
Leher : JVP meningkat
Thoraks:
Jantung
Inspeksi : ictus cordis terlihat
Palpasi : ictus cordis teraba
kuat pada ICS VI MCL sinistra
Perkusi : Cardiomegali (+)
Auskultasi : SI dan SII ireguler,
SIII(+) murmur(-),
Paru
Inspeksi : simetris statis dan
dinamis
Palpasi : vocal fremitus tidak
dapat dinilai
Perkusi : sonor di seluruh lapang
paru
Auskultasi : suara nafas vesikuler
+/+, rhonki +/+ basal halus,
wheezing -/-
Abdomen Ekstrimitas
- Inspeksi : datar - Akral hangat +/+,
- Palpasi : nyeri edema -/-, sianosis (-),
tekan epigastrium (+), CRT < 2’
hepar dan lien tidak
teraba membesar
- Perkusi : timpani
- Auskultasi : bising usus
(+) normal
 Pemeriksaan Penunjang
EKG 01/11/18
Lab 01/11/18
Hb : 13,1 g/dL
Ht : 42,3 %
Leukosit : 10.000/mm3
Trombosit : 300.000/mm3
GDS : 167 mg/dL
Ureum : 23,8 mg/dL
Kreatinin : 0,9 mg/dL
Natrium : 138,80 mg/dL
Kalium : 4,96 mg/dL
 Diagnosis
• AF RVR
• CHF Fc IV
• HHD
• CAD OMI Anteroseptal
• Sindrom Dispepsia
 Penatalaksanaan
• O2 3 lpm via NC
• Pasang FC
• IVFD Asering 500ml/24jam
• Inj Furosemide 40mg IV
• Digoxin 0,5mg IV diencerkan dalam RL 10ml
bolus IV pelan
• Konsul ke SpJP
• Pro HCU
Advis SpJP
• Pro HCU
• Bed rest, O2 3 lpm via NC
• Diit RG 1500 kkal/24jam
• IVFD Asering 500ml/24jam (setelah 24 jam ganti
dengan RL 500ml/24jam)
• Furosemide 40mg-20mg-0 IV
• Ramipril 0-0-2,5mg PO
• Nitrokaf 0-2,5mg-0 PO
• Warfarin 0-0-1mg PO
• Curcuma 3x1 tab PO
• Vit BC 1x1 tab PO
• Alprazolam 0-0-0,5mg PO
• OMZ 2x40mg IV
• EKG/24jam + Lead II panjang
• Foto Thorax PA
• Cek GDP, As Urat, Profil Lipid
 Follow Up
HCU 01/11/18-02/11/18
• S : Sesak berkurang, dada berdebar (-), nyeri dada (-),
nyeri ulu hati berkurang, mual dan muntah (-), intake
makan baik
• O:
Kesadaran: CM
TD : 110/70 mmHg
N : 88x/menit ireguler,kuat
R : 20x/menit
S : 36,7 C
SaO2 : 98%
Pemeriksaan Fisik:
Leher : JVP tidak meningkat
Thoraks : VBS +/+, Rh-/-, Wh-/-
S1-S2 ireguler, s3(+),murmur (-)
Abdomen : Datar, BU(+)normal, soepel, NTE(-)
Ekstremitas: Akral hangat, edema-/-
EKG 02/11/18
Lab 02/11/18
GDP : 131,0 mg/dL 70,0-110,0
Choles. Total : 207,0 mg/dL 0,0-200,0
HDL : 19,0 mg/dL 35,0-65,0
LDL : 171,0 mg/dL 0,0-150,0
Trigliserida : 86,0 mg/dL 0,0-200,0
As.Urat : 6,6 mg/dL 2,4-5,7
• P:
- Pindah ke ruang biasa
- Terapi lanjut
PU 03/11/18
• S: Sesak (-), dada berdebar (-), nyeri dada (-), nyeri ulu
hati (-), mual dan muntah (-), intake makan baik
• O:
Kesadaran: CM
TD : 100/70 mmHg
N : 86x/menit ireguler,kuat
R : 20x/menit
S : 36,7 C
SaO2 : 98%
Pemeriksaan Fisik:
Leher : JVP tidak meningkat
Thoraks : VBS +/+, Rh-/-, Wh-/-
S1-S2 ireguler, s3(+),murmur (-)
Abdomen : Datar, BU(+)normal, soepel, NTE(-)
Ekstremitas: Akral hangat, edema-/-
EKG 03/11/18
• P:
- Terapi lanjut
- V-Bloc 2x3,125mg PO
- OMZ Stop
PU 04/11/18
• S: Sesak (-), dada berdebar (-), nyeri dada (-),
nyeri ulu hati (-), intake makan baik
• O:
Kesadaran: CM
TD : 110/70 mmHg
N : 90x/menit ireguler,kuat
R : 18x/menit
S : 36,8 C
SaO2 : 98%
Pemeriksaan Fisik:
Leher : JVP tidak meningkat
Thoraks : VBS +/+, Rh-/-, Wh-/-
S1-S2 ireguler, s3(+),murmur (-)
Abdomen : Datar, BU(+)normal, soepel, NTE(-)
Ekstremitas: Akral hangat, edema-/-
EKG 04/11/18
• P:
- Rawat jalan
- Kontrol tgl 10/11/18
- Furosemide 2x40mg PO
- Ramipril 1x2,5mg PO
- Nitrokaf 1x2,5mg PO
- Warfarin 1x1mg PO
- V-Bloc 2x3,125mg PO
- Avesco 1x20mg PO
- Curcuma 3x1 tab PO
- Vit BC 1x1 tab PO
THANK YOU