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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 CardiologyAustin Hospital Melbourne, Australia, 1992

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

    Pendidikan Dokter Universitas Airlangga; (S3) Tahun 2000

    Guru Besar tetap Universitas Indonesia; Tahun 2004

    Education

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    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 andIntervention (FSCAI)

    Head of Cardiovascular Devision Medika BSD Hospital

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    Cardiovascular Emergency :

    Focus On Acute Coronary Syndromes

    Roles of Primary Physicians

    Idris Idham

    RS MEDIKA BSD

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    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

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    Hypertensive Crisis : emergency,urgency

    Arrhythmia : AFRVR, SVT, VT, VF,

    TAVB Cardiomyopathy : PPCM, HCM, DCM.

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    CARDIOVASCULAR SPECIALIST

    COMPETENCY

    FRONTLINE DOCTORS

    FROM PALPITATION TO CVD

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    Front-line medical practitioners

    Play very important role in fightingcardiovascular 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.

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    Chest Pain

    One of the most challenging symptoms1

    Diagnosis ranges from benign esophageal

    reflux to fatal MCI

    Failure to manage fatal conditions lead tocomplications 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.

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    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

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    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)

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    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 theorgan(s) or system(s) causing the pain.

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    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

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    Anatomy of Thoracic Cavity

    I.I. - 09 / PDKI Pekanbaru

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    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.

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    Features of Major Causes of

    Chest Pain

    Esophageal reflux : burning, substernal or

    epigastric pain, relieved by antacids

    Musculoskeletal : aching, worsened bymovement, may be reproduced by localized

    pressure

    Herpes zoster : sharp, burning, dermatomaldistribution, with vesicular rash

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    Differential Diagnosis of

    Chest Pain

    Cardiac ACS: infarct,angina

    MVP

    Aortic Stenosis Hypertrophic cardio-

    myopathy

    Pericarditis

    Lungs Lung Emboli

    Pneumonia

    Pneumothorax

    Pleuritis

    GastrointestinalEsophageal reflux

    Esophageal rupture

    Gall bladder disease

    Peptic UlcerPancreatitis

    VascularAortic dissection/aneurysm

    OthersMusculoskeletal

    Herpes zoster

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    General Approach for First liners

    Targetted anamnesis and thorough physicalexams

    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, afterpatient is reasonably stabilized

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    Focus on:

    Acute Coronary Syndromes

    I.I. - 09 / PDKI Pekanbaru

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    A spectrum of clinical syndromes due to

    sudden, significantly compromised coronary

    circulation ranging from unstable angina toNSTEMI and STEMI.

    Further stages of stable angina pectoris

    Topol EJ, ed. Textbook of cardiovascular medicine 2007.

    DEFINITION

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    PATHOPHYSIOLOGY

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    FoamCells

    FattyStreak

    IntermediateLesion Atheroma

    FibrousPlaque

    ComplicatedLesion/Rupture

    Endothelial Dysfunction

    Smooth muscleand collagen

    From first decade From third decade From fourth decade

    Growth mainly by lipid accumulationThrombosis,hematoma

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

    Atherosclerosis Timeline

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    DIAGNOSIS

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    Presentation

    (Clinical, Initial ECG)ST-Seg Elevation

    Myocardial Infarction Non-STSeg ElevationAcute Coronary Syndr

    ST-Seg Elevation

    MCI

    Non-ST-seg-

    Elevation MCI

    Unstable

    Angina

    Workingdiagnosis

    Time

    Evolution ofECG &

    Biomarkers

    Finaldiagnosis

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

    Biomarker (-)Biomarker (+)

    I.I. - 09 / PDKI Pekanbaru

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    CHEST PAINAdmission

    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

    Performedin10min

    {on serial

    ECG}

    Troponin,

    CKMB (+)

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    Clinical Classification of Angina

    Typical angina (definite)

    substernal chest discomfort with a characteristic quality andduration 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

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    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

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    CHEST PAIN