ABSTRACT BOOK

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 Table of Content

ABS-01 ............................................................................................................................................................... 7
A 39 Year Old Woman Pregnancy 16-17 Week with STEMI INFERIOR : A Case Report
ABS-02 ............................................................................................................................................................... 8
Premature Coronary Artery Disease (CAD) ST-Elevation Myocardial Infarct (STEMI) with Smoking Risk Factor
in Very Young Adult (27 years old) : A Rare Case Report
ABS-03 ............................................................................................................................................................. 10
Coronary CT Angiography as a Gatekeeper to Invasive Strategy in CAD Patients, a PRCCTA (Pasar Rebo
General Hospital Coronary Computed Tomography Angiography) Registry
ABS-04 ............................................................................................................................................................. 11
Challenging management of sustained ventricular tachycardia in a patient with high risk NSTEMI and sepsis
ABS-05 ............................................................................................................................................................. 13
Caprini score as a tool to predict deep vein thrombosis: a case series.
ABS-06 ............................................................................................................................................................. 14
Continous Renal Replacement Therapy (CRRT) Post Cardiac Surgery in Acute Kidney Injury With Prolonged
Cardiac Pulmonary Bypass (CPB)
ABS-07 ............................................................................................................................................................. 15
Comparison STEMI patients outcomes based on administration onset of fibrinolytic: a Serial Case
ABS-08 ............................................................................................................................................................. 17
Suspecting the Subclavian Steal Syndrome in Rural Health Clinic : Case Report
ABS-09 ............................................................................................................................................................. 18
Impact of Metabolic Syndrome on Cardiovascular Outcome after Percutaneous Coronary Intervention
ABS-10 ............................................................................................................................................................. 19
Managing Right Ventricular Failure and Cardiorenal Syndrome in ASD-PAH Patient; an ICU Case Report
ABS-11 ............................................................................................................................................................. 21
Postcardiac Injury Syndrome : a Rare Complication of Angioplasty Procedure
ABS-12 ............................................................................................................................................................. 22
Clinical Profile in Elderly and Young Adults with Acute Decompensated Heart Failure when Admitted to The
Emergency Department
ABS-13 ............................................................................................................................................................. 23
Cardiogenic Shock and Sudden Death in Anterior Extensive STEMI Accompanied by Complete RBBB : A
Case Report
ABS-14 ............................................................................................................................................................. 24

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Failure to Stabilize Heart Rate Using Maximum Infusion Dose of Dopamine in Unstable Bradyarrhythmia Case
(Total AV Block type), Pacemaker-Dependent? A Case Report
ABS-15 ............................................................................................................................................................. 25
Acute Cardiovascular Management in Unstable Angina Pectoris (UAP) with Frequent Monomorphic Premature
Ventricular Contraction (PVC) : A Case Report
ABS-16 ............................................................................................................................................................. 26
Sudden Death in Acute Right Ventricular Infarction, A New “Trend” in Cardiogenic Shock Cases? A Case
Report
ABS-17 ............................................................................................................................................................. 27
Not All Fascicular Ventricular Tachycardia is Idiopathic
ABS-18 ............................................................................................................................................................. 30
Clinical Characteristics, Risk Factor, Management and Short-term Outcomes of Patients with Acute Coronary
Syndrome – First Trimester Observation in Prof WZ Yohanes Hospital, Kupang
ABS-19 ............................................................................................................................................................. 31
Evidence Based Case Report High-dose Isosorbide Dinitrate in Acute Heart Failure: Does it Work?
ABS-20 ............................................................................................................................................................. 32
Long QT Syndrome Induced by Electrolyte Imbalance that Leads to Torsade de Pointes Episodes
ABS-21 ............................................................................................................................................................. 33
A 40 Years-old Female with Severe Mitral Stenosis, Atrial Fibrillation, Heart Failure with Pulmonary Edema
and Diabetic Ketoacidosis
ABS-22 ............................................................................................................................................................. 34
Acute Coronary Syndrome post Hypoglycemia
ABS-23 ............................................................................................................................................................. 35
Clinical Factors as a Predictors of Major Adverse Cardiac Events in Coronary Artery Disease Patients after
Percutaneous Coronary Intervention Treatment in Tarakan National Hospital Jakarta.
ABS-24 ............................................................................................................................................................. 37
Wide QRS complex Tachycardia in Patient with non ST- Elevation Myocardial Infraction : Is always Ventricular
Tachycardia ?
ABS-25 ............................................................................................................................................................. 38
An Elevated Neutrophil to Lymphocyte Ratio Predicts In-Hospital Mortality in ST-segment Elevation
Myocardial Infarction: A Meta-Analysis
ABS-26 ............................................................................................................................................................. 40
Association between Five Types of Single-Nucleotide Polymorphisms (SNPs) in Chromosome 9p21 and Risk
of Coronary Artery Disease
ABS-27 ............................................................................................................................................................. 41
Nightmare of de winter: a dead case. What should GP do?

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ABS-28 ............................................................................................................................................................. 42
Prevalence and Causes of Failure of Receiving Thrombolytic Therapy in STEMI Patient at Non-PCI Hospital
ABS-29 ............................................................................................................................................................. 43
From Wellens Syndrome to Myocardial Infarction: A Case Report
ABS-30 ............................................................................................................................................................. 45
The Effectiveness of Intra-aortic Balloon Counterpulsation in Patients with or without Cardiogenic Shock
Following Acute Myocardial Infarct
ABS-31 ............................................................................................................................................................. 46
Triglyceride and HDL-C Serum Level in Purple Sweet Potato (Ipomoea batatas L) and Recycling Cooking Oil
Consumption
ABS-32 ............................................................................................................................................................. 47
Dossage and Drug Administration of Loop Diuretic in Acute Heart Failure
ABS-33 ............................................................................................................................................................. 48
Diagnosis and Treatment of Anemia in Patient with Tetralogy of Fallot
ABS-34 ............................................................................................................................................................. 49
Pleural effusion in patients with congestive heart failure: Is it necessary to evacuate?
ABS-35 ............................................................................................................................................................. 50
Life Threatening Ventricular Arrhythmia due to Severe Hyperkalemia in Patients with Adrenal Crisis : a Case
Report
ABS-36 ............................................................................................................................................................. 51
Clinical Characteristics, Risk Factors and In-Hospital Mortality Rate of Acute Coronary Syndrome in Young
Adults at National Cardiovascular Center Harapan Kita
ABS-37 ............................................................................................................................................................. 52
Late Presenter STEMI with Recurrent Chest Pain, would you still do lyitics ?
(LATE and EMERAS trial revisited)
ABS-38 ............................................................................................................................................................. 54
Idiopathic Left Ventricular Tachycardia
ABS-39 ............................................................................................................................................................. 55
Multi-vessel disease vs. single-vessel disease in STEMI patients:
Which one has worsened outcomes? ............................................................................................................... 55
ABS-40 ............................................................................................................................................................. 56
Evaluation of Acute Physiology and Chronic Health Evaluation II and CardShock Scoring Systems for
Prognostication of Short-Term Outcomes of Mechanically Ventilated Patients with Cardiogenic Shock in
Intensive Cardiovascular Care Unit of Saiful Anwar General Hospital

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ABS-41 ............................................................................................................................................................. 57
Mayor Adverse Cardiac Event in Patient With and Without Obstructive Coronary Artery Disease
ABS-42 ............................................................................................................................................................. 58
Association Neutrophil Lymphocyte Ratio with Right Ventricular Dysfunction in Acute Inferior or and Posterior
ST-segment Elevation Myocardial Infarction
ABS-43 ............................................................................................................................................................. 59
Acute Pulmonary Embolism in Systemic Lupus Erythematosus with Pregnancy : The Challenge of Diagnosis
and Management
ABS-44 ............................................................................................................................................................. 60
Reperfusion Therapy with Percutaneous Coronary Intervention supported with Continuous Positive Airway
Pressure in NSTEMI patient presenting with Acute Lung Oedema and Ventricular Tachycardia
ABS-45 ............................................................................................................................................................. 61
Predictive Prognostic Value of Neutrofil to Lymphocytes Ratio to Short-term Inhospital Mortality of
Mechanically Ventilated Patients with Acute Coronary Syndrome in Intensive Cardiovascular Care Unit of
Saiful Anwar General Hospital
ABS-46 ............................................................................................................................................................. 62
Anteroseptal Wall Myocardial Infarction due to Occlusion of the Right Coronary Artery: A Case Report
ABS-47 ............................................................................................................................................................. 64
Successful Reversal Of Acute Severe Heart Failure Due To Peripartum Cardiomyopathy With Aggressive
Pharmacotherapy
ABS-48 ............................................................................................................................................................. 65
The Indicator of In-Hospital Mortality Prognosis in ST-Elevation Myocardial Infarct Patients after Primary
Angioplasty
ABS-49 ............................................................................................................................................................. 66
Acute Limb Ischemia of Left Lower Extremity in Ebstein’s Anomaly with Patent Foramen Oval
ABS-50 ............................................................................................................................................................. 68
Is TIMI score Still an Useful Indicator of Inhospital Mortality of STEMI patients in Dr Sardjito General Hospital
? SCIENCE Registry Sub-Study
ABS-51 ............................................................................................................................................................. 69
Factors Associated with The Use of Renal Replacement Therapy in Patients with Acute Coronary Syndrome
Complicated by Acute Kidney Injury
Analysis from Registry of Acute and Intensive Cardiovascular Care on Outcome (RAICOM) at National
Cardiovascular Centre Harapan Kita (NCCHK)
ABS-52 ............................................................................................................................................................. 70
Right Bundle Branch Block Could Predict In-Hospital Mortality among Patients with ST-Segment Elevation
Myocardial Infarction:

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A One Year Retrospective Analysis from Registry of Acute and Intensive Cardiovascular Care on Outcome
(RAICOM) at National Cardiac Centre Harapan Kita (NCCHK)
ABS-53 ............................................................................................................................................................. 71
Mortality and Factors Associated with Malignant Ventricular Arrhythmias in Non-ST Elevation Acute Coronary
Syndrome
ABS-54 ............................................................................................................................................................. 72
Risk Model for Predicting In-Hospital Mortality of Non-ST-Segment Elevation Myocardial Infarction without
Revascularization at National Cardiovascular Center of Harapan Kita
ABS-55 ............................................................................................................................................................. 76
Double Infarction in Acute STEMI Treated With Primary PCI
ABS-56 ............................................................................................................................................................. 77
Inotropic and Vasopressor In Cardiogenic Shock Patient
ABS-57 ............................................................................................................................................................. 78
Fluid Therapy in Acute Lung Oedem and Diabetic Keto Acidosis, Restricted or Rehydrated?
ABS-58 ............................................................................................................................................................. 79
The Prevalence of Hyperlactatemia and In-Hospital Length of Stay in Patients with Cardiogenic Shock at M.
Djamil Hospital Padang
ABS-59 ............................................................................................................................................................. 80
Predictors of In-Hospital Mortality in Patients with Inferior ST-Segment Elevation Myocardial Infarction

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ABS-01

A 39 Year Old Woman Pregnancy 16-17 Week with STEMI INFERIOR : A Case Report
Ramdhani Rizcky1, Saragih E.Robert2
1Dokter Umum Rumah Sakit Umum Daerah Karawang
2Spesialis Jantung dan pembuluh darah RSUD Karawang

A 39 year old woman pregnant 16-17 weeks G4P1A2 came to IGD RSUD KARAWANG with complaints
chest pain since 3 hours smrs. Chest pain is felt continuously for approximately 30 Minutes and pain is not
reduced even at rest or lie down. The pain feel hot or pressed in the chest area, and radiates to the back and
neck of the left side. patients have a history of Hipertension who is currently taking routine medicine, physical
examination blood pressure 170/100mmHg. Ekg showed ST-elevation in the inferior lead with the result of
troponin enzyme T 0.327 Ckmb 70. Diagnosis STEMI Inferior. Carried out initial handling by giving O2, Nitrate
tablets, Antiplatelet, antiheparin and given nitrate drip and the patient consulting to obstetric. then the patient was
treated in the ICU room.

Keyword : Pregnant, Hipertension, STEMI

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ABS-02

Premature Coronary Artery Disease (CAD) ST-Elevation Myocardial Infarct (STEMI) with
Smoking Risk Factor in Very Young Adult (27 years old) : A Rare Case Report
Andrian, S1., Suryadi TE1., Loebis MI2., Hadiyat IG2

1General practitioner, Hasna Medika Heart Clinic-Hospital, Cirebon

2Cardiologist, Hasna Medika Heart Hospital, Cirebon

Introduction :
STEMI is one of the common causes of cardiac consultation and admission at emergency departments and
currently accounts for the high burden on health care services. CDC prevalence data for the year 2010 revealed
that prevalence of CAD in the age group of 18-44 years was 1.2%. the most common risk factor associated with
young CAD seems to be smoking.
In this case, we aimed to show that CAD occur in very young adult, hopefully there’s a cue to be used for
researches in regard to the CAD case in very young adult.

Case Description:
A 27-year-old man came to emergency department complaining of central chest pain one hour earlier. he is
smoker, who can spend ± 2 packs of cigarettes/day and has been smoked since at primary school.
He was conscious, alert and was able to locate the site of chest pain. Examination showed tachycardia, BP
90/60 mmHg; HR100 beats/minute. ECG showed sinus tachycardia and ST segment elevation in II,III, AVF.
Right-sided chest leads showed 1 mm ST segment elevation over V3R-V5R. Laboratory test is normal.
Presumptive diagnosis was acute inferior myocardial infarction. Aspirin, clopidogrel, and subcutaneous LMWH
was given to the patient. After a fluid challenge test, his BP was 100/70 mmHg upon transfer to Coronary Care
Unit to have an early Percutaneous Coronary Intervention.A flow-limiting 95% stenosis in the proximal right
coronary artery was identified.

Discussion :
In this case, patient is smoker and he is young adult with prematur CAD. Smoking can cause development of
atherosclerotic changes with narrowing of the vascular lumen and induction of a hypercoagulable state, which
create risk of acute thrombosis. The picture show the process that causes myocardial infarction in CAD.

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Conclusion :
CAD occur in young adult with smoking risk factor.

Keyword : PrematureCAD, Smoking,

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ABS-03

Coronary CT Angiography as a Gatekeeper to Invasive Strategy in CAD Patients, a PRCCTA

(Pasar Rebo General Hospital Coronary Computed Tomography Angiography) Registry
Sandra Puspitasari1, Sidhi Laksono Purwowiyoto2, Rido Adrianto Sukaton2

1Department of emergency medicine; 2Division of cardiac imaging, Department of cardiology and vascular
medicine
Faculty of medicine of Universitas YARSI, RSUD Pasar Rebo, East Jakarta, Indonesia

BACKGROUND:
Coronary CT Angiography (CCTA) is one of cardiac imaging modality that permits direct visualization of the
extent and severity of coronary artery disease (CAD). CCTA is used for intermediate to high pretest probability of
CAD based on ASCI (Asian Society of Cardiovascular Imaging) guidelines 2017. We determined CCTA as a
gatekeeper of invasive strategy in CAD patients.
METHODS:
We included patients from our registry (PRCCTA, Pasar Rebo General Hospital Coronary Computed
Tomography Angiography) who presented to the outpatient clinic with chest pain and were referred for cardiac
testing.
RESULTS:
In total 146 consecutive patients (median age 56 years, 54.1% females, 45.9% males) were included in the
Coronary CT Angiography between January to July 2017. All examinations were performed with a 64-slice
multidetector row CT scanner. CCTA were performed in patients with symptoms indicative of coronary artery
disease (85.6%). The pretest probability score was high (26.7%), intermediate (30.8%), low (28.1%) and very low
(14.4%) probability of obstructive CAD. The overall procedure completeness was 61%; contrast agents were
administrated in 89 patients (61%). The calcium score based on Agatston score were described as no plaque (0)
40.4%; small amount of plaque (1-10) 4.8%; mild plaque (11-100) 17.1%; moderate amount of plaque (101-400)
8.2%; and large amount of plaque (over 400) 29.5%. Vessel score distribution was LMA 7.5%, LAD 52.7%, RCA
39%, LCX 28.8%. For premedication 88.4% of the patients received bisoprolol oral, 31.5% patients received
diltiazem intravenous. All procedures of CCTA were performed in outpatient settings. Invasive coronary
angiography was recommended in 35.6% and secondary prevention (statin and/or aspirin therapy) in 64.4% of
the cases.
CONCLUSION:
The registry data has a high degree of completeness and validity. It is a safe procedure and its results have a
strong impact on patient management. Making it a valuable tool for clinical decision, epidemiological and
scientific research.

KEYWORDS:
coronary computed tomography angiography, CAD, gatekeeper, invasive strategy

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ABS-04

Challenging management of sustained ventricular tachycardia in a patient with high risk

NSTEMI and sepsis
Damaiati NE1, Chandranegara AF1
1Pasar Rebo Regional General Hospital, East Jakarta

Introduction

Several etiologies of recurrent ventricular tachycardia (VT) have been identified. Of all underlying causes,
myocardial scar resulted from myocardial infract might be at higher risk for recurrent VT. Such patients require
more aggressive evaluation and treatment.

Case Description

A 64-year-old man came to the emergency room due to shortness of breath since two hours prior to admission.
Neither chest pain nor palpitation was presented. His medical history included type 2 diabetes mellitus, coronary
arterial disease, and congestive heart failure. History of hypertension was denied. There were no prior
percutaneous coronary intervention or any other treatment have been performed. Vital signs showed blood
pressure of 160/80 mmHg, heart rate of 90 beats/minute, and respiratory rate of 36 times/minute with O 2
saturation of 80%. General physical examinations showed rales on both lungs and edema in all extremities.
Reduced ejection fraction (20%) was identified from echocardiograph. During his stay in CVCU,
electrocardiographs (ECG) showed recurrent and sustained ventricular tachycardia several times. Synchronized
cardioversion has been done followed by Lidocaine administration with a loading dose of 1 mg/kg followed by
maintenance dose of 3 mg/minute. After tapering off, VT was recurred, thus cardioversion was given and
Lidocaine was continued afterwards.

Figure 1. ECG of the patient showing VT from (A) 12-lead-ECG; (B) lead II only ECG

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Discussion and Conclusion

Treating patients with ischemic cardiomyopathy and recurrent VT is challenging. It has been identified that
catheter ablation procedure can target the reentrant pathways that is associated with the mechanism of scar
related monomorphic VT. Hence, ablation is recommended be performed in this patient with or without
continuation of antiarrhythmic drugs.

Keywords

Recurrent ventricular tachycardia, sustained ventricular tachycardia, catheter ablation, antiarrhythmic drugs,
myocardial scar

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ABS-05

Caprini score as a tool to predict deep vein thrombosis: a case series.

Nabila Edhiningtyas Damaiati1, Sidhi Laksono Purwowiyoto2

1Department of cardiology and vascular medicine,2 Division of cardiac imaging and interventional cardiology,
Department of cardiology and vascular medicine, Pasar Rebo Regional General Hospital, East Jakarta,
Indonesia

Introduction: Deep vein thrombosis (DVT) and pulmonary embolism are common causes of morbidity and
mortality in hospitalized patients, though the prevalence are not really high.Caprini is one of many tools that can
help predicting DVT, however it was originally used only for surgical patients. This study seeks to describe the
value of Caprini score for predicting DVT in hospitalized patients with any underlying condition in addition to post
surgery.

Case Description: Eleven cases of DVT were identified and reported from January 2016 to October 2017. Of all
cases, varied underlying conditions were presented. The majority risk factors was infection from any sources
(36%). Total Caprini score assessed in these patients ranged from one (low risk level) to five (high risk level).
Seven out of eleven cases were presented with total risk factor score of four which interpreted as having
moderate risk level.

Discussion and Conclusion: Caprini risk assessment score might benefit to evaluate risk of developing DVT in
all patients besides those after having elective surgery. Furthermore, such tool can also help determining
prophylaxis regimen. However, further larger study is required to investigate whether the score is also high in
patients without DVT.

Keywords: Caprini score, deep vein thrombosis, venous thromboembolism

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ABS-06

Continous Renal Replacement Therapy (CRRT) Post Cardiac Surgery in Acute Kidney Injury
With Prolonged Cardiac Pulmonary Bypass (CPB)
Samuel Dwiputra, Jefry Sianipar, Dis Bima Purwaamidjaja, Vireza Pratama
Gatot Subroto Central Army Hospital Jakarta

Background

Acute renal failure (ARF) requiring continuous renal replacement therapy is a complication of post cardiac
surgery with an estimated incidence 2-15% and in-hospital mortality >40%. Renal function disruption is an
important adverse effect of CPB that can result in significant mortality or morbility rates. During CPB nonpulsatile
perfusion, renal hypoperfusion, hypothermia, and increased inflammatory, these could be to renal dysfunction.
ARF is a critical disorder that needs rapid management. CRRT is a significant treatment strategy in patient with
severe ARF.

Case Description

Male, 54 years old, was admitted for elective CABG, Aortic Valve Replacement, and Tricuspid Valve Repair by
de Vega. The medical history before was significant for coronary artery disease with previous CAD 3 VD with
LVEF 35%. Baseline creatinine was 1.5, and ureum 35. Duration of procedure was 8 hours, total of bleeding was
1000 ml. The duration of CPB was 311 min and X-clamp 223 min.

On 2nd days, His urine output was 550 ml/24 h (furosemide 20 mg/h) with fluid balance +1175 ml/24 h, CVP : +13
cmH2O, the laboratory : ureum 94, creatinine 2.50. Then, CRRT was done for 2 days with CVVHDF mode.
Setting of CRRT would be adjusted with vital signs and fluid balance of the patient.

After CRRT, the vital signs were BP 121/86 (without inotropic and vassopresor), HR 77x/mnt, CVP +10 cmH20,
fluid balance cumulative: -1744 ml. And then extubation was done, and we have to monitor the urine output
(1880 ml/24 jam) with ureum 80, creatinine 1.2. Haemodynamic of the patients was stable so the patient had
moved to the surgical ward.

Discussion

Cardiac surgery induces a systemic inflammatory response from operative trauma, exposure to the CPB circuit,
blood transfusions, and hypothermia. CPB decrease the effective renal perfusion pressure up to 30% and
contributes to ischemia and referfusion injury. Renal perfusion is worsered by longer bypass times, intraaortic
ballon pump use, cardiogenic shock, vasopressor and inotrope use, and hemodilution.

When ARF is suspected or proven, optimization of hemodynamics should be prioritized to prevent further injury.
Recognition of ARF and early beginning of the CRRT are extremely important. The sooner the ARF after surgery
is recognized and CRRT is performed, the higher the likehood of the reduction of hospital mortality.

Conclusion
Our case show that ARF is a important complication of post cardiac surgery with prolonged CPB time and early
beginning of the CRRT is significant treatment for this patient.

Keywords : CRRT, Cardiac Surgery, ARF, CPB

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ABS-07

Comparison STEMI patients outcomes based on administration onset of fibrinolytic: a Serial

Case
Hidayat IR1.,Ginanjar A1., Rostiati D2.
1General Practitioner, Bandung Regional Public Hospital
2Cardiologist, Bandung Regional Public Hospital

Background:
PCI is the preferred reperfusion approach in acute STEMI, as it leads to greater survival with lower
rates of reinfarction and bleeding when compared to fibrinolytic therapy. However, if PCI is not
available or is likely to be delayed, fibrinolytic therapy is the reperfusion alternative. Administration of
fibrinolytic agent less than 12 hours upon an acute STEMI may restore 70-80% blood coronary
perfusion and significantly reduces the extent of tissue damage.

Case 1
A 76 year-old male came to the ER with left chest pain spread over the back and left arm since 30
minutes. He had crescendo angina since 1 month ago. Physical examination found normal. The ECG,
sinus rhythm 79bpm, ST Elevation in II,III,aVF. He was diagnosed with inferior STEMI ACS. He
received fibrinolytic, dual anti platelet therapy (DAPT) within 2 hours after onset. After fibrinolytic, chest
pain gone, ST elevation 100% reduced, echocardiography showed norm-kinetic at rest LVEF 61%.

Case 2
A 55 year-old male came to the ER with left chest pain spread over the back and left arm since 5 hours
ago. Physical examination found normal. The ECG, sinus rhythm 87bpm, ST Elevation in I,aVL,V 2-V3.
He was diagnosed with anterior STEMI ACS. He received fibrinolytic, DAPT 5 hours after onset. After
fibrinolytic, chest pain disappear, ST elevation reduce 75%, echocardiography showed hypokinetic
anterior and LVEF 49%.

Case 3
A 57 year-old male comes with chest pain complaints since 2 hours before admission. The pain spread
over the left arm and shoulder. Physical examination found normal. The Ecg sinus rhytm 59 bpm.
There are ST elevations in leads V2 and V3, T inversions in leads V4, V5, V6, I and AvL. He was
diagnosed with anterior STEMI ACS. Patients do not immediately get streptokinase for negotiating first
delayed for 1 hour so that patients get streptokinase and dual antiplatelet 3 hours after onset. After
fibrinolytic, chest pain disappear, ST elevation reduce 100%. Echocardiography show normo-kinetic at
rest LVEF 58%.

Case 4
A 54 year-old male came to the ER with a fainting complaint and a sudden weakness. At the time in the
emergency he complained of dizziness, initial examination was found Blood pressure was 84/52

15
mmHg, pulse 32 times per minute. In the ECG examination found in sinus rhythm 35 bpm, ST
elevations in leads II, III and AvF. He was diagnosed with inferior STEMI ACS and the patient is given
fluid resuscitation up to 1500 cc until the general condition improves. Patients get streptokinase 6 hours
after onset. After fibrynolitic, dizziness and weakness began to decrease. ST elevation reduce 75%.
The ecg monitor shows post reperfusion arrhythmias with a wide QRS complex with no p wave
(Accelerated junctional rhytm). Echocardiography has not been performed.

Discussion:
An immediate initiation of fibrinolysis is crucial: patients who received therapy within 2 hours of the
onset of symptoms of STEMI hold half of mortality rate rather than those who received it after 6 hours.
Administration of fibrinolytic less than 3 hours has same result as well as PCI.
In case1 and case3, fibrinolytic therapy was received within 2 hours and 3 hours after onset meanwhile
in case2 and case4 within 5 hours and 6 hours after onset. In this cases, fibrinolytic were successful,
characterized by disappearance of chest pain, and ST elevation reduction >50%. In case1 and case3
reduction of ST elevation almost 100% whereas in case2 and case4 only 75%. In echocardiography
evaluation; LVEF 61% in case1, 49% in the case2 with anterior hypokinetic wall motion and 58% in
case3. Meanwhile in case4, echocardiography has not been done. The differences of the outcomes
caused by the onset of fibrinolytic. A delay in reperfusion leads to worst outcome for patients.

Conclusion:
Fibrinolytic in early hours result better outcome seen from ECG and Echocardiography after
reperfusion.

Keywords: STEMI, Fibrinolytic, ECG, Echocardiography

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ABS-08

Suspecting the Subclavian Steal Syndrome in Rural Health Clinic : Case Report
Santoso JO1, Wibisono P1, Saragih NM1, Apriza RA1, Nisa C1, Suarsyaf P2, Ayu K2, Siswanto BB3
1Medical Student, Faculty of Medicine, Universitas Indonesia
2General Practitioner, Dompet Dhuafa Clinic, Ciputat
3Cardiologist, Harapan Kita Hospital, Jakarta

Introduction
Subclavian Steal Syndrome (SSS) is an occlusion of the subclavian artery that cause a retrograde blood flow
from vertebral artery to the affected arm. It is characterized by an unequal blood pressures (BP) in both arms.
The diagnosis of this syndrome on our clinics is challenging because of the facilities limitations. This case report
aimed to present a case of SSS.
Case Description
A male patient, 69 years old, with history of long-standing hypertension, came with a chief complaints of
dizziness, blurred vision, and discomfort in the right arm. In primary survey, airway and breathing are clear, BP
on the left hand was 200/120 mmHg and regular heart rate of 104 beats per-minute. Chest pain or palpitations
were denied. ECG indicated 1o degree AV-block and QT-prolongation (Qtc=450) but no atrial fibrillation. No
neurological deficit was found and ureum/creatinine parameters were normal. Furthermore, BP was examined on
the right hand showing 130/70 mmHg, then 15 minutes after supine position the BP became equal in both hand
with 120/70 mmHg. No bruit on the carotid. Heart’s sound was regular S1-S2 with holosystolic murmur 3/6 on
apices radiating to the axilla which was not affected by respiration. There was also wide splitting S2 in ULSB.
BP’s examination in supine and standing position was done to rule-out orthostatic hypertension but it was found
that BP after 3 minutes of standing position was 90/60 mmHg while in supine position was 120/70 mmHg. After
that, patient referred to larger hospital because there was no anticoagulant available for stroke prevention.
Discussion
We suspecting SSS because there was possibility that the patient had paroxysmal-atrial fibrillation results from
mitral regurgitation causing thrombus on the right subclavian artery. Initial management on this patient was to
prevent stroke and hypertensive crisis with administration of anti-hypertensive drugs. The risk of ischemic stroke
in these patients was high because of the possibility of valvular-AF, thus administration of VKA is required. In the
end, patient should be referred to the hospital that capable of angiography procedure.
Conclusion
It is important for primary care doctor to recognize SSS’ symptoms, thus to prevent its recurrence.
Keywords : Mitral Regurgitation, Paroxysmal Atrial Fibrillation, Subclavian Steal Syndrome

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ABS-09

Impact of Metabolic Syndrome on Cardiovascular Outcome after Percutaneous Coronary

Intervention
Santoso JO1, Billy M1, Panjaitan HPB1, Amin LA2
1Medical Student, Faculty of Medicine, Universitas Indonesia
2Cipto Mangunkusumo Hospital, Internal Medicine Department, Jakarta

Introduction
There is an increased prevalence of metabolic syndrome, especially in Indonesia. It is widely known that the
metabolic syndrome increase the risk of cardiovascular disease. It also known that the metabolic syndrome
increase the risk of post-PCI restenosis. But, the effect of metabolic syndrome on cardiovascular outcomes after
PCI is still debated.
Aim
This study aims to see whether the metabolic syndrome increase the risk of death and major cardiovascular
events (MACE) 30 days post PCI
Method
A single center, retrospective cohort study was applied as a research method. A total of 235 patients who
performed PCI procedures within the period between August 2013 and July 2014 at Cipto Mangunkusumo
Hospital was examined for the metabolic parameters. Patients were categorized to determine the presence and
absence of metabolic syndrome with NCEP-ATP III criteria. We also controls confounding factors that may affect
the outcomes such as age, gender, smoking history, ejection fraction <40%, heart failure, kidney disorders, and
PAD.
Results
From bivariate analysis, there was no association between metabolic syndrome with death (p = 0.69) and MACE
(p = 0.22) at 30 days post PCI. There was also no association between single-metabolic syndrome factors such
as hypertension, diabetes mellitus, abdominal obesity, low HDL levels, and high TG levels with the adverse
events after PCI. From the results of multivariate analysis, nor was there an association between metabolic and
adverse events after PCI.
Conclusion
There was no increased risk of death and MACE 30 days post PCI in patients with metabolic syndrome.
Keywords: metabolic syndrome, death, major cardiovascular events

18
ABS-10

Managing Right Ventricular Failure and Cardiorenal Syndrome in ASD-PAH Patient; an ICU Case
Report
R. Ahmad Anzali1, Nanda Iryuza2
1 General Practitioner, Riau Islands Province General Hospital, Tanjungpinang-Indonesia

2 Cardiologist, Riau Islands Province General Hospital, Tanjungpinang-Indonesia

Introduction.
Pulmonary arterial hypertention (PAH) is associated with a poor prognosis. The estimated median survival from
diagnosis is 2.8 years and the 1-year and 5-year survival rates are only 68% and 34%, respectively. More than
70% of PAH patients will die as a result of right ventricular failure. Predictors of a poor prognosis in PAH are
related to the development of right ventricular failure. Renal dysfunction is highly prevalent in patients with heart
failure due to low pressure circullation. Furthermore, worsening renal function in patients with heart failure, the
so-called cardiorenal syndrome, impacts short and long-term morbidity and mortality.

Objective
We report a case of a woman with Atrial Septal Defect (ASD) and PAH presenting with acute right ventricular
failure and Cardiorenal Syndrome (CRS)

Case Illustration
Our patient is a 36-year-old woman with acute decompensated heart failure who has had several admissions for
worsening shortness of breath, lower-extremity edema, and increased abdominal girth. She was readmitted with
the same symptoms, and diagnosed thyroid heart disease before it.
Physical examination revealed 110/70 mmHg BP, 88% oxygen saturation, jugular veins distention, bilateral
rhales, mild ascites and bilateral lower limbs edema. Heart rate was regular with a II/VI wide split systolic
murmur loudest at the left sternal border. Laboratory results shown renal insufficiency with eGFR 35 mL/min. The
ECG revealed normo-sinus rhytm and RVH. Trans-thoracic echocardiography shown D-shaped LV, TR V max
4,1 m/sec, mPAP 50 mmHg, and intra atrial septum gap 2,1 cm.
The Patient was diagnosed with ASD-PAH with ADHF and Cardiorenal Syndrome, and then admitted to the ICU.
Patient was given mechanical respiratory support, lasix drip, and dobutamine renal dose. 48 hours in ICU,
patient's condition improved. Heart failure resolved, urine output and kidney function improved.

Discussion
Progressive PAH presents a pressure overload state to the right ventricle, increasing right ventricular workload
leading to concentric hypertrophy . With persistent pressure overload, the right ventricle undergoes a remodeling
process eventually leading to right ventricular failure. The right ventricular chamber dilates and the concentric
hypertrophy transitions to eccentric hypertrophy, resulting in increased wall stress and systolic dysfunction.
Increased heart rate and right ventricular wall stress lead to significant increases in right ventricular myocardial
oxygen consumption. This, in combination with reduced right ventricular endomyocardial coronary perfusion
leads to right ventricular ischemia and worsening right ventricular diastolic and systolic function. 1
Low pressure circulation causes reduce renal perfusion. The neurohumoral adaptations to reduced renal
perfusion result in stimulation of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous
system, as well as vasopressin and endothelin release, all of which promote systemic vasoconstriction and
further decrease in GFR, then called cardiorenal syndrome (CRS).2

19
Right heart failure management strategies consist of preload optimization, afterload optimization and RV
contractile support. Low-dose dobutamine (5-10 µg/kg/min) has been shown to restore RV-pulmonary artery
coupling and cardiac output better than norepinephrine because of its more pronounced inotropic effect. Given
that it is an inodilator, it is preferably used in normotensive patients.3

Conclusions
From this case report we conclude the importance of the role of low doses of dobutamine in management of right
heart failure with cardiorenal syndrome

Keyword
right heart failure, cardiorenal syndrome, dobutamine

20
ABS-11

Postcardiac Injury Syndrome : a Rare Complication of Angioplasty Procedure

Yudhistira Kurnia, Vebiona Kartini Prima Putri, Dasdo Antonius Sinaga
Awal Bros Pekanbaru Hospital

Introduction

Coronary heart diseases currently rank number one as the cause of death in developing countries, with acute
myocardial infarction as the most frequent clinical manifestation. Percutaneus cardiac intervention (PCI) still be
the recommended procedure for this condition. Several complications happen following this procedure, range
from mild to severe complication. Postcardiac Injury Syndrome (PCIS) is a condition characterized by
inflammation of the pericardium, pleura, and pulmonary parenchyma following a cardiac injury. Even though it is
rarely found, PCIS was reported in a few cases as a complication of endovascular procedure such as PCI.

Objective

Objective of this case report is to describe the occurence of Postcardiac Injury Syndrome after PCI Procedure.

Case Illustration

A 57 years old man was referred from pheriperal hospital after 2 days of hospitalization due to acute inferior
STEMI and cardiogenic shock. He was treated with PCI angioplasty and 1 Drug Eluting Stent was implanted on
Right Coronary Artery 2 days after his arrival.

Few days after the procedure, the patient developed fever, dyspnea and pleuritic pain. Echocardiography
examination revealed pericardial and pleural effusion that did not exist before. Serial thoracocentesis and
pericardiocentesis were done due to life threatening cardiac tamponade and massive pleural effusion.
Administration of colchicine and corticosteroid gave a good progress. Patient was sent home 4 weeks after PCI
procedure.

Discussion

According to 2015 ESC Guidelines, a diagnosis of PCIS requires history of the pericardium and/or myocardium
injury and at least two of following; (1) fever without alternative causes, (2) pericarditis or pleuritic chest pain, (3)
pericardial or pleural rubs, (4) Evidence of pericardial effusion, or (5) pleural effusion with elevated C-reactive
Protein. PCIS can occurs within five days after myocardial infarction (early infarct-associated pericarditis), with
delayed angioplasty as major risk factor. The usage of anti-inflammatory drugs (NSAIDs, corcticosteroids,
Colchicine) shows a remarkable response. Pericardiocentesis or Thoracocentesis is sometimes needed to treat
life threatening pericardial or pleural effusion.

Conclusion

Despite of its rare occurrence and low morbidity/mortality rate, an immediate diagnosis and prompt treatment of
PCIS is needed to prevent life threatening condition.

Keyword : Postcardiac Injury Syndrome, STEMI, Percutaneus Coronary Intervention, Pericarditis, Coronary
heart disease

21
ABS-12

Clinical Profile in Elderly and Young Adults with Acute Decompensated Heart Failure when
Admitted to The Emergency Department
dr. Windy Yulianti

Rumah Sakit Karya Medika I, Cikarang Barat

Acute decompensated heart failure is a common and potentially fatal cause of acute respiratory distress. The
clinical syndrome is characterized by the development of dyspnea, generally associated with rapid accumulation
of fluid within the lung's interstitial and alveolar spaces, which is the result of acutely elevated cardiac filling
pressures (cardiogenic pulmonary edema).
Objectives. To describe the clinical profile and hemodynamic profile assessment of both group when they come
to ED. Patients and method. One hundred ninety patients with ADHF data were collected from medical record
that divided into two groups: young adult (≤50 years) and elderly (>50 years).
Results. Young adult patients (n=164) were mostly women had almost have similar clinical characteristics and
hemodynamic profile assessment with the elderly patients (n=26). At admission, evidently both group patients
were most likely to have dypneu, cardiomegaly in thorax Xray, and they had history of hypertension before.
Diabetes were found in young adult, at 26%, compared in elderly, they were having both risk factor (DM+HT),at
42 %.The ECG findings were similar in both groups, it was Q Pathology. In young adult were more common with
NSTEMI, while in elderly came with AF. On hemodynamic profile assessment, in young adults almost present
with adequate peripheral perfusion and signs symptoms of congestion. While in elderly, half of them, still on
normal hemodynamic and the rest turn into adequate peripheral perfusion and signs symptoms of congestion,
similar with young adults at 42,3%. It can provide important information about the degree of decompensation and
overall prognosis.
Conclusions. Clinical characteristic and hemodynamic profile assessment of both group were not significantly
different.
Keywords : ADHF, cardiogenic pulmonary edema, ED, AF

22
ABS-13

Cardiogenic Shock and Sudden Death in Anterior Extensive STEMI Accompanied by Complete
RBBB : A Case Report
M. Adhitya Nagara, M. Rizky Felani, Revan Satrio

Emergency Department, Siti Khodijah Hospital, Palembang

Introduction
Anterior extensive STEMI is still one of the most dangerous case because it can lead to cardiogenic
shock and sudden death. Even more when it’s accompanied by Complete Right Bundle Branch Block
(RBBB), which is the late electrical impulse from right ventricle pump. Unfortunately, in Indonesia,
research on the increases death risk in extensive anterior STEMI with RBBB is very minimum.

Case Description
A 49-year-old male with history of uncontrolled DM came to the ER with chief complaints of shortness
of breath and chest pain since ± 4 hours prior to admission. BP is 110/70 mmHg with heart rate of 83
bpm, anterior extensive STEMI + complete RBBB was determined from EKG, random blood glucose
level is 254 mg/dl. Framingham criteria for heart failure is negative. Initial algorithm for ACS had been
performed immediately with oxygen 4 l/m, ISDN SL (2x), aspilet 320 mg, CPG 160 mg. But not long
after (before it’s even possible to administer fibrinolytics), the patient’s condition worsened, his
consciousness dropped and went into cardiac arrest (asystole). CPR was performed for about 20
minutes and the patient went into VF, which was immediately defibrillated. However, in the end, it still
wasn’t enough to save the patient.

Discussion
Based on research from other countries (HERO-2 and NRMI-2 included), the presence of RBBB in
anterior STEMI incident can become a predictor in higher death risk, when compared to other
combinations of STEMI and BBB. It is believed that this theory is in line with the case. All lab results
were unremarkable, so the sudden death in this patient was suggested to be purely caused by
cardiogenic shock.

Conclusion
Research on a more fatal anterior extensive STEMI with RBBB in Indonesia couldn’t be found, so the
case is still a grueling challenge in doctor’s part to manage. Reperfusion therapy (during golden period)
is still a definitive therapy to prevent further heart damage.

Keywords : Right bundle branch, infarction, cardiogenic chock, sudden death

23
ABS-14

Failure to Stabilize Heart Rate Using Maximum Infusion Dose of Dopamine in Unstable
Bradyarrhythmia Case (Total AV Block type), Pacemaker-Dependent? A Case Report
M. Rizky Felani, M. Adhitya Nagara, Revan Satrio, Rangga Mandara, Assilia Dharani, \
Ferry Usnizar

Emergency Department, Hermina Hospital, Palembang

Introduction
Total AV Block is a type of disrhythmia with the worst prognosis toward permanent AV nodes’ function.
Total AV Block incidences is caused mostly by severe occlusion in the RCA. Dopamine IV infusion is
one of the drugs of choice to treat bradyarrhythmia.

Case Description
A 60-year-old male patient was admitted to the ER with chief complaint of burning sensation in
epigastrium starting ± 26 hours before. BP was 90/60 mmHg with HR at 30 bpm, ECG showed
inferoposterior STEMI + RV infarction + total AV block with junctional escape rhythm (intranodal block).
Bradyarrythmia and ACS algorithm were performed simultaneously with the administration of SA 0.5
mg IV, aspilet 320 mg, CPG 300 mg, pantoprazole 20 mg IV, oxygen with nasal cannula 5 l/m, lovenox
30 mg IV, 250 cc RL loading, and the preparation for ICU transfer (A-type hospitals’ ICCU are full). SA
administration didn’t give any results toward HR, therefore titrated dopamine infusion was administered.
36 hours later, patient was finally be able to be referred to A-type hospital. Prior to referral, HR was still
35 bpm, BP 95/70 mmHg, with dopamine infusion (20 mcg/kg/min), lovenox 60 mg SC (every 12
hours), and fluid therapy.

Discussion
Management for unstable bradyarrhythmia strives for rapid HR increase. Unfortunately, the STEMI had
been going for > 12 hours (presence of pathological Q-waves). Because of unavailability of
transcutaneous pacemaker device, patient was given SA to see HR response. Alas, it failed, the patient
was transferred to ICU, and dopamine infusion was given. It was expected to increase HR and BP, so it
was uptitrated to maximum dose, yet the results were unsatisfactory.
Conclusion
Total AV block with myocardial infarction that has gone past its golden period is terrible case, it required
pacemaker implantation. Even the administration of maximum dose dopamine didn’t bear any results
for his hemodynamic status. Unfortunately, there were no publications regarding the research for
dopamine and epinephrine infusion administration simultaneously in unstable bradyarrhythmia (with
intranodal type of block), and some guidelines didn’t mention the legality of the combination of the 2
drugs.

Keyword : Total AV block, infarction, dopamine, pacemaker

24
ABS-15

Acute Cardiovascular Management in Unstable Angina Pectoris (UAP) with Frequent

Monomorphic Premature Ventricular Contraction (PVC) : A Case Report
M. Adhitya Nagara, M. Rizky Felani, Gadtra Alputra, Revan Satrio

Emergency Department, Siti Khodijah Hospital, Palembang

Introduction
Premature Ventricular Contraction (PVC) is premature heart beat that originated from the ventricles. PVC can be
found in normal individuals as well as people with altered heart structure, including coronary artery disease.
Frequent PVCs in Acute Coronary Syndrome (ACS) has to be immediately terminated to prevent more malignant
ventricle arrrhythmias.

Case Description
A 54-year-old female was admitted to ER with chief complaints of shortness of breath and squeezing chest pain
since ± 12 hours prior to admission, accompanied with palpitations and weakness. BP was 140/80, HR 80 bpm,
and RR 28 x/m. She had history of uncontrolled hypertension. ECG showed constant monomorphic bigeminous
PVC + first degree AV block, no ST-T changes and pathological Q-waves were found. In ER, aspilet 160 mg,
CPG 150 mg, 4 l/m of oxygen, ISDN SL 5 mg, amiodarone 300 mg infusion (to be finished in 30 minutes) were
administered. The patient was also prepared for ICCU transfer. Lab results showed normal cardiac enzymes.
After initial therapy in the ER, chest pain was relieved. ECG results 30 minutes later showed no signs of PVCs.
The patient was transferred to ICCU thereafter with amiodarone 720 mg infusion for 24 hours.

Discussion
Typical chest pain with constant bigeminous PVC in ECG findings is a sign of lethality in patients’ heart condition,
hence it’s classified as malignant PVC. Even though there’s an absence of significant ST-T segment changes,
the management algorithm for ACS must be immediately performed to prevent mortality. After initial therapy for
ACS, amiodarone administration in this case is expected to lower BP, vasodilate the coronaries, and optimize
cardiac output.

Conclusion
Patient is still suggested to undergo coronary angiography ASAP as the gold standard for coronary event
management. The use of amiodarone in the ER was proved to succeed in the management of frequent PVC,
and then with the right dose, it’s expected to prevent more malignant arrhythmias.

Keywords : Premature ventricular contraction, ventricular arrhythmia, acute coronary syndrome, amiodarone

25
ABS-16

Sudden Death in Acute Right Ventricular Infarction, A New “Trend” in Cardiogenic Shock
Cases? A Case Report
M. Rizky Felani, M. Adhitya Nagara, Revan Satrio, Rangga Mandara, Assilia Dharani,
Ferry Usnizar

Emergency Department, Hermina Hospital, Palembang

Introduction
Cardiogenic shock caused by pumping failure (post-extensive anterior STEMI) has thoroughly been
widely recognized by physicians, including in Indonesia. There’s still a lot of mysteries regarding
whether acute right ventricular (RV) infarction is as lethal as cardiogenic shock in general, considering
the limited information to physicians about RV infarction cases.

Case Description
An unconscious 83-year-old female patient was admitted to ER. Her BP was 98/67 with HR 79 bpm.
Her chief complaint before falling unconscious was squeezing pain in the left area of chest since ± 7
hours prior to admission. ECG showed Inferoposterior STEMI + RV infarction + first degree AV block.
Therapy given in the ER were Aspilet 320 mg, CPG 300 mg, oxygen with nasal cannula 5 l/m,
continued with Arixtra 2,5 mg IV, 200 cc of RL loading, dobutamine infusion, and immediately escorted
to ICU. About an hour later, patient’s condition worsened and there was severe hypotension, she went
into cardiac arrest 3 hours later. Management for cardiac arrest was established for ± 30 minutes, but
the patient couldn’t be saved.

Discussion
Based on observational data, RV infarction is bad factor in mortality rate of inferior STEMI. But in
Indonesia, the morbidity and mortality rate of RV infarction has not been known well. Adequate fluid
therapy and inotropic drugs administration are believed to be able to optimize heart function, while
reperfusion therapy in golden period is still the most important factor in the survival rate of patients. In
this case, patient had been given agressive therapy until the administration of norepinephrine infusion
at maximum dose. Unfortunately, fibrinolytics couldn’t be administered, and primary PCI couldn’t be
done because the patient was unstable to be referred.
Conclusion
The incidence of RV infarction is still considered dangerous, because it can cause severe hypotension
and worsens to be cardiogenic shock that leads to death. In Indonesia, further studies to determine the
severity of cardiogenic shock caused by RV infarction is very limited, contrary to incidence of pumping
failure (extensive anterior STEMI).

Keywords : Infarction, right ventricle, cardiogenic shock, acute coronary syndrome

26
ABS-17

Not All Fascicular Ventricular Tachycardia is Idiopathic

Filipus Michael Yofrido 1,2, Nur Aini M. 2, Dian Kartika 2, Rhesa Prasetya 2, Tiar Oktavian 2, Devina Nataliany 2,
Eka Devinta 2, Ivor Wiguna W. 2, Achmad Lefi 2
1 Faculty of Medicine, Widya Mandala Catholic University, Surabaya, Indonesia
2 Darmo Hospital, Surabaya, Indonesia

INTRODUCTION: Fascicular ventricular tachycardia (FVT) is a common form of sustained idiopathic left
ventricular tachycardia (ILVT) with an Asian preponderance. In the setting of ishemic cardiomyopathy, most of
VT originate in left ventricle, but rarely in left fascicle area.

CASE DESCRIPTION: A 84-years-old woman came to our emergency department, complaining shortness of
breath. This patient had history of advanced HF (NYHA functional class IV). She feels shortness of breath daily,
sometimes even at rest. In the last week before she came to hospital, her shortness of breath deteriorated and
accompanied with upper back discomfort. She was tachycardic (HR 140 bpm) and dyspneic (RR 32/min) with
108/69 mmHg BP and 99% SaO2 in simple mask oxygenation. ECG monitor revealed sinus tachycardia and
multiple ventricular ectopic beats followed by sustained narrow-complex tachycardia (172 bpm). On 12-lead ECG
showed a regular, monomorphic, modest wide QRS complex (QRS duration 136 ms) tachycardia with RBBB-like
morphology, left superior axis (frontal axis at -70o), and also there were several fusion beats and AV dissociation
(Fig. 1). Chest radiography showed cardiomegali and early pulmonary edema. Laboratory result showed
elevated aspartate transaminase (SGOT), and elevated troponin T (0.45 ng/mL; N < 0.05 ng/mL). Her rhythm
was converted into sinus rhythm after 150 mg amiodaron administration (Fig. 2).

DISCUSSION: On her ECG report, she was highly suggestive suffered from fascicular ventricular tachycardia.
Based on Segal criteria (Fig. 3), the ectopic focus came from posterobasal origin, consistent with left posterior
fascicular VT. Almost fascicular VT has idiopathic ethiology, but in this patient, according to her history and
laboratory result, that rhythm can be caused by structural heart disease and/or myocardial infarction (NSTEMI).
There was also ST-segment elevation in aVR lead that can be a sign of left main coronary artery occlusion (Fig.
2). Verapamil wasn’t chosen to terminate her VT because of its cardiac depressive effect.

CONCLUSIONS: Fascicular VT is usually come from posterior fascicle and mostly idiopathic. However, ischemic
and structural-related fascicular VT is also possible. Cardiac imaging, electrophysiology study, and intensive
cardiac care is needed to perform optimum treatment.

Keywords: Fascicular Ventricular Tachycardia, Left Posterior Fascicular VT, myocardial infarction, heart failure.

27
Figure 1. Initial ECG report.

Figure 2. ECG report after termination by 150 mg Amiodaron.

28
Figure 3. Segal (et al) criteria for differentiating venctricular ectopic origin.

29
ABS-18

Clinical Characteristics, Risk Factor, Management and Short-term Outcomes of Patients with
Acute Coronary Syndrome – First Trimester Observation in Prof WZ Yohanes Hospital, Kupang
Akbar Sinaga 1 , Leonora Tiluata 2
1 General Practitioner, Prof WZ Yohanes Hospital, Kupang
2 Cardiologist, Prof WZ Yohanes Hospital, Kupang

Background: Acute coronary syndrome (ACS), manifested as ST-segment elevation myocardial infarction
(STEMI), non-STEMI (NSTEMI), and unstable angina (UA) is a life-threatening disease. The data regarding
clinical characteristic, management, and outcome after acute coronary syndrome (ACS) are limited in East Nusa
Tenggara, especially Kupang. Objective: The objective of this study was to identify the clinical characteristic,
risk factor, and management of ACS patients in Prof WZ Yohanes Hospital, Kupang.
Methods: The data was collected at admission, during the in-hospital stay, and at 1,3,6 months post-discharge
Results: From 29 patients enrolled, 16 ( 55.2%) were diagnosed with STEMI. Diabetes mellitus, dyslipidemia,
hypertension, smoking were the risk factor which significantly higher in STEMI group patients (p < 0.05). About
100% patients received heparinization. There were 2(12.5%) STEMI patients that get thrombolytic agent. In 1
month follow up there was 1 (7.7%) patient got hospitalization and died in NSTEMI/UAP group.
Conclusion: In this study, dyslipidemia and diabetes mellitus were the highest risk factor in ACS. Mostly STEMI
patients didn’t aware with the symptomp of ACS and delayed go to hospital resulting low thrombolysis associated
pathologic Q finding in ECG.

30
ABS-19

Evidence Based Case Report High-dose Isosorbide Dinitrate in Acute Heart Failure: Does it
Work?
Audie Christopher1, Evan Hindoro2

1Internship Doctor at RSUD Dr. Abdul Aziz, Singkawang, Indonesia

2Internship Doctor at RSUD Belitung Timur, Belitung, Indonesia

Background: Acute heart failure is one of the most common presentation in emergency department, especially
in elderly patients. The mortality and morbidity for acute heart failure in developing countries are still high. In
Indonesia, the clinical presentation of patients tends to be worse and younger compared to those in Europe and
United States. It is well known that the mainstay of treatment consists of diuretic and vasodilator. The use of
high-dose isosorbide dinitrate is associated with arteriodilatation, which reduces the afterload thereby increasing
the cardiac output. Few studies have revealed that they are associated with faster improvement in symptoms of
respiratory distress. However, is it worth the risk?

Aim: To evaluate the effect of adding high-dose isosorbide dinitrate compared to conventional treatment in
terms of in-hospital mortality, by using evidence based medicine.

Method: Literature searching was conducted by using PubMed and Cochrane. 1 randomized controlled trial and
1 retrospective cohort studies were obtained after selection.

Result: One study by Cotter et al is a valid Randomized Controlled Trial. It demonstrated better outcome in the
high-dose ISDN group despite statistical significance (p=0.61). Another study by Freund et al, a valid
Retrospective Cohort verified the latter outcome however it also lacks statistical significance (p=0.32).

Conclusion: The effectiveness of high-dose ISDN in treating acute cardiogenic pulmonary edema is
inconclusive. Further researches are needed to evaluate the effect of this therapy

Key Words: Acute Heart Failure, Pulmonary Edema, Nitrate, Isosorbide Dinitrate

31
ABS-20

Long QT Syndrome Induced by Electrolyte Imbalance that Leads to Torsade de Pointes

Episodes
Andrian, S1., Suryadi TE1., Loebis MI2.

1General practitioner, Hasna Medika Heart Clinic-Hospital, Cirebon

2Cardiologist, Hasna Medika Heart Hospital, Cirebon

Introduction :
Long QT syndrome (LQTS) is a rare inherited congenital disorder or an acquired heart condition in which a
delayed repolarization of the heart followed by a heartbeat that increases the risk of episodes of torsades de
pointes (TdP). Acquired LQTS is most often caused by drugs, combined with risk factors such as gender
(female), electrolytes imbalance (hypokalemia, hypomagnesemia and hypocalcemia), bradycardia, and structural
heart disease, may precipitate the occurrence of torsade de pointes.

Case Description:
A 37 year-old female administered to the ER with dyspneu especially on physical activity. In physical
examination the BP is 140/90,HR 89 bpm, and RR 26. ECG showssinus rhythm with inverted T waves and LQT
interval. After an IV bolus of 40mgs Furosemide is administered, the patient suddenly unconscious with unstable
haemodynamics.ECG shows polymorphic VT which the QRS complexes “twist” and then immediate
defibrillation administered.She given 2gs bolus of magnesium sulfate and followed by intravenous infusion of
magnesium at a rate of 2 mg per minute. Laboratory test results showed severe Hypokalemia (K = 1.97) with
normal Magnesium and Calcium. The patientalso received KCL20 meq/hour. The patient has stabilized and
transferred to ICCU for monitoring.

Discussion :
in this case, the patient had hypokalemia which resulted in the occurrence of Long QT syndrome triggering
Torsade de pointes. Low extracellular potassium paradoxically reduces rapid delayed reactifier (Ikr) by enhanced
inactivation or exaggerated competitive block by sodium. As a result, hypokalemia prolongs the QT interval.
Prolonged repolarization can cause early after depolarizations (EADs). EADs that reach threshold voltage can
cause a ventricular extrasystole lead to TdP.

Conclusion :
The goal of treating LQTS is to prevent life-threatening, abnormal heart rhythms (ex. TdP) and fainting spells. An
Acquired LQTS disappear once the causative factor is overcome.

Keyword : LQTS, TdP, Hypokalemia

32
ABS-21

A 40 Years-old Female with Severe Mitral Stenosis, Atrial Fibrillation, Heart Failure with
Pulmonary Edema and Diabetic Ketoacidosis
D.J.S.S. Dewi¹, M. Alfiansyah¹, A. Bestara¹, T. Wasyanto²

¹Resident of Cardiology and Vascular Medicine, Sebelas Maret University, Surakarta, Indonesia; ²Cardiologist at
Cardiology and Vascular Medicine/dr. Moewardi General Hospital, Sebelas Maret University, Surakarta

Background: Mitral stenosis is a valvular heart disease resulting from rheumatic fever characterized by the
presence of thickened leaflet edges, commissural fusion, and chordal shortening and fusion. Patients who
develop severe mitral stenosis are often have symptoms of heart failure such as fatigue due to low cardiac
output, decreased exercise tolerance, and are at risk of experiencing attacks of frank pulmonary edema. Diabetic
ketoacidosis (DKA) is a potentially fatal hyperglycemic crisis due to insulin deficiency, causing inability of the
body to use glucose as energy source. Heart failure management in patients with DKA is quite challenging
because the use of diuretics as the cornerstone therapy in acute heart failure may worsen dehydration during the
state of insulin deficiency in DKA.The aim of this case report is to describe the diagnosis and management of
patient with severe mitral stenosis and heart failure with co-existing DKA.

Case Ilustration: a 40 years-old female came to Moewardi General Hospital emergency department complaining
of rapid heartbeat since 7 hours before coming to the hospital while she was at rest. She also complained of
shortness of breath, coughing, and swelling of her legs. Her medical history including having valvular heart
disease with irregular heart rhythm and adult onset diabetes mellitus. Echocardiographic study showed a severe
mitral stenosis with mitral valve planimetry of 0.5 cm² and pressure half-time of 0.6-0.9 cm², mild mitral and
tricuspid insufficiency, EF 64% with global normokinetic and LA thrombus. Laboratory findings revealed Hgb 14
g/dl, Hct 44%, WBC 12.2.00/ul, plt 165.000/ul, RBG 540 mg/dl, Na 120 mmol/l, K 5.5 mmol/l, Cl 87 mmol/l, pH
7.280, HCO3 15.2 mmol/l, ketone +3. ECG findings showed atrial fibrillation with rapid ventricular response.
Discussion: Mitral valve stenosis is one of valvular heart disease caused by rheumatic fever. One of it’s
complication is development of heart failure with pulmonary edema. DKA is a fatal hyperglycemic crisis in
diabetes mellitus with dehydration during a state of insulin deficiency. In the state of heart failure with pulmonary
edema and co-existing DKA, the proper management with adjustment in each condition should be performed.
Key word: Mitral stenosis, diabetic ketoacidosis, heart failure.

33
ABS-22

Acute Coronary Syndrome post Hypoglycemia

Melissa Dharmawan,1 Rodry Mikhael,1 Christian TH Kawengian2

1General Practitioner, Belitung Timur General Hospital, Manggar, Indonesia

2Department of Internal Medicine, Belitung Timur General Hospital, Manggar, Indonesia

Background
Hypoglycemia is a clinical condition caused by low blood glucose levels (<70 mg/dL), that leads to
increased levels of catecholamines and regulatory hormones. However there are also increase levels of
inflammatory markers, platelet activation and endothelial dysfunction that are thought to cause blood vessel
damage.

Case Illustration
A 46-year-old man was brought to the Emergency Department (ED) due to loss of consciousness three
hours before admission. He had a history of hypertension and type 2 diabetes mellitus, treated with captopril,
glibenclamide and metformin. Previously the patient was examined at a clinic with a blood glucose level of 28
mg/dL and gained consciousness after receiving 50 ml of 40% dextrose.
In ED he complained with general weakness and left sided chest pain, defined as retrosternal, pressed-like
quality, radiates to the back and left arm, lasting for thirty minutes. General examination showed Glasgow Coma
Scale of 15, blood pressure 140/80 mmHg, heart rate 88 times/minute, respiration rate 22 times/minute. Other
physical examinations are within normal range. Laboratory results showed blood glucose level 50 mg/dL, while
CKMB and Troponin T examination is not available. Electrocardiogram shows ST Segment elevation in lead V1-
V4 with reciprocal changes in lead II, III, aVF. He was diagnosed as hypoglycemia due to sulfonylureas and ST-
Elevation Myocardial Infarct. Patients then received oxygen, D40% bolus followed by D10% 500 ml per 6 hours,
aspirin, clopidogrel, isosorbide dinitrat, simvastatin and captopril, but the administration of fibrinolytic,
anticoagulant or Percutaneous Coronary Intervention can not be performed due to facility shortage. After 4 days
of hospitalization, his symptoms are fully resolved and random blood glucose level has reached normal value. A
re-examination of ECG showed normalization of ST segment in lead V1-V4. The patient then discharged from
the hospital.

Discussion
Hypoglycemia is often caused by excess of insulin or oral antidiabetic drugs especially sulfonylurea.
Hypoglycemia state will trigger the release of glucagon, catecholamine, cortisol and growth hormone secretions
to increase gluconeogenesis, glycogenolysis and lipolysis. Catecholamine will increase heart rate, peripheral
systolic blood pressure, cardiac contractility, ejection fraction and decreased peripheral resistance. Blood flow to
other organs will be decreased to maintain flow to the heart and brain. Catecholamines can also cause coronary
vasoconstriction resulting in an imbalance between the needs and myocardial oxygen supply.
Hypoglycemia also leads to increasing production of P-selectin, fibrinogen, factor VIII and decrease of
plasminogen activator inhibitor-1, with increased platelet activation, thus resulting in a procoagulatory state.
Furthermore there are increases in various inflammatory markers such as Interleukin (IL) 6, IL-8, Tumor Necrosis
Factor α , C-reactive protein, endothelin 1, that will cause endothelial dysfunction. The above mechanisms may
precipitate myocardial ischaemia and arrhythmias.

Conclusion
Hypoglycemia, through various mechanisms, can precipitate myocardial ischemia and symptoms
corresponding to Acute Coronary Syndrome. Improvement in blood glucose levels may improve the symptoms of
myocardial ischemia.

34
Keywords: hypoglycemia, acute myocardial infarction, STEMI

ABS-23

Clinical Factors as a Predictors of Major Adverse Cardiac Events in Coronary Artery Disease
Patients after Percutaneous Coronary Intervention Treatment in Tarakan National Hospital
Jakarta.
R.A. Nurafrilya2, T.H. Pratikto1, Y.A. Wibowo2, E. Ratnaningsih1, S. Manurung1, Z. Khan1

1 Cardiology and Vascular Department, Tarakan National Hospital Jakarta

2 Cardiology and Vascular Department Research Assistant, Tarakan National Hospital Jakarta

Background
Despite recent advances in stent design and constantly improving pharmacological strategies, complications and
adverse events following percutaneous coronary interventions (PCI) are still major factors influencing morbidity
and mortality. Therefore, we sought to identify predictors of major adverse cardiac events (MACE) on patients
underwent percutaneous coronary intervention.

Methods
We Conduct Prospective, Case Control, Single Center Study, Ranged from January 2015 – December 2015,
with 211 patient, Who underwent any type of PCI at Tarakan National Hospital. We Analyzed Clinical
Characteristics, Angiographic Findings, MACE between 2 years follow up (Comprising death, Nonfatal
reinfarction and Stroke), and risk factor of CAD. All the data were processed with univariate and bivariate first,
then continued to multivariate logistic regression by a constant and rounding the result to the nearest integer.

Results
We studied 211 patients that underwent PCI in the given period; and found 48 patients (22.78%) among them
developed MACE. Independent MACE predictors after PCI were diabetes mellitus (OR: 2.077, 95% CI; 1.082 -
3.987 ; p<0.05) and smoker (OR: 2.290, 95% CI; 1.096-4.784 ; p<0.05 ).

Conclusion
Having Diabetes Mellitus and smoking independently predicted MACE in patients with CAD post PCI procedure
after long-term follow-up. Fortunately, these factors are modifiable and should be identified and monitored early.

Keyword
Coronary Artery Disease, Percutaneous Coronary Intervention, Major Adverse Cardiac Event.

35
36
ABS-24

Wide QRS complex Tachycardia in Patient with non ST- Elevation Myocardial Infraction : Is
always Ventricular Tachycardia ?
Nasruddin, S.P.I1, Yasa, A.2

1Resident of Cardiology and Vascular Medicine , Sebelas Maret University, Surakarta, Indonesia; 2Cardiologist of
Cardiology and Vascular Medicine , Sebelas Maret University/Dr Moewardi General Hospital, Surakarta,
Indonesia.

Background: Myocardial infarction leads to electrophysiological changes that induce life-threatening

arrhythmias. The most common cause of wide QRS complex tachycardia (WCT) is Ventricular Tachycardia (VT)
(80%). Supraventricular tachycardia (SVT) with abnormal intraventricular conduction is the second commonest
cause of WCT (15%). The differential diagnosis of a regular, monomorphic WCT mechanism represents a great
diagnostic dilemma by the physician.
Case Illustration: A 60 – years old male, was referred by a general practitioner with diagnosis of
tachyarrhythmia. He complained about palpitation since 4 hours before admitted. He also complained of chest
pain that radiated to the left arm for more that 30 minutes, diaphoresis and nausea. He has a past medical
history for hypertension and smoker.

From physical examination, there was hemodynamically stable tachycardia. Electrocardiographic (ECG) study
showed WCT with QRS duration of 160ms, heart rate 180 bpm, there was R and S wave in lead V1, R to S
interval was 40 ms, no A-V dissociation, therefore it does not meet the criteria for VT. Intravenous amidarone
was administered to terminate the WCT. Post pharmacological cardioversion, ECG revealed Wolff Parkinson
White (WPW) with PR interval 80ms, delta wave, QRS prolongation 120ms. Cardiac enzime was elevated.
Discussion: In this patient WCT did not meet brugada criteria for VT , after the WCT was terminated, resting
ECG revealed WPW phenomenon. It suggested that the WCT was due to preexcited SVT with anterograde
conduction over an accessory pathway.
The mechanism of antidromic tachycardia occur when the accessory pathway only conduct anterogradely and
the impulse returns to the atria via atrioventricular node. These broad complex tachycardias can be difficult to
distinguish from a VT and are less common, occuring in around 10 % of WPW. The relationship between non ST
elevation myocardial infraction (NSTEMI) and antidromic AVRT remains unknown.
Summary: During WCT the differentiation between VT and SVT is important. Brugada criteria have been
developed to aid in this differentiation. It is important to keep in mind that WCT in NSTEMI patient not always due
to VT.
Keyword: NSTEMI, Ventricular Tachycardia, Antidromic AVRT.

37
ABS-25

An Elevated Neutrophil to Lymphocyte Ratio Predicts In-Hospital Mortality in ST-segment

Elevation Myocardial Infarction: A Meta-Analysis
Mikhael R1, Hindoro E2, Taner S2, Putrajaya LL3, Lukito AA4

1Faculty of Medicine, University of Indonesia 2Faculty of Medicine, University of Pelita Harapan, Tangerang,
Indonesia 3Faculty of Medicine, Maranatha Christian University 4Department of Cardiology, University of Pelita
Harapan – Siloam Hospital, Tangerang, Indonesia

Background: ST-Elevation Myocardial Infarction is the most life-threatening condition of Acute Coronary
Syndrome that carries poor prognosis of in-hospital mortality. Multiple scoring systems have been developed to
predict in-hospital mortality as well as other cardiovascular events. There is scarcely any usage of the Neutrophil-
to-Lymphocyte Ratio (NLR) as a predictor of in-hospital mortality.

Objectives: To determine the predictive value of elevated NLR in regards to in-hospital mortality in STEMI
patients by using an advanced quantification analysis.

Methods: Literature searching and pooled analysis of the studies in electronic databases and manual hand
searching and abstract/titles screening in PubMed/MedLINE, ScienceDirect, Cochrane, EBSCO and Proquest.
Inclusion criteria were met if they were cohort studies, STEMI patients, contained pretreatment NLR cutoff and
in-hospital mortality, defined as cardiac or all causes mortality.

Results: We found 12 relevant studies with a total of 7043 STEMI subjects with median NLR cutoff value of 5.6.
Elevated NLR on admission carries higher risk of in-hospital mortality (OR 3.38, 95% CI 2.71-4.21). There was a
slightly higher risk of all-causes mortality (OR 3.51, 95% CI 2.42-5.10), compared to cardiac related mortality
(OR= 3.30, 95% CI 2.51-4.34). No significant heterogeneity was observed (x2=0.30, I2=15%).

Conclusion: Elevated NLR predicts a higher in-hospital mortality rate of STEMI patients.

Keywords: STEMI, Neutrophil to Lymphocyte Ratio, Mortality, In-hospital

38
39
ABS-26

Association between Five Types of Single-Nucleotide Polymorphisms (SNPs) in Chromosome

9p21 and Risk of Coronary Artery Disease
Irma Maghfirah1, M. Yusuf Alsagaff 2

1FirstAuthor: Irma Maghfirah

2Second Author: M. Yusuf Alsagaff
1,2Department of Cardiology & Vascular Medicine, Faculty of Medicine, University of Airlangga Surabaya

INTRODUCTION:
Coronary artery disease (CAD) is the leading cause of death worldwide. The molecular mechanisms related to
genetic factor that is involved in pathogenesis of CAD remains to be determined. Some types of single nucleotide
polymorphisms (SNPs) in chromosome 9p21 have been reported that may increase the risk if CAD, but other
studies mentioned otherwise. Thus, chromosome 9p21 polymorphisms roles in pathogenesis of CAD remains
unknown.

OBJECTIVE:
This study aims to analyze the relationship between variants of SNPs in chromosome 9p21 (rs10757274,
rs2383206, rs2383207, rs10757278, rs1333049) with risk of CAD.

METHOD:

We conducted a comprehensive search to identify all eligible studies from PubMed, MEDLINE, EBSCO,
ProQuest, Science Direct, and Cochrane databases for case-control studies to evaluate the relationship between
five types of SNPs in chromosome 9p21 and CAD. All studies were assessed under Hardy-Weinberg
Equilibrium, additive model. The meta-analysis was performed by RevMan 5.3 (fixed-effects and random-effects
model based on heterogeneity test) to provide pooled estimate for odds ratio (ORs) with 95% confidence
intervals (95% CIs). Our primary outcome was risk of CAD for each type of SNPs.

RESULTS:
Nine clinical studies met our inclusion criteria and included a total of 16.926 patients. These studies included
8244 patients with CAD and 8682 were controls. The crude odds ratio (ORs) of meta-analysis under 4 variants
SNPs of 9p21 were associated with CAD. These polymorphism increase the risk of CAD. As for rs10757274
(odds ratio(ORs)=1.33 (95% CI, 1.21-1.47); p<0.0001, I2=87%}. Then for rs2383206 (ORs=1.24 (95% CI, 1.12-
1.37); p<0.0001, I2=73%}; rs10757278 (ORs=1.28 (95% CI, 1.14-1.44); p<0.0001, I2=0%}; rs1333049 (ORs=1.28
(95% CI, 1.18-1.39); p<0.0001, I2=89%}. Meanwhile there was no significant association between variant
rs2383207, (ORs=1.06 (95% CI, 0.95-1.18); p<0.31, I2=86%} with CAD.

CONCLUSION:

These results suggested that rs10757274, rs2383206, rs10757278, rs1333049 SNPs increase the risk of CAD.
Meanwhile, rs2383207 polymorphism might not contribute to risk of CAD

Keywords : chromosome 9-21, single-nucleotide polymorphisms (SNPs), CAD

40
ABS-27

Nightmare of de winter: a dead case. What should GP do?

Sandra Puspita Sari1, Rido Adrianto Sukaton2,3, Sidhi Laksono Purwowiyoto2,3

1Department of Emergency Medicine, RSUD Pasar Rebo

2Department of Cardiology, RS Hermina Jatinegara
3Department of Cardiology and Vascular Medicine, RSUD Pasar Rebo – FK Yarsi

Introduction: The de Winter ECG pattern is a relatively uncommon ACS, but is very important to recognize. It
should be considered as an anterior STEMI equivalent that presents without obvious ST segment elevation. Its
signifies an acute proximal LAD artery occlusion. Key diagnostic features are chest pain with the ECG
occurrence in the precordial leads of: ST depression and peaked T waves .The de Winter ECG pattern is seen in
about 2% of acute LAD occlusions. This syndrome is under recognized by clinicians, with consequent increased
morbidity and mortality. Some authors propose that the de Winter pattern should be considered a “STEMI
equivalent”, and that patients with chest pain and a de Winter ECG pattern should receive emergent reperfusion
therapy with PCI or thrombolysis.
Case Description: We report a death case of de winter, a 47 year old man was admitted from emergency room
presenting with substernal chest pain and discomfort that was provoked by exertion (while he was gardening).
His blood pressure of 180/110 mmHg, a pulse rate 130 beats per minute, a respiratory rate of 20 breaths per
minute, and an oxygen saturation of 100% on room air. Physical examination was within normal limit. The ECG
showed ST depression in V4-6, peaked T wave in V2-4, ST segment elevation in aVR. Unfortunately five
minuites after ECG patient agitated and suffered a cardiac arrest. He underwent CPR for over 30 minuites, but
could not be resuscitated from his pulseless electrical activity arrest and unfortunately died.
Discussion: Emergency physician should be aware of this. The characteristic ECG changes within the de Winter
ECG pattern may be missed or misdiagnosed as nonspecific, reversible ischemia. This can significantly lengthen
the transportation to a center equipped with a percutaneous coronary intervention laboratory, and thus the start
of reperfusion therapy.
Conclusion: It is imperative that all practitioners learn to identify this novel ECG pattern as a STEMI equivalent
to ensure appropriate intervention in the cardiac catheterization laboratory.

Keywords: De Winter, ECG findings, role of general practitioner

41
ABS-28

Prevalence and Causes of Failure of Receiving Thrombolytic Therapy in STEMI Patient at Non-
PCI Hospital
Rahmy, NF
Faculty of Medicine Padjadjaran University

Background and Objective

Thrombolytic therapy in STEMI is generally safe and effective. There is overwhelming evidence of the beneficial
effects provided by reperfusion strategies in patients with STEMI, however, thrombolytic therapy is still
underused in the management of this condition. We studied the prevalence and causes of failure of receiving
thrombolytic therapy in STEMI patient in a non-PCI hospital.

Method
This was an observational, cross sectional study carried out in emergency department of a non-PCI hospital from
August 2016 until August 2017. STEMI patients as defined by ACC/AHA criteria were analyzed for receiving
thrombolytic therapy or not.

Result
Among the 50 patients, 78% (n=39) were men and 22% (n=11) were woman. The mean age was 54.82  8.69
ranging from 38-85 years. The prevalence of missed thrombolysis was 84%. Delayed presentation (>12 hours)
after the onset of symptoms represented the most common cause for failure to receive thrombolysis (50%). The
other reasons varied from poor general condition (23.8%), refused to consent (7.14%), died before reperfusion
(7.14%), drug runs out (4.76%), and age more than 75 years (2.38%).

Conclusion
In this study, the cause of patients with STEMI missed the opportunity to receive thrombolysis most likely due to
delayed presentation (50%). Therefore, community awareness to acute myocardial infarction symptoms needs to
be increased.

Keywords: STEMI, missed thrombolysis, delayed presentation

42
ABS-29

From Wellens Syndrome to Myocardial Infarction: A Case Report

Rhesa Prasetya1, Nur Aini M. Tedjowiyono1, Tiar Octavian1 , Filipus Michael Yofrido1, Dian Kartika1, Devina
Nataliany1, Eka Devinta Novidiana1, Ivor Wiguna Wilopo1, Achmad Lefi2

1 General Practitioner, Darmo Hospital, Surabaya, Indonesia

2Cardiologist, Darmo Hospital, Surabaya, Indonesia

Introduction: Wellens syndrome is characterized by abnormalities in ECG precordial T-wave segment, which is
associated with proximal LAD artery critical stenosis. Most of Wellens syndrome has Type-B morphology (deeply
inverted T-waves pattern). Meanwhile, the Type-A (biphasic T-wave pattern) isn’t well recognized by general
practitioner.

Case Description: A 64-year-old man with uncontrolled diabetes mellitus presented to the ED with intermittent
chest pain since 2-weeks ago, and worsen 1-hour before arrival. The examination showed hypertension
(180/100mmHg) only. The ECG showed ST-segment depression in leads V4-V6, biphasic T in leads V1-V4 (Fig
1.). Cardiac biomarker showed no abnormalities. Patient was given ASA, Clopidrogel, and ISDN. After an hour,
the chest discomfort was subsided and repeated ECG showed ST depression in leads V3-V6 and T-wave
inversion in leads V1-V5. Patient refused to be admitted and didn’t take the prescription. One week later, he
arrived to ED with history of self-subsided 10-minutes chest pain. The examination showed hypertension
(161/90mmHg) only. The ECG showed deeply symmetrical T-wave inversion in leads V1-V5 (Fig 2.). Cardiac
biomarker elevated (CK-MB 15.5, Troponin-T 0.38). Coronary angiography 6 days after admission showed
critical stenosis 95% at proximal LAD artery, stenosis 75% at mid-distal LAD artery (Fig 3.). Both were stented.
Two days after, patient was discharged.
Discussion: The patient showed evolution patterns of Wellens syndrome from the Type-A to Type-B. Increased
cardiac biomarker at later presentation indicated an infarction.
Conclusion: Type-A pattern Wellens syndrome can be mistakenly as normal, especially in well responder to
medical treatment. However, it carries risk of impending myocardial infarction. Hence, repeated ECG and cardiac
biomarker should be performed, especially in high risk patient.
Keywords: Wellens syndrome, left anterior descending artery critical stenosis, myocardial infarction, general
practitioner

43
Fig1

Fig 2.

Fig 3.

44
ABS-30

The Effectiveness of Intra-aortic Balloon Counterpulsation in Patients with or without

Cardiogenic Shock Following Acute Myocardial Infarct
Muhamad Fajri Adda’i1, Atika Budhy Setyani1

1Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia

Background: Result from previous studies evaluating benefit use of intra-aortic ballon pump (IABP) in acute
myocardial infarct (AMI) patient were inconclusive. This study aimed to investigate the effect of IABP in patients
with or without cardiogenic shock following AMI.

Methods: Databases (EMBASE, PUBMED, Science Direct, Cochrane, Springer, Scopus, ProQuest,
Clinicaltrial.gov, and Lilacs) were systematically searched for randomized controlled trials comparing the use of
IABP with no IABP in patients with or without cardiogenic shock following AMI. The primary endpoints were 30-
day mortality, 6-month mortality, and 12-month mortality. Secondary endpoints were reinfraction, recurrent
ischemic, reoccluded infarct-related artery (IRA), and new-onset of heart failure (HF). Safety endpoints were
bleeding, vascular compromise, and stroke. The databases were searched with predefined protocol regardless
publication time and language restriction based on PRISMA guideline. Analysis was performed in RevMan 5.3
(fixed-effects and random-effects model based on heterogeneity test) to provide pooled measures for Odd Ratio
(OR) and 95% Confidence Interval (95%CI).

Results: Fourteen randomized trials were enrolled including 1057 cases and 1053 controls. IABP intervention
showed no statistically significant compared to control group in decreasing 30-day mortality (OR 0.97,
95%CI[0.97; 1.26], p=0.80, I2=0%) and 6-month mortality (OR 0.93, 95%CI[0.71; 1.21], p=0.57, I2=0%). On the
other hand, IABP was statistically significant in reducing 12-month mortality among AMI patients without
cardiogenic shock (OR 0.60, 95%CI[0.37; 0.96], p=0.03, I2=0%). IABP intervention was statistically significant in
lowering risk of recurrent ischemic by 46% compared to controlled group (OR 0.54, 95%CI[0.35; 0.82], p=0.03,
I2=0). Reinfraction (OR 1.03, 95%CI[0.70; 1.52], p=0.88, I2=3%), reocclusion of infarct-related artery (OR 0.63,
95%CI [0.25; 1.54], p=0.31, I2=59%), and new-onset of HF (OR 0.86, 95%CI[0.61; 1.20], p=0.40, I2=%) were not
statistically different between two group. In comparison with control, IABP could increased side effects such as
bleeding (OR 1.69, 95%CI[1.10; 2.58], p=0.02, I2 =0%) and vascular compromise (OR 1.69, 95%CI[1.10; 2.58],
p=0.88, I2=0%) but not for stroke (OR 1.49, 95%CI[0.61; 3.66], p=0.26, I2=24).

Conclusions: Use of IABP may reduced 12-month mortality in AMI patients without cardiogenic shock. It also
decreased risk of reccurent ischemia. However, bleeding and vascular compromise must be considered when
using IABP.

Keywords: intra-aortic ballon pump, mortality, acute myocardial infract

45
ABS-31
Triglyceride and HDL-C Serum Level In Purple Sweet Potato (Ipomoea batatas L) and Recycling
Cooking Oil Consumption
Wibawa, S.R, Puspowardojo, I.Y., Ngestiningsih, D., Santoso.

Background and Objective: The Strong Heart Study states that high triglyceride (TG) levels and low HDL
cholesterol (HDL-C) levels are risk factors for cardiovascular disease. Recycling cooking oil, often found in
community, has been known to causes raising level of trans fatty acids, saturated fatty acids, lipid peroxides that
increases levels of TG and decreases levels of HDL-C. Purple sweet potato (PSP) is a natural exogenous
antioxidant containing anthocyanins, vitamin C, vitamin A, and βcaroten, which can improve the lipid profile. This
study conduct to analyze the effect of PSP on serum triglyceride and HDL-C levels of wistar rats given recycling
cooking oil.

Methods: A true-experimental design with post-test only control group design study using wistar as animal
model. After adaptation, samples were randomly divided into four groups (n=6 pergroup). K1 (negative control),
K2 was given recycling cooking oil 3ml/day and standard diet, K3 was given steamed PSP ad libitum and
standard diet, and P was given recycling cooking oil 3ml/day, steamed PSP ad libitum, and standard diet. Serum
triglyceride and HDL-C level was measured using GPO-PAP and homogenous method on day 29th. Data were
analyzed with One-Way ANOVA test.

Result: The mean±SD of serum triglyceride level per group are K1=75,8±22,29, K2=102,6±29,67,
K3=138,0±14,44, P=119,4±29,04 and there were significant difference.(p=0,007) Measured levels of serum
HDL-C per group are K1=47,0±10,37, K2=43,8±8,32, K3=50,0±16,60, P=46,6±14,01 and there were no
significant differences.(p=0,896)

Conclusion:PSP increase triglyceride and HDL-C serum level in rats which was given PSP ad libitum and
recycling cooking oil.

Keywords: Triglyceride, HDL-C, purple sweet potato, recycling cooking oil

46
ABS-32

Dossage and Drug Administration of Loop Diuretic in Acute Heart Failure

Patricia Feliani Sitohang

Dokter Rumah Sakit Awal Bros Panam, Riau, Indonesia

Acute heart failure is a clinical syndrome characterized by congestion and fluid retention. Intravenous loop
diuretics are used as the first-line therapy, but there is still uncertainty on the effectiveness and safety in terms of
dosage and drug administration. This report discusses cases of acute decompensated heart failure in three
patients with different profiles. In the first case, during acute conditions furosemide intravenous bolus was given
at the same dose as the total daily oral dose and intermitten bolus every 12 hours was given 2 times larger than
total daily oral dose as routine therapy. In the second case, during acute conditions furosemide intravenous
bolus was given 2.5 times larger than total daily oral dose and intermitten bolus every 12 hours was given 2
times larger than total daily oral dose as routine therapy. In the third case, during acute conditions furosemide
intravenous bolus was given 1.5 times larger than total daily oral dose and continous infusion 20mg/day was
given as routine therapy. Better clinical outcomes and shorter length of stay in hospital were obtained in second
and third cases. In “Diuretic Optimization Strategies Evaluation” (DOSE) trial, there was no significant difference
in global assessment of symptoms and changes in renal function between intermittent bolus and continuous
infusion or between low doses and high doses. Therefore, loop diuretic dose should be adjusted based on
clinical and patient response and history of previous loop diuretic therapy. While drug administration did not give
significant difference compared with drug dose.

Keywords: Acute heart failure, dosage, drug administration, loop diuretic

Schematic of a Dose‐response Curve of Loop Diuretics in Heart Failure Patients Compared with Controls

47
ABS-33

Diagnosis and Treatment of Anemia In Patient With Tetralogy Of Fallot

Yoga Waranugraha1 , Setyasih Anjarwani2
1Cardiology resident - Cardiology and Vascular Medicine Department
Faculty of Medicine Brawijaya University – dr. Saiful Anwar General Hospital
2Cardiologist-Intensivist - Cardiology and Vascular Medicine Department
Faculty of Medicine Brawijaya University – dr. Saiful Anwar General Hospital

Background: TOF is the most common type of cyanotic congenital heart disease. Anemia may exacerbate
worsening of the cardiac function and is associated with poor outcomes.
Case report: A 33-year-old woman with TOF came to RSSA with shortness of brath since 2 weeks before
admission. There were no history of orthopnea or PND. In the last 6 weeks patient suffered from melena for 2
times. Physical examination showed anemic cojunctiva and clubbing finger without cyanosis. The hemoglobin
and hematocrit were 7.2 g / dL and 22.7% respectively with normal thrombocyte and coagulation test. PRC
transfusion was given with target hemoglobin >14 g/dL. Diagnosis of iron deficiency anemia was confirmed by
blood smear that showing hypochromic microcytic anemia, MVC 60.2 fL, MCH 19.1 pg, serum iron 24 μg/dL,
TIBC 137 μg/dL, transferrin saturation 18%, and ferritin 12 ng/mL. During hospitalization the patient suffered from
melena. The GI bleeding was stopped by the administration of high-dose PPI. Iron deficiency was treated by the
administration of ferrous sulfas. Patient was discharged on day 14 in stable condition with hemoglobin 14.2 g/dL.
Discussion: Patient with TOF require hemoglobin >14 g/dL especially during postoperative periode or unstable
hemodynamic condition to improve oxygen carrying capacity. Such a strategy should be used because TOF
patients have limitations in compensating low O2 delivery. The aim of aggresive PRC transfusion was to increase
hemoglobin rapidly to improve O2 delivery. We used PPI to stop GI bleeding because the most common cause of
GI bleeding was peptic ulcer disease and patient didn’t have any sign of portal hypertension. It was important to
maintain intragastric PH >6 within first 72 hours. It could be achived by giving high dose PPI. Ferrous sulfas was
given to the patient to replace the iron storage depletion.
Conclusion: Anemia in adult with cyanotic congenital heart disease shouid be trated aggressively with target
hemoglobin >14g/dL. Treatment of anemia should be based on the etiology.

Keyword: Tetralogy of Fallot, anemia, bleeding, iron deficiency

48
ABS-34

Pleural effusion in patients with congestive heart failure: Is it necessary to evacuate?

Olivia Handayani1, Setyasih Anjarwani2
1Resident of Cardiology and Vascular Medicine, Brawijaya University, Saiful Anwar Hospital Malang, Indonesia
2Supervisor of Cardiology and Vascular Medicine, Brawijaya University, Saiful Anwar Hospital Malang, Indonesia

Background: Congestive heart failure is a common clinical syndrome with a relatively poor prognosis in its
advanced stages. During the development of heart failure, there is a decline in myocardial contractility and
activation of neurohormonal systems. In heart failure, pleural effusion results from increased interstitial fluid in
the lung due to elevated pulmonary capillary pressure. This effusion is typically bilateral, but if unilateral, it more
commonly occurs on the right side. Whether or not the evacuation is necessary, is still debatable.

Case illustrations: There were two patients presenting with congestive heart failure that occurred with acute
coronary syndrome. A-82-year-old male with non-ST-elevation myocardial infarction and congestive heart failure
NYHA class III was admitted to cardiac intensive care unit. Despite his optimal medical therapy, his oxygenation
from blood gas analysis showed hypoxemia (pO2 <80 mmHg) although his peripheral oxygen remained above
90%. It improved with non-invasive ventilation FiO2 100%, however, it worsened gradually. The lung ultrasound
showed bilateral pleural effusion, about 500 ml on the left side and 700 ml on the right. Patient’s oxygenation
improved after 2 times drainage. The pleural fluid analysis was transudate then exudate, and there was an
increase in NT-proBNP level.

Similarly, a-57-year-old woman with ST-elevation myocardial infarction and congestive heart failure, NYHA class
III was admitted to cardiac intensive care unit. She was received optimal medical therapy, however, there was a
problem with her serial oxygenation. There was bilateral pleural effusion, 800 ml on the right and 1000 ml on the
left side, shown at lung ultrasound. Her oxygenation improved immediately after 2 times evacuation. The level of
NT-pro BNP increased and the pleural fluid analysis were transudate.

Conclusion: Pleural effusion is very common in congestive heart failure, and usually resolve with optimal
treatment of heart failure. However, massive, recurrent, or significant pleural effusions may contribute to
symptoms and worsen patient’s clinical condition. It is when drainage is necessary.

Keywords: Congestive heart failure, pleural effusion, hypoxemia

49
ABS-35

Life Threatening Ventricular Arrhythmia due to Severe Hyperkalemia in Patients with Adrenal
Crisis : a Case Report
Dzikrul H. K1, Setyasih A.2

Division of Acute Cardiovascular Care – Department of Cardiology and Vascular Medicine, Faculty of Medicine
Brawijaya University – Dr. saiful Anwar General Hospital

Background : Ventricular Tachycardia is a life threatening arrhythmia, it sometimes caused by treatable or

reversible cause. Hyperkalemia is a common clinical condition that can induce deadly cardiac arrhythmias.
Hyperkalemia is one of major manifestation of adrenal crisis. We present a case of refractory hyperkalemia,
initially diagnosed as ventricular tachycardia in adrenal crisis.

Case Illustration: We are reporting a case of 48 year old female was admitted to our hospital because of
palpitation, she had been already diagnosed with Addison’s disease but unroutinely controlled.
Electrocardiography show ventricular tachycardia with HR 180 bpm and the physical examination show unstable
hemodynamic and we perform electrical cardioversion 200J and convert to Junctional Rhythm 30 bpm. Lungs
and cardiac examinations were normal. Laboratory findings shows potassium was 8.06 mmol/L, sodium 130
mmol/L, calcium 9.7mmol/L and phosphorous 7.1 mmol/L, ureum 60.8 mg/dl, creatinine 3.03 mg/dl. Correction of
Hyperkalemia use intravenous calcium gluconate 1 gram, Inj. Action rapid insulin 10 iu with 50 cc D40% iv,
Nebulizer Albuterol 1 puff for 4 cycles. Acute management of Adrenal crisis using bolus inj. Hydrocortisone
4x100mg iv and rehydration with 1500cc of NS 0,9%. She was getting refractory Hyperkalemia, and performed
hemodialysis and convert to sinus rhythm and stable conditions.

Conclusion : Ventricular Tachycardia in Adrenal crisis sometimes due to Hyperkalemia and it can be very
challenging to diagnose. The diagnosis of hyperkalemia must be considered in any patient with addison disease
accompanied by VT. Immediate treatment of hyperkalemia could prevent the development of fatal cardiac
arrhythmias.

Keyword : Hyperkalemia, ventricular Tachycardia, Addison’s disease, Adrenal crisis

50
ABS-36

Clinical Characteristics, Risk Factors and In-Hospital Mortality Rate of Acute Coronary
Syndrome in Young Adults at National Cardiovascular Center Harapan Kita
1S.Salim, 1D.A. Juzar, 2D. Ayuningtyas, 1I. Firdaus, 1S.S. Danny, 1 B. Widyantoro,
1D.P.L. Tobing,1Irmalita1, S. Soerianata1

1Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia, National
Cardiovascular Center Harapan Kita, Jakarta
2Research Assistant iSTEMI Program

Background: In the last decade, the incidence of Acute Coronary Syndrome (ACS) has been increasing at
young age (≤45 years). However, there were only few data available regarding ACS patient in young adults.
Several studies reported that young patients have different clinical characteristics from older patients.

Objective: To assess frequency, clinical characteristics, risk factors and in-hospital mortality rate of ACS in
young patients at National Cardiovascular Center Harapan Kita Jakarta.

Methods: Data was derived from iSTEMI (Indonesia STEMI) Registry database of 2.442 consecutive ACS
patients through prospective study between July 1, 2016 and June 30, 2017 at National Cardiovascular Center
Harapan Kita Jakarta. Patients were divided in two groups: younger ACS patients (age ≤ 45 years) and older
patients (age> 45 years). We compared cardiovascular clinical characteristics, risk factors, and in-hospital
mortality of both groups. Statistical analysis was performed with Chi-square test for categorical data, p value <
0.05 was considered significantly different.

Results: There were 272 (11.1%) young ACS patients observed. Most of them were men (90.8%) and mean age
was 40.4±4.3 years. Younger patients were less likely to have diabetes mellitus (28.3% vs. 39.6%, p <0.001)
and hypertension (51.1% vs. 63.3%, p <0.001). There was no significant difference in dyslipidemia. Smoking
was the most frequent risk factor in younger ACS patients (64.7%, p <0.001). The proportion of young ACS
patients with a family history of premature coronary disease was not significantly different (p=0.45). Discharge
diagnosis in the young group was ST segment elevation myocardial infarction (STEMI) 57.4%, non-ST segment
elevation myocardial infarction (NSTEMI) 23.2% and unstable angina 19.5%. Youngers patients were more likely
to have an STEMI than older group. When the analysis limited to the STEMI patients, younger patients were
more likely presented with Killip I (87.2%, p=0.001). In-hospital mortality rate young ACS was lower than older
group (4.4% vs.7.1%), but there were no significant differences between groups (p=0.09).

Conclusions: Younger patients have significant difference in clinical characteristics and risk factors than the
older group statistically. However, there were no significant difference in-hospital mortality rate between two
groups.

Keyword: Acute Coronary Syndrome, young adult, clinical characteristics, risk factor, in-hospital mortality,
STEMI

51
ABS-37

Late Presenter STEMI with Recurrent Chest Pain, would you still do lyitics ?

(LATE and EMERAS trial revisited)

Bimo Bintoro1, Firman S Dullah1, Sjarif Subijakto1, Jamaluddin2, Adhytya Pratama3
1Department of Cardiology and Vascular Medicine Bahteramas Hospital; Faculty of Medicine University of Halu
Oleo, Southeast Sulawesi
2Department of Cardiology and Vascular Medicine Kendari Hospital; Faculty of Medicine University of Halu Oleo,

Southeast Sulawesi
3General Practitioner Kendari Hospital, Southeast Sulawesi

Introduction
Myocardial infarction (MI) denotes the death of cardiac myocytes due to extended ischemia. Myocardial
reperfusion is the restoration of coronary blood flow after a period of coronary occlusion and can be done by
means of pharmacology by giving fibrinolytics agents or by mechanical reperfusion with primary PCI. In this case
presentation we would like to discuss about fibrinolytics and its use in late presenter ST elevation Myocardial
Infarction (STEMI) in the hospital with no Primary PCI facility.

Back to the history, in the 1970s, mortality rates for patients hospitalized with Acute MI ranged from 10% to 45%
among different institutions. Early attempts at using fibrinolytic therapy for STEMI showed mixed results. Finally
in 1986, a landmark study, GISSI-1 (First study of the Gruppo Italiano per lo Studio della Streptochinasi
nell’infarto Miocardico) became the first large randomized international trial to convincingly and definitively show
that intravenous fibrinolytic therapy with streptokinase improved survival. The objective of the trial was to
evaluate the efficacy of a fibrinolytic treatment with streptokinase (SK) and the in-hospital mortality of patients
with acute MI. It was an open controlled clinical trial with central randomization of 11,712 patients to SK or
control group of patients with AMI admitted within 12 hours from the onset of symptoms. Fibrinolytic treatment
significantly reduced mortality among patients treated with SK compared to controls, receiving conventional
treatments: 10.7% SK vs. 13% controls, for an 18% reduction (p=.0002). The difference in survival produced by
streptokinase and sustained up to one year was still significant at 10 years (log-rank test: p=0.02) with the
absolute benefit of 19 lives saved per 1000 patients treated.
Indeed in the early 1990s some studies, such as EMERAS (Estudio Multicéntrico Estreptoquinasa Repúblicas de
América del Sur) and LATE (Late Assessment of Thrombolytic Efficacy) specifically looked at fibrinolytic therapy
in STEMI patients presenting up to 24 hours after the onset of symptoms. EMERAS found no significant
differences in hospital mortality observed between the streptokinase and placebo groups (11.9% vs. 12.4%). The
LATE (Late Assessment of Thrombolytic Efficacy) study showed no benefit for fibrinolytic therapy in STEMI if ad-
ministered 12 to 24 h after the symptoms.
A meta-analysis of all randomized fibrinolytic trials with greater than 1000 patients was performed by the
Fibrinolytic Therapy Trialist (FTT) Collaborative group in 1994. This analysis revealed that the greatest
mortality benefit was achieved in the first three hours of symptom onset, especially the first hour. If treatment was
within the first hour of symptoms, 39 lives were saved per 1000 patients treated. If treatment was within two to
three hours, 30 lives were saved, while if treatment was within seven to twelve hours after symptom treatment,
21 lives were saved. An absolute benefit reduction of 1.6 lives was cost by each hour delay in treatment.

Case
A case of 45 years old gentleman visiting our emergency unit with chief complaint of chest pain 14 hours prior to
admission. The pain was felt as resting pain with crushing sensation with duration of 20 minutes with radiation to
his left neck and left arm. Accompanied with profuse diaphoresis and vomiting. He sought no medical attention
and took medical leave at the office to rest at his home. In the next morning, the pain was felt again with the
scale of 8/10 and his wife took him to seek medical attention.
Upon admission he looked pale with profuse sweating, claiming to still have the chest pain with his arm grasping
his chest. We did the algorithm for chest pain management, and his ECG showed anterior extensive MI. We

52
discussed further management with the family and decided to perform fibrinolysis with 1.5 millions UI of
intravenous Streptokinase. In the process there were bigeminy VPC, no other major complications of lytics were
observed. Afterwards the pain was decreasing to 4/10 and ECG evolved to Q waves.
We continued with anticoagulation by giving Fondaparinux for the next 48 hours. Afterwards in his next 24 hours,
the pain was resolved to 0/10, echo showed LVEF of 48% with RWMA according to his infarcted areas. The
patient was sent home after three days of hospitalization with dual antiplatelet, statin, ACE-I, and well tolerated to
beta-blocker.

Discussions
Though no mortality benefit was demonstrated in the LATE and EMERAS trials when fibrinolytic was routinely
administered to patients between 12-24 hours, we believe that it is still reasonable to consider fibrinolytic therapy
when PCI is not available for appropriate patients with clinical and/or electrocardiographic evidence of ongoing
ischemia within 12 to 24 hours of symptoms onset and a large area of myocardium at risk.
Persistent chest pain after the onset of symptoms correlates with a higher incidence of collateral of anterograde
flow in the infarct zone and is therefore a marker for viable myocardium that might be salvaged.

Keywords: Late presenter, STEMI, fibrinolytics

References:
GISSI. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1 (1986), pp.
397-402
EMERAS Collaborative Group. Randomised trial of late thrombolysis in patients with suspected acute myocardial
infarction. Lancet 342, (1993), pp.767-772
LATE Study Group. Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6-24 hours after onset
of acute myocardial infarction. Lancet 342, (1993), pp.759-766
FTT Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction:
collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000
patients. Lancet 343, (1994), pp. 311-322

53
ABS-38

Idiopathic Left Ventricular Tachycardia

Mayangsari V1, Purwaningtyas N2

1Resident in Cardiology and Vascular Medicine Department

2Cardiology and Vascular Medicine Department
Universitas Sebelas Maret/Dr Moewardi Hospital, Surakarta, Indonesia

Background : Idiopathic ventricular tachycardia (VT) is a defined set of tachycardias when structural or
pathological cause has been ruled out for the same. Idiopathic left ventricular tachycardia (ILVT) represents the
10%-15% of all idiopathic VT. The most common feature of ILVT is verapamil sensitivity, which is seen in second
to fourth decade of life and occurs more often in men.
Case Illustration : A 42 years old man came to emergency departement of Dr. Moewardi Hospital due to
recurrent palpitation since a week ago. He had no history of traditional risk factor of coronary artery disease
(CAD). Electrocardiographic (ECG) showed VT Right Bundle Branch Block (RBBB) morphology with left axis
configuration. The patient was initially treated with 6 hours rounds of amiodarone, which were ineffective.
Intravenous amiodarone successfully slowed the tachycardia but did not terminate it. Since verapamil injection
was unavailable in our hospital, the patient received 240 mg verapamil tablets, which terminated the tachycardia
with resultant sinus rhythm. The echocardiography and coroangiography examination was normal.
Discussion : ILVT typically presents in young adults and mainly affects males, like in this case. Posterior
fasicular VT (P-ILVT) is the most common form of idiopathic VT originating from the left ventricle. P-ILFVT is
electrocardiographycally characterised by RBBB morphology and left axis suggesting that the reentrant circuit
extents from the basal to the mid-apical region of the interventricular septum. During the episode, in stable
patients, first line treatment is verapamil. Verapamil slows and terminates the tachycardia by prolonging
conduction in the decremental limb of the circuit. Because of its excellent prognosis, long-term management will
depend on the severity and frequency of symptoms. Catheter ablation is recommended when symptoms are
severe and pharmacologic treatment is not effective.
Summary : We reported an ILVT in 42 years old male. Understanding the mechanism of arrythmia will lead to
make diagnosis and plan of treatment.

54
ABS-39
Multi-vessel disease vs. single-vessel disease in STEMI patients:
Which one has worsened outcomes?
Pramadya Vardhani Mustafiza1 ,Hendry Purnasidha Bagaswoto2, Nahar Taufiq2, Budi Yuli Setianto2

1Resident of Cardiology and Vascular Medicine Universitas Gadjah Mada/ Sardjito General Hospital
2Staff of Cardiology and Vascular Medicine Department Universitas Gadjah Mada/ Sardjito General Hospital

Background: Multi-vessel coronary artery disease patients are often related with worsened outcomes than
single-vessel disease patients. Those patients are more likely to have multiple risk factors, poor laboratory
parameters, and less favorable long term outcomes. It is associated with inflammatory process which more
severe and excessive in multi-vessel disease.
Objective: to investigate the impact of multi-vessel disease compared with single-vessel disease on laboratory
parameters and clinical outcomes in patients with STEMI whom admitted to Dr. Sardjito General Hospital
between January until October 2017.
Method: This is an observational study that includes consecutive patients with STEMI whom underwent
revascularization either primary PCI or fibrinolysis that continuing with coroangiography evaluation. The data was
collected from SCIENCE (Sardjito Cardiovascular Intensive Care) and ACS (Acute Coronary Syndrome) Registry
from January until October 2017. Variables observed are MACE (major cardiac adverse event), LoS (length of
stay), laboratory parameters such as PLR (platelet to lymphocyte ratio), NLR (neutrophil to lymphocyte ratio),
and creatinine serum. The patients were divided into group A (single-vessel disease) and group B (multi-vessel
disease).
Result: From our 233 STEMI patients, 97 patients (41.6%) were included into Group A and 136 patients (58.4%)
into group B. There are no significant differences in MACE (p=0.891), LoS (p=0.85), PLR (p=0.264), and NLR
(p=0.405) between group A and group B. Otherwise, patients in Group B had significant creatinin serum
difference compared with those in Group A (1.45  0.75 vs. 1.35  0.95, p=0.031)
Conclusion: Multi-vessel disease has significant impact on creatinine serum but not on other clinical outcomes
compared with single-vessel disease.
Keywords: multi vessel disease, single vessel disease, STEMI, MACE

55
ABS-40

Evaluation of Acute Physiology and Chronic Health Evaluation II and CardShock Scoring
Systems for Prognostication of Short-Term Outcomes of Mechanically Ventilated Patients with
Cardiogenic Shock in Intensive Cardiovascular Care Unit of Saiful Anwar General Hospital
Liemena Harold Adrian1*, Setyasih Anjarwani1

1Departementof Cardiology and Vascular Medicine – Faculty of Medicine Brawijaya University – Dr. Saiful
Anwar General Hospital Malang East Java Indonesia

*Correspondence email: liemenaharold@gmail.com

Objective: The aim of this study was to evaluate the influence of risk scoring system (APACHE II, CardShock
score) to predict short-term outcome (in-hospital mortality) of mechanically ventilated patients with cardiogenic
shock in Intensive Cardiovascular Care Unit (CVCU) of Saiful Anwar General Hospital.
Method: This research was a single-centre, prospective, observational study conducted between January to
June 2017. Patients on invasive mechanical ventilation with either acute coronary syndrome (ACS) or non-ACS
etiologies were enrolled within 6 hours from detection of cardiogenic shock defined as severe hypotension with
clinical signs of hypoperfusion despite fluid resuscitation (n = 41, mean age 60, 63% men). Data on clinical
presentation, demographic characteristics, prior history, ventilator setting and biochemical variables were
recorded for each patient separately within 24 hours after diagnosis of cardiogenic shock was made. We
assessed APACHE II and CardShock risk scores. Data were presented in homogenous distribution. Receiver
operator characteristic (ROC) curves, Hosmer-Lemeshow test, and logistic regression were used in the statistical
analysis (95% confidence interval). Significance was defined as p <0.05, for all statistical tests were performed
using SPSS version 22.00 for Windows.
Results: From 72 subjects on invasive mechanical ventilation, there were 41 subjects diagnosed with
cardiogenic shock. Data analysis showed a significant statistical difference in APACHE II and CardShock scores
between survivors and nonsurvivors patients (P=0.037, P=0.015; respectively). The discrimination power was
acceptable for APACHE II and CardShock score (area under ROC [AUC] curve: 65.8% (standard error [SE]:
9%), 77.3% [SE: 7.4%]; respectively). The acceptable calibration were seen in either APACHE II score or
CardShock score ( = 5.120, P=0.645 ; = 6.604, P=0.252, respectively).
Conclusion: Both APACHE II and CardShock score showed good predictive accuracy for predicting short-term
outcome (in-hospital mortality) of mechanically ventilated patients with cardiogenic shock of any causes;
however, the CardShock is preferred choice to select, because of being simpler to record data and easier to
facilitate early decision-making in Intensive Cardiovascular Care Unit.
Keywords: Acute Physiology and Chronic Health Evaluation II; CardShock; cardiogenic shock; mechanical
ventilation; in-hospital mortality

56
ABS-41
Mayor Adverse Cardiac Event in Patient With and Without Obstructive Coronary Artery Disease
Muflihatul Baroroh Rochmat1, Hendry Purnasidha Bagaswoto2, Nahar Taufiq2, Budi Yuli Setianto2
1 Resident of Departement of Cardiology and Vascular Medicine, Faculty of Medicine,
Gadjah Mada University, Yogyakarta
2 Staff of Departement of Cardiology and Vascular Medicine, Faculty of Medicine,

Gadjah Mada University, Yogyakarta

Background : Myocardial infarction without or non obstructive coronary arteries (MINOCA [<50% stenosis]) is
more common among younger patients and women, and MINOCA has a better prognosis than MI with
obstructive coronary artery disease (MICAD). The relationship between sex, age, comorbidities, obstructive CAD
status, and mayor adverse cardiac event (MACE) has not been established.
Objective : To find out the correlation between baseline characteristics (sex, age, and comorbidities) and
obstructive CAD status (MINOCA and MI-CAD) and the impact of obstructive CAD status (MINOCA and MI-CAD)
to the MACE in myocardial infarct patients whom hospitalized in RSUP Dr. Sardjito from January until October
2017.
Method : This is an observational study for patients with acute ST-segment-elevation and non-ST-segment-
elevation MI, with comparative and correlation methods. The data was collected from SCIENCE (Sardjito
Cardiovascular Intensive Care) and ACS (Acute Coronary Syndrome) Registry from January until October 2017.
Variables observed were baseline characteristics included sex, age, comorbidities (pneumonia, diabetes mellitus,
hypertension, and arrhythmia) compared by CAD status (MINOCA and MI-CAD). The primary outcome was CAD
status (MINOCA or MI-CAD) compared by MACE.
Result : Among 406 patients with MI, MINOCA occurred in 26 (6,4%) and MI-CAD in 380 (93.6%). MINOCA was
more common in women than men (12.9% versus 5.1%; p =0.015), had more comorbidities like pneumonia
(15.4%; p = 0.000) and arrhythmia (61.5%; p = 0.004) compared by MI-CAD patients. Other variables were not
significant for the event of CAD status (MINOCA or MI-CAD) included age (>60 years old versus <60 years old; p
= 0.789), diabetes mellitus (p = 0.529), and hypertension (p = 0.096). Mayor adverse cardiac events outcome
was analyzed by CAD status. In this study, MINOCA had higher mortality than MI-CAD (26.9% versus 10.5%; p
= 0.011).
Conclusion : MINOCA was associated with higher mortality than MI-CAD, because in this study patients with
MINOCA have more comorbidities than MI-CAD. Other causes still need to be investigated.
Keywords : obstructive coronary artery disease, myocardial infarction, mortality

57
ABS-42

Association Neutrophil Lymphocyte Ratio with Right Ventricular Dysfunction in Acute Inferior or
and Posterior ST-segment Elevation Myocardial Infarction
E.D.N. Rahmawati 1, H.P. Bagaswoto 2, N. Taufiq 2, B.Y. Setianto 2
1Resident of Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Gadjah Mada University,
Yogyakarta
2Staff of Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Gadjah Mada University,
Yogyakarta

Background: Acute inferior and posterior ST-segment elevation myocardial infarction (STEMI) is associated with
increase in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV)
involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac
events and mortality in patients with myocardial infarction. This study evaluated the relationship between the
NLR and RV dysfunction (RVD) in patients with inferior and or posterior STEMI who underwent revascularization
either percutaneous coronary intervention or thrombolysis.

Methods : Design of this study is cross-sectional with total of 122 subjects with inferior and or posterior STEMI
who underwent revascularization either percutaneous coronary intervention or thrombolysis collected from
SCIENCE (Sardjito Cardiovascular Intensive Care) and ACS (Acute Coronary Syndrome) registry Sardjito
Hospital, Yogyakarta from January until October 2017. The complete blood count (CBC) was obtained from all
subjects at admission. Total Leucocyte were counted and differential count was obtained for neutrophils,
lymphocytes and neutrophil to lymphocyte ratio (NLR) were evaluated. The subjects were divided into two groups
according to presence of RVD, measured by Tricuspid Annular Plane Systolic Excursion (TAPSE). RVD is
defined by TAPSE < 17 mm. The association of NLR and RVD were analyzed using SPSS application with Chi-
Square analysis.
Result : There is a significant difference (p<0.05) in high NLR (>4.5) for having RVD (TAPSE < 17 mm). High
NLR showed 87% of sensitivity and 31% of specificity to estimate RVD in patients with acute inferior and or
posterior STEMI. Moreover, the negative predictive value showed 79% and 44% for positive predictive value.
Conclusion: High NLR had 87% of sensitivity and 31% of specificity to estimate RVD in patients with inferior and
or posterior STEMI undergoing revascularization either percutaneous coronary intervention or thrombolysis.
Keyword: Neutrophil Lymphocyte Ratio, Right Ventricular Dysfunction, TAPSE, Acute Inferior-Posterior STEMI,
Revascularization

58
ABS-43

Acute Pulmonary Embolism in Systemic Lupus Erythematosus with Pregnancy : The Challenge
of Diagnosis and Management
Aditya Reza Pratama1, Setyasih Anjarwani2
1Cardiology resident of Cardiology and Vascular Medicine Departement Faculty of Medicine Brawijaya University
– dr. Saiful Anwar General Hospital
2Intensive cardiologist of Cardiology and Vascular Medicine Departement Faculty of Medicine Brawijaya
University – dr. Saiful Anwar General Hospital

Background: Pulmonary Embolism remains poorly understood because it can be asymptomatic. Rates of
clinical outcomes such as death and recurrence vary widely among trials. Patient with systemic lupus
erythematosus and pregnancy suspected pulmonary embolism require proper diagnosis to reduce
misdiagnosis.


Case report: A 36 year-old female with gravida 26-28 weeks suffered from shortness of breathing since 4
months of pregnancy. At 6 months of pregnancy, SOB gets worse when she did mild activity, improved during
the break and she had unproductive cough. A week before admission, the patient felt SOB got heavier, so the
patient just sleep since then. At the time of admission the patient complained sudden breathing got worse than
before the patient even sleep. Patient had no history of PND and orthopnea. Patient had lupus since 2007 she
got siklosporin and replaced with klorokuin 250 mg and methylprednisolone 4 mg when she was pregnant. She
had no history of HT and DM. Patient had ictus palpable 2 cm lateral MCL Sinistra. in the ECG Show sinus
rhythm 95 bpm with RAD and S1 Q3 T3. Chest X-Ray show cardiomegaly. We perform Echocardiography with
result EF: 84%, PH severe with RA and RV dilatation, PR moderate dan TR severe, Mc.Connell’s sign, D-
Shaped interventricularis. TR Vmax 3.22 m/s, Mpap 52mmHg, PASP: 67,14 mmHg. Laboratory result; Hb: 9,3;
Wbc: 12,1; Plt: 235; Ur: 16,6; Cr: 0,44; Na: 129; K: 3,82; Cl: 109 and BGA: Ph: 7,41; Pco2: 21,3; Po2: 135,3;
hco3: 13,7; BE: -11,2; SpO2: 99,1%. Treatment: UFH injection 80 U/KgBB and continued 18 U/KgBB/hour,
Enoxaparin 2x0,6cc, Kloroquin 1x250mg, Methylprednisolone 1x4mg, Cefadroxil 2x500 mg. She got terminated
pregnancy at 31 weeks and planning CT angiography.


Conclusion: Diagnostic pulmonary emboli remains a challenge because of the risk of radiation exposure in
mother and fetus because the diagnostic recommendations of pulmonary embolism are limited. In this case a
safe diagnostic like venous ultrasound may be an alternative. Anamnesis, physical examination and clinical
probabilities remain important in the initiation of LMWH SC until delivery, or with UFH SC if any limitations,
immediate removal with oral anticoagulant is needed after labor.
Keywords: Pulmonary Embolism, Systemic Lupus Erythematous, ECG, Echocardiography, CT angiography,
UFH, Enouxaparin, Gravida, Sectio Caesaria

59
ABS-44

Reperfusion Therapy with Percutaneous Coronary Intervention supported with Continuous

Positive Airway Pressure in NSTEMI patient presenting with Acute Lung Oedema and
Ventricular Tachycardia
M.Y. Putera1 ,

1General Practitioner, M. Yunus Regional Public Hospital

Background : Acute Myocardial Infraction indicate a blocked/limited artery blood flow by stenosis. Immediate
response might take form as reperfusion therapy to restore the blood flow as well correcting oxygenation flow.
Non invasive mechanical ventilation such Continuous Positive Airway Pressure can be used to improve
oxygenation and normalize abnormal respiratory patterns.

Case Report : A 66 years old man was admitted to emergency department with sudden onset of dyspneu since
24 hours prehospital gradually worsening. The ECG revealed ischemic signs at inferior and lateral area and
positive troponin marker in blood test. Arterial blood gas analysis shows metabolic acidosis. Soon after that
patient had onset of ventricular tachycardia. We treated the patient with electrical cardioversion and oxygenation
support using CPAP. Then we perform urgent percutaneous coronary intervention. The Angiogram showed CAD
2 VD; diffuse disease with severe stenosis at proximal to distal RCA and chronic total occlusion at proximal LAD
with feeding collateral from RCA. So we decided to deploy 2 DES at RCA. Clinically the patient achieving good
resolution of acute symptoms with stable hemodynamic states and arterial blood gas analysis revealed within
normal limit without CPAP support.

Conclusion : Reperfusion therapy such as Percutaneus Coronary Intervention is indicated to all patient
diagnosed with Acute Myocardial Infraction. We can use CPAP for treating respiratory problems that might
occured on these patient.

Keyword : Myocard Infarct, PCI, CPAP

60
ABS-45

Predictive Prognostic Value of Neutrofil to Lymphocytes Ratio to Short-term Inhospital Mortality

of Mechanically Ventilated Patients with Acute Coronary Syndrome in Intensive Cardiovascular
Care Unit of Saiful Anwar General Hospital
F.W Nugroho, L.A Adrian, S. Anjarwani

Cardiology and Vascular Medicine Department, Medical Faculty Brawijaya University, Malang
Correspondence email : fariswahyunugroho@gmail.com

Objective : The goal of this study was to investigate the utility of neutrofil to lymphocytes ratio (NLR) in
predicting of short-term inhospital mortality in mechanically ventilated patient with Acute Coronary Syndrome
(ACS) in Intensive Cardiovascular Care Unit of Saiful Anwar General Hospital
Method : This Research was a single-centre, prospective, observastional study. There were 35 of mechanically
ventilated patient with ACS period from January until June 2017. Patient were divided into two gruop based on
NLR value. Chi-square test is used in this research to analyze correlation between NLR value and inhospital
mortality. The primary outcome were the comparison short-term inhospital mortality probability between patients
with high NLR value and patients with low NLR value. Chi-square pearson test is used to test the interrelations
between two variable categories. Significance was defined as p <0.05, for statistical test were performed using
SPSS version 24.0 for windows
Result : The results of this study showed that patients with high NLR values had a risk of inhospital mortality
0.540 times than patients with low NLR values. P-value of chi-square test is 0,490 , P-value > α (0,05) means
there is no significant correlation between NLR value and inhospital mortality. this study result also show that
there is no difference inhospital mortality probability between patients with high NLR value and patients with low
NLR value.
Conclusion : There is no difference short-term inhospital mortality in mechanically ventilated patient with Acute
Coronary Syndrome (ACS) with high NLR value and low NLR value in Intensive Cardiovascular Care Unit of
Saiful Anwar General Hospital
Keywords : Neutrofil to Lymphocyte Ratio (NLR), Acute Coronary Syndrome, Mechanical Ventilation

61
ABS-46

Anteroseptal Wall Myocardial Infarction due to Occlusion of the Right Coronary Artery: A Case
Report
An Aldia Asrial, Anggit Pudjiastuti, Rinaldi Putra, Lanjar Raharjoyo, Sodiqur Rifqi
Department of Cardiology and Vascular Medicine, Diponegoro University Faculty of Medicine - Dr. Kariadi
General Hospital, Semarang, Indonesia

Introduction
Anteroseptal wall myocardial infarction (MI) typically arise from Left anterior descending (LAD) coronary artery as
culprit and rarely caused by proximal right coronary artery (RCA) occlusion. We report a case of an ST-segment
elevation in anteroseptal leads by electrocardioraphy but angiography revealed acute total occlusion of the ostial-
proximal RCA.
Case Presentation
A 57 year old male patient referred to Kariadi Hospital complained of shortness of breath and history of severe
chest pain 6 days before. Electrocardiography (ECG) revealed ST segmen elevation in leads V1-V4 and
pathological Q wave in lead II, III, aVF. He was diagnosed as acute anteroseptal wall MI. Angiography of left
coronary artery found 60% stenosis in distal Left Main and total occlusion in mid LAD but likely chronic. In
contrast, angiography of right coronary showed acute total occlusion in ostial proksimal. Two DES Stent was
inserted in RCA lesion. Post stenting angiography showed a collateral to distal LAD arise from distal RCA.
Echocardiography revealed hypokinetic in basal-mid anteroseptal, inferior and inferoseptal with LVEF 29%.
Discussion
In this case, ECG finding was consistent with anteroseptal wall MI contrary to angiographic finding. The presence
of Q wave in inferior lead brought us a question, is it anteroseptal MI only or with concomitant inferor MI? We
didn’t had any ST-elevation in inferior leads data in this case, but the angiography and echocardiography findings
made the inferior MI concomitant with the anteroseptal MI was possible. The coroangiography showed total
occlusion in ostial proximal RCA who gave collateral to distal LAD from its distal portion, while mid LAD had a
total occlusion. These findings made the possible explanation of an anteroseptal wall MI may caused by the RCA
total occlusion who gave collateral to LAD. The total occlusion made the decreased of blood flow to LAD wall
territory too.
Conclusions
We reported an anteroseptal MI with the evidence of acute occlusion in ostial-proximal RCA and chronic total
occlusion in mid LAD. The possible mechanism is the decreased of blood flow to LAD territory arise from RCA’s
collateral while mid LAD had a chronic total occlusion. Angiography accompanied with the electrocardiography
were important tools to analyze the culprit vessel of an MI and help us to decide which vessel we should
intervened.
Keywords: Anteroseptal MI, Right Coronary Artery Occlusion

62
 Coronary angiography LCA and RCA Post RCA intervention

References

1. Zhonghua Minguo Xin Zang Xue Hui Za Zhi. Precordial ST-Segmen Elevation Caused by Proximal
Occlusin of a Non-Dominant Right Coronary Artery. Acta Cardiologica Sinica.2014 Sep; 30(5): 497–500.
2. Muhammad KI, Kapadia SR. Anterior ST-segment elevation with right coronary artery occlusion: a
unique case of isolated right ventricular infarction. Angiology. 2008;59:622–624.
3. Cafri C, Orlov G, Weinstein JM, et al. ST elevation in the anterior precordial leads during right
ventricular infarction:lessons learned during primary coronary angioplasty -- a case
report. Angiology. 2001;52:417–420.
4. Kida M, Morishita H, Yokoi H, et al. Precordial ST-segment elevation caused by right coronary artery
occlusion. J Cardiol. 1987;17:4554–4564.
5. Triantafyllis DG, Vrahatis A, Zaharoulis A. Electrocardiographic picture of acute anterior infarction due to
proximal obstruction of the right coronary artery. Hellenic J Cardiol. 2005;46:154–157.
6. Lopez-Sendon J, Coma-Canella I, Alcasena S, et al. Electrocardiographic findings in acute right
ventricular infarction:sensitivity and specificity of electrocardiographic alterations in right precordial leads
V4R, V3R, V1, V2, and V3. J Am Coll Cardiol. 1985;6:1273–1279.

63
ABS-47

Successful Reversal Of Acute Severe Heart Failure Due To Peripartum Cardiomyopathy With
Aggressive Pharmacotherapy
Widyawati DG, Rangga Wibhuti IB, Badjra Nadha K

Cardiology and Vascular Medicine Departement, Faculty of Medicine, Udayana University

Introduction
Acute heart failure (AHF) due to peripartum cardiomyopathy (PPCM) provides a challenge for treating
physicians. In patients still pregnant, therapeutic interventions need always to consider the health of
both the mother and the foetus. Especially challenging are severe forms of PPCM, as the mortality of
these women is quite high.
Case Illustration
A 33 years old woman G2P1001 presented with 1 week history of shortness of breath on her 39th
weeks pregnancy. Her past medical history was unremarkable. On admission, she had BP 120/80
mmHg, HR 110 beats/min, RR 30 times/min, and SaO2 92% on room air. Physical examination
revealed rales on two third of her lungs and pedal edema. ECG showed sinus tachycardia. Laboratory
findings was hypokalemia (K 2,5). Diagnosis PPCM was confirmed by echocardiogram that revealed LV
dilatation (LVEDD 6,1cm), severely decreased of LV function (EF Biplane 25%), global hyokinetic, MR
severe, and TR severe. She was initially managed with nitroglycerin and loop diuretic infusion and
planned to had emergency Caesarean section. She was admitted into ICCU and her medical condition
was optimized by BIPAP, PEEP 5, FiO2 50%. Dobutamin and norepinephrine were added due to
cardiogenic shock. After stabilization, patient was treated with ACE-I, BB, MRA, and diuretic until
optimal dosage and discharged after 10 days. Her echocardiogram 7 months after diagnosis, revealed
successful reversal of LV function, with findings normal dimension of heart chambers, normal systolic
LV function (EF 62%), global normokinetic, MR mild, and TR mild.

Discussion
PPCM is idiopathic heart failure occuring in the absence of any heart disease during the last month of
pregnancy or the months after delivery. PPCM is a diagosis of exclusion, therefore several additional
test should be performed. Medical treatment with evidence based therapy for heart failure is the key to
achieve the highest recovery state. In the presence of signs of cardiogenic shock, haemodynamics
should be rapidly restored to avoid irreversible organ damage. Prognosis appears to be better than
other forms of dilated cadiomyopathy. Survival largely depends on recovery of left ventricular function.
References
1. Patel PA et al. A Contemporary Review Of Peripartum Cardiomyopathy. Clinical Medicine.
2017;17:316-321.
2. Sliwa K et al. Current State Of Knowledge On Aetiology, Diagnosis, Management, And Therapy
Of Peripartum Cardiomyopathy: A Position Statement From The Heart Failure Association Of
The European Society Of Cardiology Working Group On Peripartum Cardiomyopathy.
European Journal Of Heart Failure. 2010;12:767-778.
3. Bauersachs J et al. Current Management Of Patients With Severe Acute Peripartum
Cardiomyopathy: Practical Guidance From The Heart Failure Association Of The European
Society Of Cardiology Study Group On Peripartum Cardiomyopathy. European Journal Of
Heart Failure. 2016;18:1096-1105

64
ABS-48

The Indicator of In-Hospital Mortality Prognosis in ST-Elevation Myocardial Infarct Patients after
Primary Angioplasty
Rozqie, R.1, Bagaswoto, HP.2, Taufiq, N. 2, Setianto, BY2.
1Resident of Cardiology and Vascular Medicine, Universitas Gadjah Mada/ Dr. Sardjito Hospital
2Department of Cardiology and Vascular Medicine, Universitas Gadjah Mada/ Dr. Sardjito Hospital

Background:
Patients with acute coronary syndromes are still prone to have in-hospital mortality even after primary
angioplasty. Several studies have reported some factors are related with the increase of mortality risk in acute
coronary syndrome patients. However, what indicator can be used to assess the prognostic of mortality in ST-
segment elevated myocardial infarct (STEMI) patients especially in Indonesia is still questioned. Here, we
managed to answer by identify any possible variables that may related with in-hospital mortality risk among
STEMI patient who underwent primary intervention.

Aim:
To examine the incidence of in-hospital mortality after primary angioplasty and analyse the predictor risk
associated with in-hospital mortality in patients with ST-elevation myocardial infarct.
Methods and results:
Data were collected from SCIENCE (Sardjito Cardiovascular Intensive Care) and ACS (Acute Coronary
Syndrome) registry at Dr. Sardjito Hospital which begin from January until October 2017. There were 170
patients diagnosed with STEMI who had primary angioplasty involved in this registry and the in-hospitality
mortality rate was 8.8% (15 patients). This study identified several factors related with the increased of in-hospital
mortality risk which are the blood glucose level at admission, the presence of any electrical instability, and the
alanine aminotransferase (ALT or SGPT) level. By performing multivariate analysis, the presence of any
electrical instability (Odd ratio 3.744 p<0.05) and the increase of ALT level at admission (odd ratio 4.069 p<0.05)
are the independent factors for predicting in-hospital mortality events in STEMI patients after primary
angioplasty.
Conclusion:
According to this study, STEMI patients with the presence of any electrical instability and higher admission ALT
level who undergo primary angioplasty should be managed more carefully since its association with the increase
of in-hospital mortality risk.

Keywords: STEMI, primary angioplasty, ALT, SGPT, electrical instability, mortality.

65
ABS-49

Acute Limb Ischemia of Left Lower Extremity in Ebstein’s Anomaly with Patent Foramen Oval
I Made Agus Endra Permana, I Made Adi Satria Darma, Luh Oliva Saraswati Suastika
Department of Cardiology and Vascular Medicine
Udayana University/Sanglah Hospital

Introduction: Ebstein’s anomaly (EA) is a rare congenital cardiac malformation which is characterized by the
apical displacement of the tricuspid valve leaflets. Such a displacement leads to the atrialization of the right
ventricle; that is, the atrium and ventricle become one functional unit, giving rise to an atrialized segment 1. Acute
limb ischemia (ALI) is defined as a sudden (<14 days) decrease in limb perfusion that threatens the viability of
the limb.2

Description: The case is female 14 year old with chief complaint of black colored on left foot with pain. History of
dyspnea on exertion since 6 month before admission. Physical examination results necrotic on left forefoot, cold
on palpation, oxygen saturation not detected, posterior tibial artery pulsation (-), popliteal artery pulsation (-),
and femoral artery pulsation (+), clubbing finger (+). Echocardiograpy showing ebstein anomaly, PS valvar
supravalvar severe, stretched PFO 10 mm, R to L shunt. Laboratorium results hemoconcentration with
hematocrit 66,50% and hemoglobin 21,41 g/dl.

Discussion: Patient diagnosed with EA, stretched PFO, eisenmenger syndrome, ALI left lower extremity
Rutherford III. EA commonly accompanied by structural abnormalities such as atrial septal defect (ASD),
pulmonary stenosis or atresia, patent foramen ovale (PFO), conduction system abnormalities and ventricular
septal defect (VSD)1,3. Etiology of ALI maybe cause by paradoxical embolism accompanied with
hemoconcentration4. Treatment for ALI stage III is amputation2. CT angiography examination done before
amputation to evaluate level of occlusion, and the result are total occlusion 1/3 proximal popliteal artery until
bifurcation of anterior posterior tibial artery and occlusion 1/3 proximal anterior tibial artery. Patient died in
operation, cause of death maybe desaturation in eisenmenger syndrome and malignan arrhythmia in EA5,6.

Conclusion: Patient diagnosed with EA, stretched PFO, eisenmenger syndrome, ALI left lower extremity
Rutherford III. Etiology of ALI maybe cause by paradoxical embolism accompanied with hemoconcentration.
Although high risk for operation, but amputation should be done to prevent infection. Unfortunately patient
passed away in operation.

66
Figure 1. ALI left lower extremity.

References:
1. Yuan SM. Ebstein’s Anomaly: Genetics, Clinical Manifestations, and Management. Ped Neo
2017;58:211-215.
2. European Society of Cardiology. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral
Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J
2017;00:1-60.
3. Kron IL, Roeser ME. Management of Ebstein’s anomaly. Ann Cardiothorac Surg 2017;6(3):266-269.
4. Li JS, Ma J, Yan ZY, Cheng DM, Chang L, Zhang HC, Lu JY. Acute arterial embolism of left lower
extremity caused by paradoxical embolism in Ebstein’s anomaly. A case report. Medicine 2017;96:1-5.
5. Ghahramani M, Domaradzki L. Undiagnosed Patent Foramen Ovale Presenting As Platypnea-
Orthodeoxia And Acute Limb Ischemia In A Patient With Pulmonary Embolism. JACC 2016;76(3):1090
6. Anand A, Srivastava N, Barwad P, Ramakrishnan S, Roy A, Bhargava B. Dyspnea in Eisenmenger
syndrome and its amelioration by sildenafil: Role of J receptors. Int J Cardiol 2014;04:1-5.

67
ABS-50

Is TIMI score Still an Useful Indicator of Inhospital Mortality of STEMI patients in Dr Sardjito
General Hospital ? SCIENCE Registry Sub-Study

Asa Rizka Gemilang1 Hendry Purnasidha2 Nahar Taufiq2, Budi Yuli Setianto2
1Resident of Cardiology and Vascular Medicine Gadjah Mada University/ Sardjito General Hospital
2Staff of Cardiology and Vascular Medicine Gadjah Mada University/ Sardjito General Hospital

Background Thrombolysis in Myocardial Infarction (TIMI) score was one of the most well known risk score in
managing STEMI. It was elaborated from data of 15,000 patients and corresponds to the sum of eight variables
predictors of mortality. The variable consists of age, history of diabetes, hypertension or angina, systolic blood
pressure < 100 mmHg, heart rate > 100 bpm , Killip Class II-IV, weight < 67 Kgs, ST segment elevation in
anterior wall or left bundle branch block, reperfusion time > 4 hours. While this score has been validated
worldwide, its use in local setting to predict inhospital mortality was questioned. Different patients characteristic
presumed to be main cause of this problems.

Aim : To correlate TIMI risk score and inhospital mortality of STEMI patients in Dr.Sardjito General Hospital
Method : This retrospective study was performed as a substudy on the SCIENCE (Sardjito Cardiovascular
Intensive Care) registry population from January 2017 until October 2017. This study conducted to correlate
inhospital mortality and TIMI risk using descriptive analytic and logistic regression approach .

Result : From our 276 patients who underwent reperfusion strategies whether fibrinolytic or Primary PCI,
inhospital mortality reached 8,3 %, higher than original study(6,1%). This fact also confirmed that majority of
STEMI patients (83%) can discharged safely from hospital. Our patients was older than the original TIMI trial
samples (58,9 vs 55,2 years old). Killip Classification was also different. As many as 80,1 % patients in our study
was Killip I (88,2 % in original study) and 19,9% was Killip II-IV (compared with 11,8% in original study).
Prevalence of hypertension history in our patient reached 52,5 % also higher than original study (41,2%). From
this population, no patient had TIMI 11 and TIMI 14 score whether TIMI 3 was the most frequent finding (23,2 %).
In contrast TIMI 12 and TIMI 13 was least common one (0,2%). TIMI 12 has the highest mortality (1 of 1 patients,
100 %) followed by TIMI 8 (4 of 9 patients, 50 %) and then TIMI 9 (33,3%, respectively) with no specific graphic
pattern correlating TIMI score and inhospital mortality. We try to correlate this with Kendall tau b with coefficient
0,141, considered not significant.

Discussion : In our study , there were no significant correlation between TIMI Risk score and in hospital
mortality of STEMI patiens who get reperfused, besides of its worldwide use. The fact that our patients were
older, had more severe Killip Class, and had more hypertensive history should produce higher TIMI scores, but
this did not happen in our study. Higher TIMI score (≥8) in our study has higher mortality (42,8%) than TIMI 1-7
combined (5,5%) but didn’t give any specific correlation pattern. Larger amount of samples and centres needed
to confirm this finding. Another statistic method that can estimate discriminatory power of TIMI was
recommended.

Conclusion : TIMI Risk score didn’t correlate with inhospital mortality of STEMI patients in our local setting.
Keywords : TIMI Risk score, STEMI ,

68
ABS-51

Factors Associated with The Use of Renal Replacement Therapy in Patients with Acute
Coronary Syndrome Complicated by Acute Kidney Injury

Analysis from Registry of Acute and Intensive Cardiovascular Care on Outcome (RAICOM) at
National Cardiovascular Centre Harapan Kita (NCCHK)

Rizki1, Firmanda W1, Firmansyah DK1, Firiana L1, Widyantoro B1, Zamroni D1, Firdaus I1, Dani SS1 , Juzar DA1,
Tobing DPL1, Irmalita1
1Department of Cardiology and Vascular Medicine, Universitas Indonesia / National Cardiovascular Centre

Harapan Kita, Jakarta, Indonesia

Background and Objective:

Acute coronary syndrome (ACS) complicated with acute kidney injury (AKI) were associated with increased
mortality. Renal replacement therapy (RRT) may be necessary in management patients with AKI. We aim to
identify the predisposing factors of RRT in patients with ACS and AKI.

Methods:
We identify ACS patients complicated with AKI recorded in the RAICOM registry from September 2014 to
September 2015. Demographic, previous medical history, clinical profiles on admission, comorbidities that were
associated with the use of renal replacement therapy were analyzed. Modalities of RRT include intermittent
hemodialysis (IHD) and continuous renal replacement therapy (CRRT). Factors associated with RRT were
analyzed using logistic regression.
Results:
Acute kidney injury was identified in 585 (36.7%) of 1592 ACS patients recorded in RAICOM registry. RRT was
used in 27 patients (4%), 16 patients treated with IHD, 10 used CRRT, and 1 patients used both. Variables
associated with the RRT use were history of previous chronic kidney disease (CKD) (odds ratio [OR] 8.26 (p
<0.001); 95% confidence interval [CI] 2.65-25.68); acute heart failure (OR 3.72 (p=0.03); 95% CI 1.12-12.35) and
hypotension on admission (OR 4.57 (p=0.018); 95% CI 1.3-16.05); pneumonia (OR 4.96 (p=0.004); 95% CI 1.66-
14.81); and bleeding of any cause (OR 3.1 (p=0.048); 95% CI 1.01-9.51) as comorbidities.
Conclusion:
Renal replacement therapy was indicated in 4% of ACS patients complicated by AKI. We identified five factors
associated with use of RRT in these patients. Further evaluation was needed to confirm the role of these factors
as predictors of RRT use.

Keywords: acute coronary syndrome, acute kidney injury, renal replacement therapy

69
ABS-52

Right Bundle Branch Block Could Predict In-Hospital Mortality among Patients with ST-Segment
Elevation Myocardial Infarction:

A One Year Retrospective Analysis from Registry of Acute and Intensive Cardiovascular Care
on Outcome (RAICOM) at National Cardiac Centre Harapan Kita (NCCHK)
Firmansyah DK1, Rizki1, Firmanda W1, Tedjasukmana F1, Widyantoro B1, Zamroni D1, Firdaus I1, Juzar DA1,
Tobing DPL1, Irmalita1

Departement of Cardiology and Vascular Medicine, Universitas Indonesia/ National Cardiovascular Centre
Harapan Kita, Jakarta, Indonesia

Background : The 2017 European Society of Cardiology guidelines for the management of acute myocardial
infarction in patients with ST-segment elevation (STEMI) have acknowledged RBBB ECG pattern as an
indication for emergent reperfusion therapy in the presence of persistent ischemic symptoms as it carries poor
prognosis.1

Objective: to investigate the prognostic value of STEMI associated with RBBB and the factors that may
influence the prognosis.
Method: A cohort of 910 STEMI patients from RAICOM registry from September 2014-2015 in NCCHK was
analyzed retrospectively. Baseline clinical characteristics, ECG patterns, coronary angiographic, were correlated
with in-hospital outcomes. A Relative Risk (RR) of in-hospital mortality endpoint was calculated using chi-square
study. The factors that may influence the outcome were identified using multiple logistic regression analysis.
Results: Of A total 910 STEMI patients, RBBB and LBBB were present in 4.7% and 1% respectively. The RBBB
was more common in male, age below 65 years old (mean age 55±11 years old) and the extensive anterior ST
segment elevation ECG presentation (28.6%). Among STEMI patients with new or presumably new RBBB
admitted less than 12 hours onset, 92% underwent Primary PCI, 52.2% was 1 vessel disease CAD. In-hospital
mortality was 21.4% within this group, the mortality risk was higher than those without bundle branch block (RR
4.19, 95% CI [2.1 – 8.3]; p = 0.001). There was no significant difference of mortality risk compared to those with
LBBB. Cardiogenic shock was occurred in 16.7% patient STEMI with RBBB and significantly predict in-hospital
mortality among this group (OR= 8.0, p = 0.021).
Conclusion: STEMI patients with new or presumably new RBBB has four-fold risk of mortality than without
bundle branch block. Cardiogenic shock was highly associated with mortality in this group. This should
encourage for emergent reperfusion therapy when persistent ischemic symptoms occur in the presence of
RBBB.

Keywords: STEMI, Right Bundle Branch Block, In-hospital Mortality, Cardiogenic shock

70
ABS-53

Mortality and Factors Associated with Malignant Ventricular Arrhythmias in Non-ST Elevation
Acute Coronary Syndrome

Tedjasukmana F1, Rizki1, Maulana AR1, Apriansyah FP1, Firmansyah DK1, Widyantoro B1, Zamroni D1, Firdaus
I1, Danny SS1, Tobing DPL1, Juzar DA1

1Department of Cardiology and Vascular Medicine, Universitas Indonesia / National Cardiovascular Center
Harapan Kita, Jakarta, Indonesia

Background:
Life-threathening ventricular arrhythnias are frequent complications in patients with acute coronary syndrome
(ACS). The incident of ventricular arrhythnias in ACS patients is reported between 2-20%. Ventricular
arrhythmias predict higher mortality rate in ST elevation myocardial infarction (STEMI) patients, however, data of
its incident and impact in non-ST elevation myocardial infarction (NSTEMI) patients is not aplenty.

Methods:
Data collected from the Registry of Acute and Intesive Cardivascular Care on Outcome (RAICOM) from
September 2014 to September 2015. There were total of 428 patients with NSTEMI that were included in this
study. We studied the mortality rate associated with malignant ventricular arrhythmia in this patients. Malignant
ventricular arrhythmias were defined as ventricular tachycardia (VT) or ventricular fibrillation (VF). Several factors
that could contribute to the incident of malignant ventricular arrhythmias were studied, such as: age, sex,
hypertension, diabetes mellitus, dyslipidemia, history of smoking, presence of LBBB or RBBB, leukocyte count,
hsTropT level, creatinine level, potassium level, magnesium level, GRACE score, and ejection fraction (EF).

Results:
Incident of malignant ventricular arrhythmias in these patients was 7,9%. Mortality rate was higher in patients
who develop ventricular arrhythmias (p<0,001). Some factors were associated with the incident of malignant
ventricular arrhythmias, such as: hsTropT level (p 0,048), creatinine level (p 0,001), GRACE score (p 0,049), and
ejection fraction (p 0,02). HsTropT and creatinine levels were higher in patients who develop malignant
ventricular arrhythmia, whereas ejection fraction was lower in those patients. Patients who were categorized as
high risk according to GRACE score were more likely to suffer from malignant ventricular arrhythmia.

Conclusion:
Mortality rate was significantly higher in NSTEMI patients with malignant ventricular arrhythmias compared to
those without. High hsTropT levels, high creatinine levels, GRACE score, and low ejection fraction were the
contributing factors to their incidents.

71
ABS-54

Risk Model for Predicting In-Hospital Mortality of Non-ST-Segment Elevation Myocardial

Infarction without Revascularization at National Cardiovascular Center of Harapan Kita

Dwi Yuda Herdanto, Dwisetyo Gusti Arilaksono, Wibisono Firmanda, Bambang Widyantoro, Isman Firdaus,
Dafsah Arifa Juzar, Dian Zamroni, Siska Suridanda Danny, Surya Dharma, Daniel PL Tobing, Irmalita
Cardiology and Vascular Medicine Department, Faculty of Medicine, University of Indonesia; National
Cardiovascular Center Harapan Kita

Background: Risk stratification of patients with Non-ST Elevation Myocardial Infarction (NSTEMI) allows for
prediction of in-hospital mortality and to decide aggressive revascularization therapy. Currently, we use the
Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) as risk
prediction models for NSTEMI patient. However, there is still no risk prediction models for in-hospital mortality of
Indonesian patients with NSTEMI without revascularization.
Objectives: To establish a novel score system based on clinical characteristic of NSTEMI patient without
revascularization and to evaluate the risk of in-hospital mortality of NSTEMI without revascularization.
Methods: Data were collected from the RAICOM (Registry of Acute and Intensive Cardiovascular Care on
Outcome), from September 2014 to September 2015, 648 patients were diagnosed with NSTEMI, 279 patients
were excluded due to data missing, 37 patients were excluded due to undergo revascularization during
hospitalization. Total of 332 patients with NSTEMI were included in the study. All observed parameters were
listed on table 1. Multivariate analysis with logistic regression was conducted to evaluate independent risk factor
of the parameters in predicting mortality. Discrimination and calibration was assessed by Area Under Curve
(AUC) and Hosmer-Lemeshow Goodness-of-fit test, respectively.
Results: A total 332 patients were included in this study. Hospital mortality was 9% (30/332). Group were
classified into in-hospital survivor and non-survivor. Bivariate analysis (Table 1) of parameter risk showed all type
VT, VF/Pulseless VT, cardiac arrest, acute heart failure (AHF), hypertension status, bleeding, stroke, sepsis,
using IABP, using ventilator, using hemodialysis, using inotropic / vasopressor before or during CVC, low systolic
or diastolic blood pressure during emergency or CVC admission, low mean arterial pressure during CVC
admission, low TAPSE (<1.7), normal thrombocyte, hyperkalemia (>5mEq/L) were associated with in-hospital
mortality (P <0.05). Then, multivariate logistic regression analysis (Table 2) was conducted and showed only
stroke (OR 10,875; 95% Confidence Interval [CI] 1.533 – 77,144; P = 0,017), sepsis (OR 22,894; 95% CI 2.082 –
251,714; P = 0,01), using IABP (OR 27,53; 95% CI 3.663 – 206,91; P = 0,001) and using inotropic or
vasopressor during CVC (OR 4,748; 95% CI 1.759 – 12,816; P = 0,002) as independent risk factor for predicting
mortality. AUC for this model (Table 4) was 0.846 (95% CI: 0.766 to 0.926) and excellent calibration was
observed (Hosmer-Lemeshow p=0.777 with 20 steps). To predict in-hospital mortality, all independent factors
scored as 1 point and multiplied by each coefficient (Table 3).
Conclusion: This risk model score is able to accurately predict the risk of in-hospital mortality in patient with
NSTEMI without revascularization. Risk parameters that independently associated with in-hospital mortality are
stroke, sepsis, IABP and using inotropic or vasopressor during CVC.

72
Table 1. Bivariate Analysis of Risk Factor In-Hospital Mortality of NSTEMI Patients

73
Table 1. Bivariate Analysis of Risk Factor In-Hospital Mortality of NSTEMI Patients (Continue)

74
Table 2. Independent Risk Factor In-Hospital Mortality of NSTEMI Patients

Table 3. Risk Model Prediction of In-Hospital Mortality in NSTEMI Patients

Table 4. Area Under Curve Risk Model Prediction of In-Hospital Mortality in NSTEMI Patients

75
ABS-55

Double Infarction in Acute STEMI Treated With Primary PCI

Finesa Adyatessa Hasye, Yose Ramda Ilhami, Muhammad Fadil

Introduction : Coronary artery disease is the leading cause of mortality and morbidity in developing as well as
developed countries. Acute myocardial infarction (AMI) involving two or more culprit lesions at the same time,
known as double or combined infarction, is an extremely rare event with a grave prognosis.
Case Ilustration : A 48-year-old man presented with typical chest pain of six hours duration. The risk factors
included hypertension and smoking. On examination HR was 102x/min and BP was 140/78 mmHg. ECG showed
ST elevation anterior leads (V1–V6), Q wave and T inverted inferior leads (II, III, aVF), and troponin T was
elevated. We made a diagnosis of acute anterior STEMI whom immediately shifted to the cath lab for primary
PCI. Coronary angiograms showed thrombus burden grade III of the prox LAD and thrombotic occlusion of the
proximal RCA.

The proximal LAD was deployed a 3.0 × 15 mm Combo stent for 12 atm. Then the proximal RCA was deployed
a Combo 2,75×33 mm stent at 12 atm. TIMI 3 flow was established in both vessel. Patient discharged one day
after PPCI without any complication.
Discussion : Double infarction of two separate vessels is extremely rare. AMI with multiple vessel obstruction
often causes extensive myocardial injury and death occurs before the patient arrives at the hospital. The factors
responsible for simultaneous acute thrombosis of multiple coronary arteries include: (1) heightened inflammatory
response and catecholamine leading to occlusion of another vessel; (2) hemodynamic instability resulting in
blood stasis and acute occlusion of another artery; (3) prolonged coronary vasospasm; (4) hypercoagulable
states; and (5) coronary embolism and coronary arteritis.1 To conclude, the possibility of multi-vessel coronary
thrombosis in this patient was inflammatory response. Expeditious restoration of coronary blood flow will salvage
the myocardium and reduce mortality risk.2

Reference
1. Biplab Paul, Pranab K. Biswas, Biswajit Majumder, Debojyoti Sarkar, Aritra Konar. Advances in Interventional
Cardiology 2015;11,3(41).
2. Rajiv Ananthakrishna, Li-Jun Wang, Liang Ping Zhao, and Huay Cheem Tan. Singapore Med
Journal.2017;58;225-7.

76
ABS-56

Inotropic and Vasopressor In Cardiogenic Shock Patient

Finesa A Hasye, Yose Ramda Ilhami, Muhammad Fadil

Background: Cardiogenic shock is characterized by a decrease in myocardial contractility, and

presents a high mortality rate. Inotropic and vasopressor agents have been recommended and used for
several years in the treatment of patients in shock, but they remain controversial. Despite its beneficial
effect on myocardial contractility, the side effects of inotropic therapy (arrhythmias and increased
myocardial oxygen consumption) may be associated with increased mortality.1
Purpose : The aim of this study was to analyze the ultilization of inotropic and vasopressor in
cardiogenic shock patient, the maximum dose of the drugs, number of inotropic and vasopressor
usage, length of stay of the patient and mortality rate at CVCU Dr. M Djamil Hospital Padang.
Method : The study was retrospective using data from medical records during January –December
2017.
Result : There were 20 patients who diagnosed cardiogenic shock from January-December 2017. On
average, systolic blood pressure was 76 and mean arterial pressure 52 mmHg at detection of shock.
Vasopressors and/or inotropes were administered principally within the first 24 hours. Those agents
were dopamine, dobutamine, norepinephrine and vasopressin. From those patients, 60 % (12) patients
received several vasopressors. The maximal dose of each drugs were norepinephrine
0,5mcg/kgbw/min, dopamin 10 mcg/kgbw/min, dobutamine 7 mcg/kgbw/min, and vasopressin 0,04
unit/hr. The average of length of stay in the hospital was 8,7 days and 50% of mortality rate.
Discussion : Vasopressors and/or inotropes are almost invariably used in the treatment of CS and
were initiated soon after detection of shock. Norepinephrine should be the first-line drug for CS patients
with hypotension. Adding vasopressin should be considered in those needing high doses of
norepinephrine and in those with an unstable heart rhythm, in whom raising the norepinephrine dose
would be unsafe. Dobutamine with noradrenaline appeared to be a prognostically equal alternative;
these combinations should be favored in the early management of CS.
Keyword : cardiogenic shock, inotropic, vasopressor.

77
ABS-57

Fluid Therapy in Acute Lung Oedem and Diabetic Keto Acidosis, Restricted or Rehydrated?
Prima Ursila, Yose Ramda Ilhami, Muhammad Fadil

Introduction : Acute Lung Oedem (ALO) and Diabetic Keto Acidosis (DKA) may occasionally co-exist in the
same individual. When ALO as its presenting feature, its co-existence with DKA can pose unique therapeutic
challenges.
Case Illustration : A 56- year-old woman with typical chest pain since 5 hours. Electrocardiography revealed
Total Atrio Ventricular Block (TAVB). Laboratory findings are anemic state, leukocytosis, random blood glucose
744 mg/dl, and ketonuria, and severe metabolic ascidosis. Patient was diagnosed as inferoposterior ST-
Elevation Myocardial Infarction, TAVB, and DKA. Patient had cardiac arrest before Primary Percutaneous
Coronary Intervention (PPCI). In cardiovascular care unit, the patient was on mechanical ventilation. We continue
normal saline 3750 ml in 5 hours, insulin in 2nd hour 180 mU/kgBB continue 90 mU/hour/kgBW, bicarbonat
correction according to DKA protocol. The patient’s BP, HR, RR, oxygen saturation were 170/70 mmHg, 120
x/minute, 28 x/minute, 88%. We found increasing of jugular vein pressure and fine rales. We add furosemide 40
mg bolus continue with 2x20 mg intravenous, nitroglycerin, and ramipril. On the next day, the symptoms of ALO
was improved, glucose level, metabolic acidosis returned to normal, and urine keton negative. Patient was
extubated on 5th day and discharged on 7th day.
Discussion: It has been reported that DKA and ALO may be presented together. The presence of
hyperglycemia and metabolic acidosis warranted us to check for urine ketones that turned out to be significant.
Treatment for patient with ALO and DKA are intravenous drip of normal saline and insulin according to the
protocol, with minimal use of diuretic. In brief, in the context of ALO, especially when it co-exists with DKA, there
are huge opportunities to explore the paradigm of minimal use of diuretic.
References:
1. Tretjak M, Verovnik F. Severe DKA Associated with AMI. Diabetes Care 2003;26:2959-2960
2. Mohamad N, Ahmad R. Chest pain in ED: A diagnosis of DKA must be ruled out. International Journal
of Case Reports and Images 2010;1(3):6-9.

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ABS-58

The Prevalence of Hyperlactatemia and In-Hospital Length of Stay in Patients with Cardiogenic
Shock at M. Djamil Hospital Padang

Prima Ursila, Yose Ramda Ilhami, Muhammad Fadil

Background : Cardiogenic shock is defined as a condition of inadequate tissue perfusion that results in an
increase in anaerobic metabolism and lactate production as a consequence of regional hypoxia. Hyperlactatemia
is commonly used as a diagnostic and prognostic tool in intensive care settings. The goal of this study was to
determined the prevalence of elevated lactate levels and length of stay in patients with cardiogenic shock.
Methods : We retrospectively analized the plasma lactate levels in cardiogenic shock patients from January to
December 2017.
Results : Plasma lactate was available for 20 patients from January-December 2017. Among patients with
measured lactate levels, the prevalence of elevated lactate higher than 2.0 mmol/L was in 16 (80%) patients and
normal lactate levels was in 4 (20%) patients. The average of length of stay in the hospital was 8,7 days (9,75
days in patients with hyperlactatemia and 4,5 days in patient with normal lactate levels).
Conclusion : There is increasing evidence supporting the use of lactate as a diagnostic, therapeutic, and
prognostic marker of global tissue hypoxia in cases of circulatory shock. Lactate values higher than 2.0 mmol/L
was one of the diagnostic criteria for impaired end-organ perfusion. So far there is no cut-off value of lactate
associated with worse outcome. Elevated lactate levels is believed as an indicator of global tissue hypoxia in
cardiogenic shock and associated with in-hospital length of stay. In our study, lactate levels when measured
during cardiogenic shock were associated with in-hospital length of stay.

Keyword : cardiogenic shock, lactate, in-hospital length of stay

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ABS-59

Predictors of In-Hospital Mortality in Patients with Inferior ST-Segment Elevation Myocardial

Infarction
Dwita Rian Desandri, *Evan Hindoro, Rizki, Nitia Almaida, Darwin Maulana, Muammar Ryandi, Bambang
Widyantoro, Dian Zamroni, Siska Suridanda Danny, Isman Firdaus, Dafsah Arifa Juzar, Daniel PL Tobing,
Amiliana Mardiani Soesanto
Department of Cardiology Universitas Indonesia, National Cardiovascular Center Harapan Kita Jakarta,
Indonesia
*Cardiology Division, Belitung Timur General Hospital, Indonesia

Background
Inferior STEMI is known to have lower in-hospital mortality compared to anterior STEMI. But all factors that
predicting in-hospital mortality in inferior STEMI have not been well established.
Objective
To identify the predictive factors of in-hospital mortality in patients with inferior STEMI.
Results
From 1846 STEMI patients in RAICOM registry, 451 patients had inferior STEMI. Thirty one (7%) of them died
during hospitalization. By bivariate analysis, the predictors of in-hospital mortality in inferior STEMI included heart
rate > 80 beat per minutes (bpm), systolic blood pressure (SBP) < 100 mmHg, pneumonia, reduced left
ventricular ejection fraction (LVEF) < 40%, and killip class ≥ II. After adjustments for baseline variables, the
factors associated with in-hospital mortality included heart rate > 80 bpm (OR 2.68, p 0.034, CI95% 1.1 – 6.0),
reduced LVEF (OR 2.83 p 0.018 CI95% 1.2 – 6.7), and killip class ≥ II (OR 12.8 p 0.0001 CI95% 4.8 – 33.6).
Conclusion
Reduced LV ejection fraction, Killip class ≥ II, and heart rate > 80 bpm are significant predictors of in-hospital
mortality in patients with inferior STEMI.

Baseline Characteristics
Hidup (n= 281) Meninggal (n=31)

Age (years), mean + SD 56.6 + 10.50 60.1 + 9.33

Male sex, n (%) 232 (82) 29 (93)
Hypertension, n (%) 165 (58) 18 (58)
Diabetes Mellitus, n (%) 88 (31) 10 (32)
Smoking, n (%) 185 (66) 20 (64)
Pneumonia, n (%) 21 (8) 8 (25)

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Sepsis, n (%) 3 (2) 2 (6)
Heart rate (bpm), mean + SD 79.8 + 22.32 94.5 + 32.25
Systolic blood pressure (mmHg), mean + SD 129.9 + 28.44 111.6 + 30.36
Serum creatinine (md/dL), mean + SD 1.4 + 0.95 1.9 + 0.93
KILLIP class, n (%):

 Class I 170 (60) 15 (50)

 Class II
49 (17) 8 (25)
 Class III
 Class IV 45 (16) 0 (0)
17 (7) 8 (25)
Atrio-ventricular block, n (%):

 1st degree AV block 18 (6) 1 (3)

 2nd degree AV block
5 (2) 0 (0)
 3rd degree AV block / TAVB
35 (12) 4 (13)
Echocardiographic parameters:

 LVEF (%), mean + SD 47.8 + 13.13 38.1 + 16.13

 TAPSE (mm), mean + SD
1.7 + 0.44 1.5 + 0.43

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 ANALISIS BIVARIATE

Mortalitas
Nilai P OR IK95%
Meninggal Hidup
Laki - laki 29 (11.1%) 232 (88.9%)
Jenis Kelamin 0,13 3,06 0.7 to 13.2
Perempuan 2 (3.9%) 49 (96.1%)
> 60 tahun 15 (12.2%) 108 (87.8%)
Usia 0,33 1,50 0.7 to 3.1
< 60 tahun 16 (8.5%) 173 (91.5%)
Ya 18 (9.8%) 165 (90.2%)
Hipertensi 1,00 0,97 0.4 to 2.0
Tidak 13 (10.1%) 116 (89.9%)
Ya 10 (10.2%) 88 (89.8%)
Diabetes Mellitus 1,00 1,04 0.4 to 2.3
Tidak 21 (9.8%) 193 (90.2%)
Ya 20 (9.8%) 185 (90.2%)
Merokok 1,00 0,94 0.4 to 2.0
Tidak 11 (10.3%) 96 (89.7%)
> 80 kali/menit 22 (14.1%) 134 (85.9%)
Denyut Nadi 0,02 2,68 1.1 to 6.0
< 80 kali/menit 9 (5.8%) 147 (94.2%)
Tekanan Darah < 100 mmHg 8 (25.8%) 33 (11.7%)
0,04 2,61 1.0 to 6.3
Sistolik > 100 mmHg 23 (74.2%) 248 (88.3%)
Mobitz type II, TAVB 4 (12.9%) 38 (13.5%)
AV block 1st degree AVB, Mobitz 1,00 0,94 0.3 to 2.8
27 (87.1%) 243 (86.5%)
type I
Ya 8 (25.8%) 21 (7.5%) 1.7 to
Pneumonia 0,004 4,30
Tidak 23 (74.2%) 260 (92.5%) 10.7

Ya 2 (6.5%) 3 (1.1%)
Sepsis 0,08 6,36 1.0 to 39.6
Tidak 29 (93.5%) 277 (98.9%)
> 1.2 mg/dL 14 (10.1%) 125 (89.9%)
Serum Kreatinine 1,00 1,02 0.4 to 2.1
< 1.2 mg/dL 17 (9.8%) 156 (90.2%)
> 40 % 16 (19.8%) 65 (80.2%)
Fraksi Ejeksi LV 0,002 3,54 1.6 to 7.5
< 40 % 15 (6.5%) 216 (93.5%)
> 1.7 mm 15 (13.2%) 99 (86.8%)
TAPSE 0,17 1,72 0.8 to 3.6
< 1.7 mm 16 (8.1%) 182 (91.9%)
II - IV 25 (26.3%) 70 (73.7%) 4.9 to
KILLIP 0,001 12,50
I 6 (2.8%) 211 (97.2%) 31.8

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 Analisis Multivariate Regresi Logistik

Koefisien S.E Wald dF Nilai P OR IK95%

Laki - Laki 1,156 0,780 2,194 1 0,139 3,17 0.6 to 14.6
DN > 80 kali/menit 0,997 0,470 4,506 1 0,034 2,71 1.1 to 6.8
TDS < 100 mmHg 0,907 0,536 2,865 1 0,091 2,47 0.8 to 7.0
Fraksi Ejeksi LV < 40% 1,042 0,439 5,639 1 0,018 2,83 1.2 to 6.7
KILLIP II - IV 2,550 0,493 26,729 1 0,0001 12,8 4.8 to 33.6
Konstanta -5,734 0,922 38,709 1 0,0001 0,003

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