 History :

- Family members (usually from earlier generation) with "unknown cause” of

swollen feet, anule, legs
- Cancer
- Injuries
- Burn (severe)

 sign & symptoms :

- edema (tevrama ekstremitas)

- hiperkeratosis (tebal & bersisik)
- lymphangioma (gelembung pecah di kulit)
- lymphorrhea (cairan limfa keluar kulit)

 Physical exam :

- skin : Kering, tebal, riperheratosis, limfangiona, hagat/panas, gelap, nodul

- Papilomatosis : cobblestone appearance (dilated & distended lymph vesse
enveloped in fibrotic tissue)
- Positive Stemmer's sign : inability to pinch a fold of skin at the root of 2 nd toe
→ early D/ primary lymphedema, developed later in secondary lymphedema

 Diagnons : lymphoscintigraphy (use small around of radioactive protein-dye

injected in to the web space between 1 st & 2nd digits of affected limb) dye outside
lymphatic structure → edena lymphatic Alternatif : 30 mRi, CT, USG, bioelectrical
impedance

soft tissu edema exclude OVT, CVI

 Therapy :

- decongestive lymphedena therapy (OLT) → 1st th/→ for mod - severe &
mobilites lymph & dissipates fibroscleotic tissue
- Manual lymph drainage (MLD) → massage
 - Compression
- Skincare → prevent 2nd infection
- Exercise
- Drvg thl → only for pain or 2nd infection
- surgery (debulking ineffective, microsurgical → lymphatico venous
anastomoses (LVA), varwlar lymph noce transfer (VLNT), Suction assisted
protein lipectomy (SAPL)).

 DD
/: CHF, OVT, malignancy, pretibial myxedena, baker cyst, sewlitis, cvi,....
 Lymphedena stages :

- stage o (Latency Prage): "at rish" Ca mannae

- stage I spontaneous) : reversible, Pitting edina, respond to elevation
- stage 2 (spontaneously irreversible) : tissue fibrosis not respond to elwation,
skin & tissue thickening, pitring (+) but difficult to assess due to fibrosis.
- stage 3 (lymphostatic elephantians) : pitring edena, fibrosis, shin charges (dry),
bisa ada papilloma, infeksi/sewlitis

* Stemmer sign may not be (+) in Stage 1 or 2.

 Progruosis : susah sembuh, hanya mengurangi gejala, memperlambat/stop progresi

penyakit Bila sudah >10 tahun → resiko jadi limfangiosarkoma (+ 10%) → sangat
agresif, radikal amputasi, very poor prognosis → 5 year ourival rate <10%.
 Komplikasi : sewlitis, limfangitis, ovt, lymphangioadenitis, superficial bakterial &
fungal infection, Psychosocial dysfunction, amputation, cosmetic embarrasment,
severe functional impairment MR junta 9/4’21 : perempuan, 34 tahun, SVT, HFrEF,
CAD, AKI, hipo K, dyslipidemia, subklinis hipotiroid AFM
 Algoritma Norrow QRS tachycardia ESC 2019
 Norrow QRS tochycardia

(QRS ≤ 120 ms)

Regular
yes no

no
Visible P AT

yes AFWT + VOR. Conl

MAT
Prate > QRS rate

yes
no

A Flut

AT
QRS rate > prate
AVNRT
yes

no

High septal VT

JET Concider RP intu

AVNRT

Nodoverticular/ foscicular
RP < PR RP < PR RP ≥ PR
Nodal Al-entry
RP ≤ 90ms RP > 90ms

Typical AVNRT AVRT AT

AT AT AVRT
JET
AVRT Atypical Atypical

AVNRT AVNRT
 Acute Thl of Narrow QRS tachycardia :

Narrow QRS tachycardia

Hemodynamic instability

no yes

Vagal manuver (I B) Synchronited cardioversion (I B)

ineffective

IV adenosine (I B)

ineffective

IV verapamil or IV beta-bloker

diltiazen (II a)

(II a)

 Vagal Manouure : efektifitas 19-54%

Stimulasi nevus vagus → pelepasan asetilkolin → hantaran listrik ke AV Node
↓→ HR ↓
 Macam" vagal mawver :
1. Valsalva : lebih efektif pada dewasa dan AVRT daripada AVNRT
2. Modified Valsalva : tiup spuit 10 cc kuat-kuat hingga bergerak, lalu baring dan
passive leg raising
3. Carutid sinus massage : px noleh ke arah berlawanan SS leher yg akan
dimassage. Massage unilateral saja selama 5 detik. KI : T1A, stroke, carotid
bruit
4. Facial immersion in cold water
5. Forceful coughing
6. Eyeball massage → oculocardiac reflex (OCR)
= Aschner phenomenon/reflex atau Aschner-Dagnini reflex atau Trigemino
Vagal reflex (TVR)
 Adenosine : 6-18 mg IV bolus rapid, frush → v. Lubiri
- Memperlambat kondisi AV Node (efek pada AH/atrial-his inteval
- DOR singkat : 20-30 detik, ⁖ dosis ulang dikasi selang i menit (6-12-11 mg)
- Efek samping : transient dysproe (karena stimulasi pulmonary – vagal C
fibres), tlushing (vasodilatasi, situs ↑), chest poin karena iskemik,
bronkhokonstriksi (KI = asma)
 CCB (verapama / dilsiazen) & BB (Esmolul Metoprolol) IV → KI : AHF , EFC
40%, VT, AF
- Dosis : Verapanil : 0.075-0.15 mg/kg IV
(average 5-10 mg) over 2 min
- Diltiazem : 0.25 mg/kg (average 20 mg)
over 2 min
- Esmolol : 0.5mg/kg IV bolus
0.05-0.3 mg/kg/min/intus
- Metoprolol : 2.5-15 mg IV in 2.5 mg bolus
- Etripannil : short acting L-type CCb rapid onret intranasan
 DD
/ Wide QRS (> 120 ms) tachycardia :
1. D
/utama : VT sampai terbukti bukan
2. DD/
:
o SVT with BBB (pre-existing BBB/aberrancy) → RBBB due to RP ≫
(Phase -3 block)
o Antidromic AVRT
o SVT with widering QRS e.c drugs/ellectrolit imbalance (Class IA & IC →
use-depending slow conduction, class III → prolong refrakter at this
purkinie » vertinue) → atypical BBB
o pacemaker - related endless loop tachycardia & artefal
 Summary ECG criteria suggest VT rather than SVT :
1. AV dissociation : Ventricular rate > atrial rate
2. Fusion/capture beats : beda morfologi QRS as takikordia
3. Chest lead Ө concordance : all precordial lead Ө
tidak ada
4. RS di precordial :
 RS > 100 ms di semua lead

inition R wave

5. QRS di AV R initial R wave > 40ms

Noten + at predominant Ө complex

6. QRS axis : -90 ± 180o baik RBBB/ LBBB morfologi

7. R wave peak time in lead II : ≥50m prabbit ession

VI : monofasin R, Rsr’ (prabbit ession), bifasik

qR,

broad R (740ms)

8. RBBB morph :

V6 : RLS <1 (rs, as pattem)

V1 : broad R ware, slurred 5, delayed nadir of S

ware
9. LBBB morph :

V6 : Q or QS wave

Wide QRS Tachycordia

Hemodynamic instability

Ic Vagal Mannuver Synchronited cardioversion Ib

If ineffective

NIV. Adenosine
II a
(bukan pre-eksitasi)

If ineffective

II a IV procainamide IV Amiodarone II b

If ineffective
 Penyebab sirus takikardia fisiologis :
1. E
/fisiologis : emosi, nyeri, hamil, sex interlourse, exercise
2. E
/patologis : anxieras, panic attack, anemia, demam, dehidrasi, hipertiroid,
PE,
Ml, Cushing,…
3. Obat : Epi, Non Epi, dopa, dobu, doxorubicin, β2 agonis
4. Illicit drugs : amferamine, konami, ectasi
5. Lain-lain : caffein, alcohol

Sinus takikardia

Thl penyakit/penyebab reversibel Ic

If ineffective

II a Ivabradinee Beta blocker II a

If ineffective

Symptomatic & reccurent

Sinus none re-entry

yes no

Drug Thl desirable Ivabradine + BB II a

no
yes

Verapamil II b Catheser Ablation II a

If ineffective
/dilriazem

 Rekom thl sirus takikardia :

urasi penyakit dasar
1. Inappropiate sirus takikardia : Ivabradine +/- BB
 BB untuk simpramatik

CCB NDP (Vera/Diltiate)

2. Sirus rudal re-entrant takikadiar :
Cariner ablation

Reg. exercise

≤ 2- 3 L air + 10 – 12 gr NaCl

3. Postual ortistatic tachy synar

Midodrine/pyridostigmine

Ivabradine

 Klasifikasi AVNRT

HA VA (His) AH/HA

Typical AVNRT ≤ 70 ms ≤ 60 ms >1

Atypical AVNRT > 70 ms > 60 ms Variable

- fast – slow <1

> 70 ms > 60 ms
AH < 100 ms

- slow - slow > 70 ms > 60 ms AH> 250 ms

 AVNRT

Paties out of hospital

yes no

Ib Vagal manuver Hemodynamic instability

no
yes

Ib Vagal manuver Synchrorized

Ib cardioversion
If ineffective

IV. adenosine Ib

If ineffective

II a IV verapamil/dilriaton IV BB II a

If ineffective
Acute AVNRT

Patient out of hospital

yes no

Ib Vagal manoeuvvresmanu Hymodinamic instability

no yes

Ib Vagal manuvver Synchronited

cardioversion
If ineffective

Orthodromic
yes no

Ib N Adenasine IV ibutilide/procainamide

Or IV propafenare/flecainide
If ineffective
Or synchr. Cardioversion

II a

IV II a N B era Bloker II a
verapamil/Dilriazen
If ineffective

Chronic Orthopromic AVRT

no yes
Catherer ablation

Propafinone/ Dilriazen/
II a
plecarnide Verapamu/BB
ineff ineff
 AVRT pre-excited AF KI AV Nodal Blocker
(BB,diyocin)

Hemodinamic instability

no yes

Synchronited Ib
cardioversion

a IV ibutlide/ procanamide IV flecainide/propafenone II b

If ineffective

SYNCOPE

 Definisi : TLOC due to cerebral hyperfusion, characterited by : rapid onser,

short duration, spontaneous complete relovery.
 TLOC : a stave of real/apperent LOC with loss of awareness → aronesia at
unconsciousness, 2abN motor control, 3loss of responsiveness, 4 short duration.
 Pre-syncope : symptoms & signs before syncope → prodrome of syncope not
follow by LOC.
 traumatic TLOC (head trauma)
 TLOC Syncope refiex syncope
non-traumatick orthostatic hypotesi
cardiac
Epileptic tonic
Clonic
Tonic-clonic
Aronic
Psychogenic PPS
PNES
Rare subclavian sreal synd
vertebrobasiler TIA
subarachnoid hemorrhagie
lyanotic breath holding spell
 Klasifinas syncope :
1. Reflex (Neurally mediated) syncope
 Vasovagal : orthostatic VVS = standing, sitting (<<)
Emotional = fear, pain (somatic I vitral), ironmentation,
blood phobia
 Sinasional : micturation, 61 stimulation (swallow, BAB) tough, sneeze, post
exercise, laughing
 Carolid sinus syndrome (CSS)
  Non classical form (without prodromes / triggers /atpiche presentation) →
semua penyebab lain telah dieksklusi (kelainan structural Ө ) atan timbul
saat tilt test. Now also contains low adenosine plasma level.
 Orthostatic Hypotension (OH)
- hipotensi karena venous pooling during exercise lexu side induced), after meals,
after prolong bed-rest
- Drug Induced: vasodilator, diuretic, antidepresant, Pherothiazine
- Volune depletion : hemorrhage, diare, vomiting

- Primary awonanic failure (neurogenic OH) :

pure autonomic failure, multiple system atrophy, Parkinson's disease, dementia
with Lewy bodies
- secondary autonomic failure (newogenic OH) :
DM, amyloidosis, spinal cord injury, auto-immune autonomic neurapathy,
paraneoplastic autonomic neuropathy, hidney failure

Cardinc syncope

- Arimio Bradi : SND, AV block

Tani : supraventricular, ventricular

- Struktural : AS, ACS, HCM, massa cardiac (atrial myxoma), tamponade,

ALCAPA, prot thetic value dysfunction

- Cardiopulmonary & Great vessel : PE, AAS, PH

 Insidensi terbanyak : reflex syncope & OH

More severt if : medication causing BP ↓, alcohol use, volume ↓ (diare, bleeding),

paru-paru (supply O2 otak ↓), thermal stress

 2 patofisiologi utama reflex syncope (tigtg trigger) :

- Vasodepression : insufisient sympathetic vasoconstriction → hypotension

- Cardioinhibition : ada bradikardia / asystole → dominan parasimpatis

 Penyebab kardiovaskular dari orthostatic intolerance →classical OH, initial OH,

delayed OH, POTS, VVS

 Carotid sinus massage (CSM) is indicated for > 40y.o with syncope of unknown

origin compatible with reflex mechanism.

 CSS : CSM cause brodicardia / asystole/ hypotension

 Carotis sinus hypersensitivity : CSM + tanpa riwayat sinkop

→ ventricular pause > 3 second and/or fall of BP > 50mmHg

→ >> ortu (♂, CVO +) asystole > 6 second

→ pengecualian pada pasien usía < 40 tahun

→ spesifitas  pingsan saat CSM (5% pada asympt > 65 tahun)

 Syarat CSM :

- Supin & upright position

- Continuous beat=to=beat BP monitoring

→better in tilt lab

 Komplikasi neurologis CSM : TIA : hati-hati pada pasien dengan riwayat TIA,

stroke, carotid stereosis > 70%

 3 metode untuk menilai OH (from supire to erect):

- active standing :

1. ukur BP & HR baraing & berdiri selama 3 menit

2. continuous beat-to-beat non-invasive BP measurenen

- kriteria o/ :

1. TO5↓≥20 / TOD ≥ 10 / TO5 < 90 mmHg

2. Orthostatic HR : HR tidak  /  < 10bpm pada neurogenic OH,  pada

anemia/hypovolemia
 Highly sugestive OH : syncope / pre-syncope saat berdiri, tidak saat baring, less
severt / absert saat duduk. Membaik bila duduk / baring, memburuk setelah
exercise / makan / suhu , no *autonomic activation*
 Kalau POTS : orthostatic HR  > 30 bpm atau > 120bpm dan 10 min beriri tanpa
OH
 Tilt testing : variation protocol in initial stabilization phase, duration, tilt angle, type
of support & pharmacological provocation.
 paling sering pakai Trinitrogliserine (TNG) 300 – 400 µg sublingual after 20 min
unmedicated phase or low-dose IV isoproterenol test (≤3µg/hari untuk
meningkatkan HR 20-25% dari baseline
 positive rate dengan TNG 66%, isoproterenol 11%
 Indikasi tilt testing : susp reflex syncope, OH, POTS, PPS (IIa) & educate px
ricognite symptomps & learn physical manouvers (IIb)
 Diagnosis kriteria : reflex syncope, POTS, or PPS should be consider if tilt test
reproduce symptoms along with characteristic circulatory pattern (IIa)
 Tilt tset (-) doesn’t exclude reflex syncope
 Adanya hypotensive saat test (hypotensive susceptibility) → reflex syncope /
cardiac syncope →guiding PPM/ga
 Cardioinhibitory response (asystole) → PPM
 Tilt test
-Membedakan sinkop dari ab (V) move epilepsy
-Bedakan sinkop dengan falls
-Bedakan sinkop dengan PPS ( (+) EEG )
-Jangan untuk menilai efikasi terhadap obat
 Tilt test positivity rate :
-92% VVS, emotional trigger
-47% cardiac
-45% tachdaritmia
 Ambulatory BP monitoring (ABPM) for 24 hours
 OH : nocturnal non dipping / reverse dipping BP in autonomic failure
 untuk investigasi penyebab orthostatic intolerance (vertigo, motor inbalane in
Parkinson disease) → evidence is weak
 untuk klarifikasi BP tidak menurun saat PPS
 Basic Autonomic Function test

1. Valsalva

- tidak ada BP & HR naik saat Valsalva : patognomonik neurogenic OH

- BP ↓ tiap hari (N) : situasional syncope (batuk, nyanyi, angkat berat, main alat

music tiup)

2. Deep Breathing

a) (N) : HR  saat inspirasi, HR ↓ saat expirasi. HR variabilityy ( expiratory

inspiratory index atau E/I index) ≥ 15bpm pada orang sehat umur > 50tahun

b) HR variability (-) : parasymphatetic dysfunction

3. Lain-lain : 30:50 ratio, cold preasure test (tidak bisa pada rhynoudis), sustained

hard, grip trst (tidak bisa pada tremor/parkinsonism (IIb)), mental arithmetic

→weak evidence

 Asimptomatik signifikasi aritmia untuk diagnosi (IIa) :

- Prolong asystole (≥ 3 sec)

- SVT ( >160 bpm atau > 32 beats)

- VT

- Mobitz II / 3rd degree AV block

 Diagnosis kriteria aritmia sinkop (I) : Correlation syncope → aritmia (Bardi /

takiaritmia)

 Hotler EKG → frequent syncope / pre (≥ 1 eps/week) IIa

 External loop recorder : early after index event, inter=symptom interval ≤4 weeks

 Implantable Loop Recorder (ILR) Indication :

- Early phast evaluation in reccurent syncope of uncertain origin, high risk criteria

(-), high reccurence within battery life of device (I)

- High risk criteria tapi belum tau kausalnya, dan belum indikasi preventif primer

dengan ICD / PPM (I)

- Suspected / certain reflex syncope with requent / severe syncope episode (IIa)

- Susp. Epilepsy tapi th/ tidak efektif (IIb)

- Unexplained falls (IIb)

 Indikasi Eletrofisiologi Study pada Sinkop:

- Syncope & previous MI/other scar-related conditions → syncope remain

unexplain after non-invasive evaluation (I)

- Syncope & bifasikular BBB (IIa)

- Syncope & asymptomatic sinus bradycardia (IIb)

- Syncope preceded sudden & brief palpitation (IIb)

 Indikasi EPS-guided Therapy

- Syncope + bifasikular BBB, pacmaker is indicated in baseline H-V interval ≥

70ms, 2nd / 3rd degree his-purkinje block during incremental atrial pacing or with

pharmacological challenge (I)

- Syncope + MI / other scar related indication sustained monomorphic VT →

manage according current guidelines

- Syncope without structural heart discare, precead by falpitation, induction of rapid

SVT/VT→ hipotensi / spontaneous symptom →manage sesuai guideline (I)

 - Syncope + asymp.sinus brodikardia →parameter if prolonged SNRT is present

(IIa)

 EPS tidak berguna pada pasien syncope dengan EKG(N), no heart disease, no

palpitation.

 Terhadap Reflex Syncope :

- Education & lifestyle modification: avoid triggers

- Discontinue hypotensive terhadap : pada vasodepressor syncope

- Physical manouvers : isometric PCM (Physical Counterpressure Manouvers)

untuk pasien <60 tahun, tilt training for young pasien.

- Pharmacology th/ :

a) Fludrocortisone : young pasien VVS orthostatic, low-(N) BP, kontraindikasi

obat (-). (IIb)

b) Midodrine : orthostatic VVS (IIb)

c) BB → kontraindikasi (IIb)

- Cardiac pacing :

a) 40 tahun, symptomaticarytolic pause >3dtk atau asymptomatic pause >6dtk

karena sinus arrest, AV block, atau kombinasi keduanya (IIa)

b) CSS > 40 tahun with reccurent unpredict syncope (IIb)

c) Clinical features of adenosine-sensitive syncope (IIb)

d) Kontraindikasi tanpa bukti cardioinhibitory reflex (III)

 Tilt test response : strongest predictor parameter efficaty → tilt test (-)→ reccurent

syncope↓

 Terhadap OH :
 - Penjelasan penyakit, triggers, risk of reccurence (I)

- Adekuat hidrasi dan salt intake (I)

- Discontinuation hypotensive drug (IIa)

- Isometric PCM (IIa)

- Abdominal binders &/ support stocking untuk menurunkan venous pooling (IIa)

- Head-up tilt sleeping (>100) meningkatkan fluid volume (IIa)

- Midridine in symptom persist (IIa)

- Fludrocortisone if symptom persist (IIa)

 OH (+) risk factors falls : target BP 140-150mmHg

 Obat anti hipertensi yang dianjurkan bila ada resiko tinggi jatuh : ACEi/ARB,

CCB, hindari BB & diuretic

 Indikasi pemasangan ICD class I : (PERKI 2014)

- EF≤35% NYHA II-III kausa MI, min 40 hari post MI

- EF≤30% NYHA I kausa MI, min 40 hari post MI

- Post VT/VF refrakter dengan hemodinamik tidak stabil tanpa ditemukan penyebab

revesible

- DCM non-iskemik EF ≤ 35% NYHA II-III

- VT tidak stabil karena MI , EF<40% dan VT/VF menetap yanag terinduksi saat

EPS

- Terdapat kelainan struktural jantung dan VT menetap & spontan, baik

hemodinamik stabil / tidak

- Riwayat sinkop tanpa sebab jelas disertai VT/VF yang menetap & hemodinamik

tidak stabil saat EPS

 Kontraindikasi pemasangan ICD class III :

 - VT reversible tanpa penyakit jantung structural (e.c electrolit imbalance, obat-

obatan , trauma)

- Angka harapan hidup dengan status fungsional baik <1 tahun, walaupun

memenuhi kriteria class I & IIa

- VT/VF tidak dapat dihentikan

- Gangguan jiwa serius yang dapat diperberat bila implantasi & sulit memantau

lanjutan ICD

- Sinkop unknown etiology, tanpa takiaritmia terinduksi dan tanpa penyakit

struktural jantung

- VT/VF dapat diatasi dengan ablasi kateter/bedah

 Indikasi pemasangan CRT : (ESC 2013)

1. Pada pasien sinus ritme :

- LBBB, QRS > 150 mscc, EF ≤ 35% (I)

- LBBB< QRS 120-150 mscc, EF ≤ 35% (I)

- Non-LBBB, QRS >150mscc, EF ≤ 35% (IIa)

- Non-LBBB, QRS 120-150mssc, EF ≤ 35% (IIb)

2. Pada pasien permanen AF :

- HF, EF ≤ 35%, intrinsik QRS > 120 mscc, NYHA III-IV (IIa)

- HF tidak terkontrol dan kandidat ablasi AV junction, EF ≤ 35% (IIa)

3. Pada pasien sudah terpasang paramaker / ICD :

- HF, EF ≤ 35%, tetap NYHA III-IV dengan OMT (I)

- HF, EF ≤ 35%, butuh pawventrikel untuk menurunkan gejala (IIa)

 Factor resiko yang mempengaruhi respon terhadap CRT :

- QRS lebar, LBBB, ♀ , non-iskemik cardiomiophaty (respon tertinggi)

 - ♂, kardiomyopati iskemik

- QRS sempit, non-LBBB (respon terendah)

 Macam-macam disinkroni : (th/ → CRT)

- AV-disinkroni : atrial & ventrikel tidak sama (TAVB)

- Interventrikuler : RV-LV tidak sama pompanya (BBB)

- Intraventicular : tidak sama antar segmen saat kontraksi LV (IVCD → HF)

 Indikasi pemasangan PPM class I :

1. SND : documented symptomatic sinus bradi + frequent sinus pause,

symptomatic chronotropic incompetence (tidak mencapai 85% target HR

tidak umur saat Latihan)

2. AV Block : 30 AV block, molbitz I & II bergejala, Mobitz II dengan QRS

lebar, exercised-inducer 20/30 AV block tanpa MI

3. Chronic Bifasicular Block : advance 20 AV block / intermeten 30 AV

block, alternating BBB, AV block 20/II

4. After acute MI : persistent 20 AV block + alternating BBB / 30 AV block

below his-purkinse after STEMI, transient advanced 20/30 inframadal AV

block + BBB, persisten & symptomatic 20/30 AV block

5. Neurocardiogenic syncope & hypertensive CSS :

reccurent syncope ocuring CSS that induced asystole > 3 sec

6. Post-cardiac transplant : in app/symp.bradi can’t residue

7. HCM : HCM (+) SND & AV Block

8. Pacing to prevent tachycardia : sustained pause dependent VT, with /

without QT prolongation
9. CRT in severt systolic HF : EF≤35%, LBBB, NYHA, II-IV still

symptomatic with OMT, QRS > 150mscc, CRT with / without ICD 15

indicated

10. CHD :

- advanced 20/30AV Block (+) symptomatic bradi, LV dysfunction, low

CO/ advanced 20/30AV Block not expected to resolve / persist ≥ 7 days

after cardiac surgery

- SND = symptoms during age inappropriate brady

- Congenital 30 AV block + wide QRS escape rhythm, VES, or LV

dysfunction

- Congerital 30 AV block in infart with ventricle rate ≤55bpm / with CHD

(+) HR ≤ 70bpm