PENANGANAN KEGAWATAN

PADA PENDERITA SERANGAN JANTUNG

DI FKTP PERKOTAAN

Dr.Donny Hendrasto,SpJP FIHA

RSU Haji Surabaya
 10 penyakit paling mematikan
di Indonesia menurut WHO
WHO pada tahun 2012 dalam profil statistik Indonesia secara
resmi merilis 10 penyakit penyebab kematian paling tinggi di
Indonesia.
Stroke 21%
Ischemic Heart Disease 9%
Diabetes 7%
Lower Respiratory Infections 5%
TB 4%
Cirrhosis 3%
Chronic Obstructive Pulmonary Disease 3%
Road Injury 3%
Hypertensive Heart Disease 3%
Kidney Diseases 3%
10 penyakit paling mematikan di
Indonesia menurut Balitbangkes

Cerebrovaskular atau pembuluh darah di otak seperti pada

pasien stroke.
Penyakit jantung iskemik.
Diabetes Melitus dengan komplikasi.
Tubercolusis pernapasan.
Hipertensi atau tekanan darah tinggi dengan komplikasi.
Penyakit pernapasan khususnya Penyakit Paru Obstruktif
Kronis (PPOK).
Penyakit liver atau hati.
Akibat kecelakaan lalu lintas.
Pneumonia atau radang paru-paru.
Diare atau gastro-enteritis yang berasal dari infeksi.
Figure 3
Figure 2
 RISK STRATIFICATION
Based on initial
Evaluation, ECG, and
Cardiac markers
STEMI
Patient?
YES NO

- Assess for reperfusion UA or NSTEMI

- Select & implement - Evaluate for Invasive vs.
reperfusion therapy conservative treatment
- Directed medical - Directed medical
therapy therapy
Time to Treatment Is Critical in STEMI
0.4 million
discharges per
year
for STEMI Not PCI
in US capable

EMS on-scene
Onset of 9-1-1 • Encourage 12-lead ECGs
symptoms of EMS • Consider prehospital fibrinolytic if
STEMI dispatch capable and EMS-to-needle within
30 min PCI
GOALS capable
5 8
EMS Transport
min min
Patient Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min
within 30 min Patient self-transport
Dispatch
Hospital door-to-balloon
1 min
within 90 min
Golden hr = 1st 60 min Total ischemic time: within 120 min
● Time to reperfusion is a critical determinant of the extent of
myocardial damage and clinical outcomes in patients with STEMI
● Key factors in STEMI care are rapid, accurate diagnosis and
keeping the encounter time to reperfusion as short as possible
 ACS AND RURAL HOSPITALS

• 4897 community hospitals in the United States 1

– 2900 are located in urban areas1
– 1997 are located in rural areas1
• Although primary PCI is often the preferred strategy for STEMI, only about 25% of US
hospitals are capable of performing PCI2
• Non–PCI-capable institutions are often located in rural areas and face challenges
related to their distance from PCI centers
• Almost 60% of US adults live in an area where a non–PCI-capable institution is their
closest hospital2
– Guideline-based multidisciplinary care and coordinated transfer protocols are
important for best outcomes

1. American Hospital Association Statistics. Available at:

www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html
. Accessed May 23, 2010.
2. Nallamothu BK, et al. Circulation. 2006;113(9):1189-1195.
 The Thrombus in STEMI
STEMI is generally caused by a Results from stabilization by fibrin
completely occlusive fibrin-rich mesh of a platelet aggregate at site
thrombus in a coronary artery of plaque rupture

*RBC = red blood cell.

GP IIb-IIIa inhibitors are not indicated for STEMI.
Van de Werf F. Thromb Haemost. 1997;78(1):210-213; White HD. Am J Cardiol. 1997;80(4A):2B-10B;
Davies MJ. Heart. 2000;83(3):361-366.
 Reperfusion
Recommendations
I IIa IIb III
- STEMI patients presenting to a hospital with
A PCI capability should be treated with primary
PCI within 90 minutes of first medical contact.

I IIa IIb III

• STEMI patients presenting to a hospital without
PCI capability and who cannot be transferred to
a PCI center for intervention within 90 minutes
B of first medical contact should be treated with
fibrinolytic therapy within 30 minutes of
hospital presentation, unless contraindicated.

ACC/AHA 2007 STEMI Focused Update

Circulation 2007; on line, December 10.
Tatalaksana

 Perawatan Umum:
 ICU 24 jam
 Tirah baring total dan dipasang monitor EKG, tensi,
pulse oxymetri, untuk mengetahui secara dini
timbulnya penyulit; misal syok, aritmia
 Dipasang akses intravena
 Diberikan O2 2-4 L/m bila tjd distres nafas
 Diet lunak dg porsi kecil
 Mengendalikan faktor risiko
Tatalaksana STEMI
 Medikamentosa
 Antiplatelet: aspirin atau clopidogrel
 Nitrat: nitrogliserin
 Morfin: atasi nyeri, menenangkan penderita, kurangi beban
jantung dg cr kurangi preload. Dosis kecil secara titrasi, 1 – 2,5
mg IV
 Betablocker: untuk mengurangi kontraktilitas jantung sehingga
akan menurunkan kebutuhan oksigen miokard
 Ace inhibitor: bila IMA disertai dengan hipertensi atau gagal
jantung asalkan tekanan sistolik > 90 mmHG
 Trombolitik: pada infark akut dg ST elevasi >0,1 mV;
streptokinase 1,5 juta unit dalam 30-60 menit
 Heparin
 Magnesium: bila kadar kurang dr normal, bolus iv 1-2 g
konsentrasi 20%
Tatalaksana STEMI

 Tatalaksana Invasif
 PTCA secara primer sbg alternatif tx trombolitik
 Pd penderita yg kontraindikasi tx trombolitik
 Pd penderita yg gagal trombolitik
 Dilakukan <12 jam pd awal infark
 ACS AND RURAL HOSPITALS

• 4897 community hospitals in the United States 1

– 2900 are located in urban areas1
– 1997 are located in rural areas1
• Although primary PCI is often the preferred strategy for STEMI, only about 25% of US
hospitals are capable of performing PCI2
• Non–PCI-capable institutions are often located in rural areas and face challenges
related to their distance from PCI centers
• Almost 60% of US adults live in an area where a non–PCI-capable institution is their
closest hospital2
– Guideline-based multidisciplinary care and coordinated transfer protocols are
important for best outcomes

1. American Hospital Association Statistics. Available at:

www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html
. Accessed May 23, 2010.
2. Nallamothu BK, et al. Circulation. 2006;113(9):1189-1195.
Tatalaksana NSTEMI

 Medikamentosa:
 Aspirin:
 Nitrat: sublingual, nitrogliserin
 Betablocker: bila tdk ada kontraindikasi
 Antagonis kalsium
 Heparin
INTERVENSI KORONER PERKUTAN
(PERCUTANEUS CORONARY INTERVENTION/PCI
CORONARY ARTERY BYPASS GRAFTING (CABG)
 Komplikasi
 Gagal jantung akut / Edema Paru Akut
 Aritmia
 Ruptur dinding ventrikel, ruptur septum
interventrikularis
 Regurgitasi mitral akut (Disfungsi / ruptur muskulus
papilaris)
 Syok kardiogenik
 Kematian
 Prognosis
 Tergantung 3 Faktor :
 Fungsi Ventrikel Kiri
 Banyaknya A. Koroner yang mengalami Oklusi dan
adanya Kolateral
 Adanya Aritmia Ventrikel
 Mortalitas
 Usia < 50 th : 10 - 20%
 Usia Lanjut : 20%
Thank you