2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)

8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)

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Nama : Arief Wibisono

Tmp/Tgl Lahir : Surabaya/24 Maret 1969

Riw Pendidikan : SD-SMA Surabaya

S1 : FKUI Jakarta 1995Spesialis : Unair Surabaya 2007

Pekerjaan : RSUD Dr Iskak Tulungagung

Curiculum vitae



Arief Wibisono , MD

What Do I Have to Dofor Reffering My Patient for

Better Treatment



Background

Time to Treatment is critical for

STEMI patients

For patients with ST-segment elevation myocardial

infarction (STEMI), percutaneous coronary intervention(PCI) is the preferred method of reperfusion

Both the American College of Cardiology / American

Heart Association ( ACC/AHA) and the European

Society of Cardiology (ESC) recommend a door-to-balloon time of less than 90 minutes



Improving door-to-balloon time for

primary PCI has been shown to decreasemortality

Door to Ballon Time (min)

<90 >90-120 >120-150 >150

M

O

R

T

A

L

IT

Y



Time Is Muscle

• 1/3 pts with STEMI will die within 24 hours

• •Majority of deaths within the first 2 hours

•

•Average patient does not seek care for 2hours

• •Each minute a patient remains in VF, survival

odds decrease 7-10%• •Patients with STEMI should use ambulance



Miedema Study

2,028 STEMI patients analyzed from 2003-200864% of patients had a delay time > 45 minutes

Cause of Delay Patients

No delay 36%Awaiting Transport 26%

ED Delay 14%

Nondiagnostic ECG 9%

Diagnostic Dilemma 9%

Cardiac arrest 6%



STEMI SYSTEM OF CARE

•

AHA 2010 Guidelines recommend a System of Careapproach to effectively handle STEMI patient care

Communities

EMS Providers

Referral Hospital

PCI Hospital

Cardilogy

Goal: get a STEMI patient to appropriate

treatment as quickly as possible



Patient Rapid access to appropriate treatment

EMS CareTeam

Provide critical data to hospital teamsquickly

Transport patient to most appropriate

facility

HospitalCare Team

Early identification of a STEMI

patient

Advanced warning and activation of

Cath Lab and teams

Cardilogy

Early diagnosis of a STEMI patient

Remotely review and diagnose difficult rhythms

Hospital

AdministastrationImprove (reduce) door-to-balloon metrics



ESC Guidelines



How about us, especially....

< 30 min is difficult to achieve

Study: 14.821 STEMI patients transferred for PPCI, only 11%

of patients had < than 30 min



REFERRAL AND PCI HOSPITALS

1. Symptom onset

2. Medical contact

3. ECG

4. Decision

5. Door to needle

6. Door to departure



Symptoms of ACS

Typical presentation of ACS

(considered medical emergencies):

Chest discomfort at rest or for a

prolonged period (more than 30

minutes, not relieved by sublingual

nitrates), recurrent chest discomfortor discomfort associated with

syncope/acute heart failure

Other presentations of ACS mayinclude back, neck, arm or

epigastric pain, chest tightness,

dyspnoea, diaphoresis, nausea

and vomiting



The prehospital 12-lead ECG is a

critical tool in identifying and

diagnosing a STEMI patient and

shortening the time to treatment



STEMI (ST-segment

elevation myocardial

infarction)

High-risk unstable angina

(UA) or NSTEMI (non-ST-

segment elevation

myocardial infarction)

Intermediate or low risk

UA

Definition: ST segment

elevation greater than 1

mm (0.1 mV) in 2 or morecontiguous precordial

leads or 2 or more

adjacent limb leads -OR-

New or presumed new

left bundle branch block

Definition: Ischemic ST-

segment depression of

0.5 mm (0.5 mV) or

greater -OR- Dynamic T

wave inversion with pain

or discomfort / Transient

ST elevation of 0.5 mm or

greater for less than 20

minutes

Definition: Normal or

non-diagnostic changes in

ST segment or T wave

that are inconclusive and

require further risk

stratification / Includes

people with normal ECGs

and those who have ST-

segment deviation in

either direction that is

less than 0.5 mm or T

wave inversion of 2 mmor 0.2 mV or less

Classification:

INFARCTIONClassification: ISCHEMIA Classification: NORMAL?

Treadmill Test



ECG Finding







Treatment Time Goal



Critical points for delay time

• Lack of early recognition by the patient ofACS symptoms

• Delays in diagnosis and risk stratification

• Lack of system co-ordination and integration

• Lack of guideline and protocol to optimisepatient flows and delivery

• Specific needs for high-risk groups, including

disadvantaged population groups



Raise community awareness of the warning signs of ACS

First contact with medical services

Promote emergency ambulance

Lack of early recognition by the patient of ACS

symptoms



Delays in diagnosis and risk stratification

Support and training for health professionals at :

• Interpretation of d ECGs

• ACLS

• Workshop and courses esp ACS



• Improved lines of communication and health

professional roles and responsibilities

• Interventional cardiology centres operating as

24/7

Lack of system co-ordination and integration





Specific needs for high-risk groups, including

disadvantaged population groups

Spreading of outreach cardiologistImprove the confidence and knowledge of GP in peripheral



SUMMARY

• Primary Percutaneous Coronary Intervention (PCI) is

the most complex, multi-disciplinary, and time-

sensitive therapeutic intervention in the world of

medicine.• Our process is measured in Minutes

• Our outcomes are measured in terms of Mortality

• Teamwork and smooth Transitions are essential



"Hai manusia, sesungguhnya telah datang kepadamu pelajaran dari

Tuhanmu dan penyembuh bagi penyakit-penyakit (yang berada) dalamdada dan petunjuk serta rahmat bagi orang-orang yang beriman."

YUNUS 57



Congratulations6 Th

Surabaya CardiologyUpdate

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2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)