Infark Jantung

  • View
    63

  • Download
    0

Embed Size (px)

DESCRIPTION

ok

Text of Infark Jantung

  • 5/21/2018 Infark Jantung

    1/79

    Iskemia / Infark

    Jantung

    Azhari Gani

  • 5/21/2018 Infark Jantung

    2/79

  • 5/21/2018 Infark Jantung

    3/79

    http://www.tctmd.com/expert-presentations/table-2.html?product_id=3112&title=Approach%20to%20Acute%20Coronary%20Syndromes&sort_key=6&large_image_p=1
  • 5/21/2018 Infark Jantung

    4/79

    Plak Stabil (stable plaque) Plak ruptur (ruptured

    plaque)

  • 5/21/2018 Infark Jantung

    5/79

    No ST Elevation ST Elevation

    Acute Coronary Syndrome

    Unstable Angina NQMI Qw MI

    NSTEMI

    Myocardial Infarction

    Davies MJ

    Heart 83:361, 2000

    Ischemic DiscomfortPresentation

    Working Dx

    ECG

    Biochem.

    Marker

    Final Dx

    Hamm Lancet 358:1533,2001

    STEMI

  • 5/21/2018 Infark Jantung

    6/79

    Sindroma Koroner Akut (SKA):

    Definisi Nyeri dada iskemik (angina) pd saat istirahat

    atau dgn aktivitas fisik minimal atau emosi(lama 2 x 5 menit atau >10 mnt)

    Adanya bukti Penyakit Jantung Koroner(PJK):

    -EKG: ST depresi, T inversi, ST elevasi

    sesaat-Peningkatan enzim CK-MB atau Trop T

    -Bukti PJK dari angiografi koroner/ perfusion

    scanningKeith AA Fox. Heart 2000;84:93-100

  • 5/21/2018 Infark Jantung

    7/79

    KRITERIA DIAGNOSTIK

    (WHO) :1. Klinis : keluhan terbanyak adalah nyeri

    dada

    2. Perubahan gambaran EKG : Dengan elevasi segmen ST : STEMI

    Tanpa elevasi segmen ST : UAP, NSTEMI

    3. Peningkatan kadar enzim jantung :1. Kadar CK, CK-MB

    2. Kadar Troponin I/ Troponin T

  • 5/21/2018 Infark Jantung

    8/79

    EKG pada ISKEMIA dan MIOKARD INFARK

  • 5/21/2018 Infark Jantung

    9/79

    Anatomi Koroner dan EKG 12 sandapan

    Sandapan V1 dan V2 menghadap septal area ventrikel kiri

    Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri

    Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap

    dinding lateral ventrikel kiri

    Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri

  • 5/21/2018 Infark Jantung

    10/79

    Lokalisasi Dinding Ventrikel Pada EKG

    (Ventrikel Kiri)

    Anteroseptal : V1-V4

    Anterior ekstensif : V1-V6, I dan aVL

    Anterolateral : V4-V6, I dan aVL Anterior terbatas : V3-V5

    Inferior : II, III dan aVF

    Lateral tinggi : I dan aVL

    Posterior murni : bayangan cermin V1, V2, V3pada garis horisontal

  • 5/21/2018 Infark Jantung

    11/79

    ISCHEMIA : ST depresi atau T inverted

    INJURI : ST Elevasi

    NECROSIS (OLD INFARCT) :gel. Q patologis atau QS

    KERUSAKAN MIOKARD :

  • 5/21/2018 Infark Jantung

    12/79

    Iskemia Depresi ST

    Inversi T

    Inversi U

  • 5/21/2018 Infark Jantung

    13/79

    ST depresi dan perubahan gelombang T

    ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J

    Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST

    Bentuk segmen ST :

    up-sloping( tidak spesifik )

    horizontal( lebih spesifik untuk iskemia )

    down-sloping( paling terpercaya untuk iskemia )

    Perubahan gelombang Tpada

    iskemia kurang begitu spesifik

    Gelombang T hiperakut

    kadang2 merupakan satu-satunya

    perubahan EKG yang terlihat

  • 5/21/2018 Infark Jantung

    14/79

    Nonpathologic (nonischemic) and pathologic (ischemic) ST-segment and T-

    wave changes.

    A, Characteristic nonischemic ST-segment change called J-depression; note

    that the ST slope is upward.

    B and C, Examples of pathologic ST-segment changes; note that the

    downward slope of the ST segment (B) or the horizontal segment is

    sustained (C).

    (From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 4th ed. Philadelphia, Mosby, 2006.)

  • 5/21/2018 Infark Jantung

    15/79

    Iskemia

    Inversi T

    Gelombang T yang negatif (vektorT berlawanan arah dengan vektorQRS)

    Tanda ini tidak terlalu spesifik

    Yang lebih spesifik gelombangT ini simetris dan berujung lancip

  • 5/21/2018 Infark Jantung

    16/79

    Inversi T pada iskemia miokard

    a. Inversi T : kurang spesifik untuk iskemia

    b. Inversi T berujung lancip & simetris (ujung anak

    panah) : spesifik untuk iskemia

  • 5/21/2018 Infark Jantung

    17/79

    7/31/2014 17

    ST Depresi

  • 5/21/2018 Infark Jantung

    18/79

    7/31/2014 18

    T Inverted

  • 5/21/2018 Infark Jantung

    19/79

    Infark miokard

  • 5/21/2018 Infark Jantung

    20/79

  • 5/21/2018 Infark Jantung

    21/79

    Progression of an Acute Myocardial

    Infarction

    An acute MI is a continuum that extends from

    the normal state to a full infarction:

    IschemiaLack of oxygen to the cardiac

    tissue, represented by ST segment

    depression, T wave inversion, or both InjuryAn arterial occlusion with ischemia,

    represented by ST segment elevation

    InfarctionDeath of tissue, represented by a

    pathological Q wave

    Normal

    Ischemia

    Injury

    Infarction

  • 5/21/2018 Infark Jantung

    22/79

    Figure. ST, QRS, and T vectors in

    myocardial infarction.

    a. ST injury vector.

    b. b. QRS vector in necrosis.

    c. c. T ischemia vector

  • 5/21/2018 Infark Jantung

    23/79

    Hubungan antara lokasi

    infark dan oklusi arteri

    koroner (panah), dan lead

    elektrocardiogram.a. Anteroseptal infark.

    b. Anterior infark

    Extensive (anterolateral

    infarction)

    c. Infark lateral isolated

    a b

    c

  • 5/21/2018 Infark Jantung

    24/79

    d

    e f

    d. Infark Inferior

    e. Infark Posterior

    f. Right ventricular

    infarction (combined

    to inferior infarction)

  • 5/21/2018 Infark Jantung

    25/79

    Figure.a. Acute infarction: correlation between

    the electrocardiogram (ECG) and the

    stage of myocardial ischemia.

    Monophasic ST deformation

    /transmural lesion = lesion / injury.

    b. Subacute infarction. Correlationbetween the ECG and the stage of

    myocardial ischemia (ST elevation =

    lesion, plus pathologic Q wave =

    necrosis, plus negative T wave =

    ischemia).

    c. Evolution of subacute infarction tochronic infarction

  • 5/21/2018 Infark Jantung

    26/79

    Figure V3 lead: Evolution of QRS and ST/T morphologies in STEMI due to

    occlusion of LAD.

    (a) Few minutes; (b) 1 hour; (c) 1 day; (d) 1 week.

  • 5/21/2018 Infark Jantung

    27/79

    The evolution of an inferior wall

    myocardial infarction, as seen in lead III

    of a 55-year-old white male. Note that

    the admission tracing shows only ST

    elevation. A Q wave is beginning to

    form by 1 hour, and ST elevation is onthe way down. By 24 hours, Q wave

    formation is complete,

    and the T wave is fully inverted. By 1

    year, a pathologic Q wave is the only

    remaining evidence of infarction.

  • 5/21/2018 Infark Jantung

    28/79

    Reciprocal Changes

    II, III, aVFI, aVL, V leads

  • 5/21/2018 Infark Jantung

    29/79

    Mid LAD occlusion

    after the first septal

    perforator (arrow) ECG : large anterior MI

  • 5/21/2018 Infark Jantung

    30/79

  • 5/21/2018 Infark Jantung

    31/79

    Proximal large RCA occlusion

    ST elevation in leads II, III, aVF, V5, and V6

    with precordial ST depression

  • 5/21/2018 Infark Jantung

    32/79

    Small inferior distal RCA occlusion

    ECG changes in leads II, III, and aVF

  • 5/21/2018 Infark Jantung

    33/79

  • 5/21/2018 Infark Jantung

    34/79

    7/31/2014 34

    ST Elevasi

  • 5/21/2018 Infark Jantung

    35/79

    Fase Evolusi Lengkap

    Elevasi ST spesifik : konveks ke atas

    T negatif dan simetris

    Q patologis

  • 5/21/2018 Infark Jantung

    36/79

  • 5/21/2018 Infark Jantung

    37/79

    7/31/2014 37

    Qs Patologis

  • 5/21/2018 Infark Jantung

    38/79

    7/31/2014

    Early Repolarisasi

  • 5/21/2018 Infark Jantung

    39/79

    Kasus 1

    Laki-laki, usia 50 tahun

    Nyeri dada semakin memberat sejak 7 jam sebelummasuk rumah sakit

    Riwayat nyeri sebelumnya (-) FR : merokok, HT dan DM tidak diketahui

    Riw Keluarga : PJK (+)

    PF : CM, TD=140/90 mmHg Cor dan Pulmo : dalam batas normal Abdomen : dalam batas normal

    Ekstremitas : edema -/-

  • 5/21/2018 Infark Jantung

    40/79

    Kasus 1

  • 5/21/2018 Infark Jantung

    41/79

    Interpretasi EKG ?

    a. STEMI Anterior dan NSTEMI

    Inferior

    b. STEMI Anteroseptal dan OMI

    Inferior

    c. STEMI Anteroseptal

    d. NSTEMI Inferior

  • 5/21/2018 Infark Jantung

    42/79

    STEMI Anteroseptal

    Terdapat perubahan pada segmen ST berupa elevasiyang merupakan terjadinya acuteinjury dianteroseptal ( leads V1-V4)

    Dengan atau tanpa perubahan resiprokal berupadepresi segmen ST pada sandapan inferolateral

    Gamb EKG : Acute Injury pada sandapan V1-V3 :

    Elevasi segmen ST upsloping

    Gel T yang tinggi

    Perubahan resiprokal pada sandapan II,III-aVF

  • 5/21/2018 Infark Jantung

    43/79

    Kasus 2

    Laki-laki, 36 tahun

    Nyeri dada hebat sejak 40 menit sebelum

    datang ke IGD rumah sakit

    FR : tidak jelas. Kadar lipid belum diperiksa

    PF : CM. TD