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Tutorial 3 Skenario D
Tutor : dr. Hibsah Ridwan, M.Sc
Moderator : Rudi Anandra
Sekretaris meja : Alham Wahyudin
Sekretaris papan : Agus Susanto
Waktu : 13.00 15.30; 19 Januari 2009

Skenario D

Nyonya Ayin, 58 tahun, datang ke UGD rumah sakit dengan keluhan jantung
berdebar-debar. Nyeri disangkal, sesak disangkal, mual dan muntah di sangkal. Dua
minggu yang lalu Nyonya Ayin mengalami nyeri dada hebat dan dinyatakan
menderita agina pectoris, namun karena kondisinya stabil, dia dipulangkan dan diberi
obat-obatan isosorbide dynitrate dan asam salisilat.

Pemeriksaan Fisik :

Keadaan umum : kesadaran compos mentis

TD 120/80 mmHg, denyut nadi 64x./menit tidak teratur, RR 18 x/menit.

Pemeriksaan Jantung : JVP 5-2 cmH2O, denyut jantung 76x/menit, S1 dan S2

terdengar jelas, irregular, gallop (-), murmur(-)

Pemeriksaan Paru : dalam batas normal

Ekstremitas : Edema

Gambaran EKG : AV Block grade 3

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Klarifikasi Istilah

1. Berdebar-debar : palpitasi ; denyut jantung yang tida teratur yang bersifat

subjektif
2. Sesak : penyempitan saluran pernapasan
3. Mual / nausea : sensai tidak menyenangkan yang secara samar mengacu pada
epigastrium abdomen untuk muntah
4. Agina pectoris : nyeri dada parosismal terutama sebelah kiri, yang
diakkibatkan gangguan suplai oksigen ke jantung
5. Asam salisilat : kristal asam yang digunakan sebagai keratoliti dan keratoplastik
topika natrium salisilat
6. Edema : pengumpulan cairan secara abnormal dalam ruang jaringan
interseluler tubuh
7. Gallop : bunyik jantung ke3 yang nyata pada penderita sakit jantung
disebabkan perubahan patologi gagalnya pengisian ventrikel saat diastolik.
8. AV block : gangguan konduksi impuls jantung dari atrium ke ventrikel yang
disebabkan oleh hambatan pada jaringan penghubung atrium ventrikuler

Indentifikasi Masalah

1. Ny.Ayin (58 th) datang ke UGD dengan keluhan jantung berdebar-debar

2. Dua minggu yang lalu Nyonya Ayin mengalami nyeri dada hebat dan
dinyatakan menderita angina pectoris, namun kondisinya stabil dia
dipulangkan dan diberi obat-obatan : isosorbide dynitrate dan asam salisilat
3. Pemeriksaan fisik : denyut nadi 64x/menit, tidak teratur
4. Pemeriksaan jantung : S1 & S2 terdengar jelas, irregular
5. Gambaran EKG : AV block grade 3

Analisis Permasalahan
1. Apa yang terjadi (penyebab) dengan jantung Ny.Ayin yang berdebar-debar ?
2. Bagaimana hubungan umur 58 tahun dengan jantung berdebar-debar ?
3. Mengapa jantung Ny.Ayin berdebar-debar, sedangkan ia tidak mengalami nyeri
dada, mual dan sesak nafas ?
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4. Adakah hubungan jantung Ny.Ayin berdebar-debar dengan agina pectoris 2

minggu lalu ?
5. Bagaimana mekanisme jantung berdebar-debar pada Ny.Ayin ?
6. Apa yang menyebabkan agina pectoris ?
7. Bagaimana mekanisme terjadinya agina pectoris ?
8. Apa faktor resiko dari agina pectoris ?
9. Jenis-jenis agina pectoris ? (Jelaskan perbedaannya !)
10. Farmakodinamik dan farmakokinetik dari isosorbide dinitrat ?
11. Farmakodinamik dan farmakokinetik dari asam salisiliat ?
12. Apa yang terjadi jika agina pectoris ini tidak segera diobati ?
13. Bagaimana seharusnya tindakan dokter dalam menangani angina pectoris
yang diderita Ny.Ayin ?
14. Mekanisme dan interpretasi denyut nadi 64x/menit tidak teratur ?
15. Mekanisme dan interpretasi bunyi jantung S1 dan S2 terdengar jelas, irregular,
76x/menit ?
16. Mengapa terjadi defisit pulsasi pada Ny. Ayin ?
17. Bagaimana interpretasi dari gambaran EKG Ny. Ayin ; AV Block grade 3 ?
18. Bagaimana mekanisme terjadinya AV Block grade 3 ?
19. Mengapa terjadi AV Block grade 3 ?
20. Bagaimana sistem konduksi jantung pada keadaan AV Block grade 3 ?
21. Bagaimana gambaran EKG yang normal ?
22. Bagaimana gambaran AV Block ?
23. Bagaimana gambaran AV Block grade 3 ?
24. Bagaimana gambaran EKG dari agina ?
25. Apa saja macam-macam AV Block ?
26. Bagaimana differential diagnosisnya ?
27. Bagaimana diagnosis kerja ?
28. Bagaiamana epidemiologinya ?
29. Bagaimana etiologinya ?
30. Bagaimana patogenesisnya ?
31. Bagaimana pemeriksaan penunjangnya ?
32. Bagaimana penatalaksanaannya ?
33. Bagaimana tindakan preventif dan promotifnya ?
34. Bagaimana komplikasinya ?
35. Bagaimana prognosisnya ?
36. Bagaimana level of competency ?

Kerangka Konsep

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Faktor resiko &

Atherosclerosis
predisposisi

Ischemia

Infark

Otot jantung
rusak

Jantung berdebar-
Gangguan debar dan defisit
hantaran pulsasi

Kontraksi
AV Block ventrikel tidak
teratur

Hipotesis
Ny.Ayin mengalami jantung berdebar-debar karena adanya AV block

Normal Conduction

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Definition heart block (The Merck Manual)

Heart Block is a delay in the conduction of electrical current as it passes through the
antrioventricular node, bundle of His or both bundle branches, all of which are
located between the atria and the ventricle.

Blok Atrioventrikel

Berbagai keadaan yang dapat menurunkan kecepatan konduksi impuls melalui berkas AV:

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o Iskemia nodus AV.insufisiensi koroner dapat menyebabkan iskemik nodus AV

sehingga dapat menyebabkan iskemia miokardium
o Kompresi berkas AV o/ jaringan parut atau o/ jantung yang mengalami
perkapuran
o Inflamasi nodus AV; misalnya pada difteri dan demam rematik
o Rangsangan yang kuat o/ nervus vagus

Symptom AV block

hemodynamic disturbance, weakness, near syncope, syncope ,dizziness, asphyxia, angina(in elder
patient and with ischemic condition) sometimes chest pain is silent.

Types of heart block (wikipedia)

A heart block can be a blockage at any level of the electrical conduction system of the heart.

Blocks that occur within the sinoatrial node (SA node) are described as SA nodal blocks.
Blocks that occur within the atrioventricular node (AV node) are described as AV nodal
blocks.

Blocks that occur below the AV node are known as infra-Hisian blocks (named after the
bundle of His).

Blocks that occur within the left or right bundle branches are known as bundle branch
blocks.

Blocks that occur within the fascicles of the left bundle branch are known as hemiblocks.

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First degree AV block

Characterized by a delay of the impulse in the AV node region.

Heart rate is usually normal and rhythm may be regular or irregular.
There is a P for every QRS complex and the most notable finding is a prolonged but constant
P-R interval.

Second degree AV Block

Is more than just a delayed impulse at the AV node. The impulse is delayed and blocked
resulting in both conducted and non-conducted P waves on the ECG.
This translates into some P waves that are followed by a QRS complex and some P waves
that occur without a subsequent QRS complex. .
There are two types of second-degree AV block that are differentiated by the character of
the P-R interval:
Mobitz type I (or Wenkebach): The P-R interval gradually lengthens until a QRS-T is dropped,
thus the P-R interval is variable. This type is a common finding in the normal horse (and can
also occur as a result of digitalis treatment or electrolyte imbalance). It is abnormal in cattle.

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Mobitz type II: The P-R interval is constant before and after the dropped beat.

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Third degree AV block

Impulse is completely blocked at the AV node region.

The P wave and QRS complex are dissociated. In awake patients, this rhythm usually
indicates disease of the A-V node.
Interval of P R : 0.25 0. 45 second
If a ventricular escape rhytm is present, the patient may have adequate cardiac output to
maintain consciousness.
This arrhythmia often necessitates treatment. A pacemaker can be placed.

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Management

Treatment for third degree AV block

1) Initial efforts should focus on assessing the need for temporary pacing and initiating the
pacing. (Atropine, transcutaneous pacing, and catecholamine infusions (dopamine or
epinephrine)
2) Once the patient has been stabilized, a decision must be made regarding permanent
pacemaker implantation.

3) Unless the heart block is due to a medication that can be discontinued or an infectious process
that can be effectively treated, most patients with acquired complete heart block should
receive permanent pacemakers or implantable cardioverter/defibrillators (ie, if a high risk of
sudden cardiac death exists).

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Artificial permanent pacemaker.

The more severe forms of heart block (some second-degree and all third-degree) usually are treated
with an artificial permanent pacemaker.

1. A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural
pacemaker) is a medical device which uses electrical impulses, delivered by
electrodes contacting the heart muscles, to regulate the beating of the heart.
2. The primary purpose of a pacemaker is to maintain an adequate heart rate, either
because the heart's native pacemaker is not fast enough, or there is a block in the
heart's electrical conduction system.

3. Modern pacemakers are externally programmable and allow the cardiologist to select
the optimum pacing modes for individual patients. Some combine a pacemaker and
defibrillator in a single implantable device. Others have multiple electrodes
stimulating differing positions within the heart to improve synchronisation of the
lower chambers of the heart.

4. This type of device typically listens for a pulse from the SA node and sends a pulse to
the AV node at an appropriate interval, essentially completing the connection between
the two nodes.

5. Pacemakers in this role are usually programmed to enforce a minimum heart rate and
to record instances of atrial flutter and atrial fibrillation, two common secondary
conditions that can accompany third degree AV block.

6. The pacemaker can take the place of a diseased sinus node or it can help the heart to
beat despite a blockage in the hearts conduction system. A lead (a thin, coated wire)
is inserted through a vein, and the tip of the lead (called the electrode) is placed in
either the upper or the lower chamber of the heart against, or attached to, the heart's
lining. (For dual-chamber pacemakers, two leads are used - one placed in the atrium
and one placed in the ventricle.) The pulse generator, which encases the electronic
circuitry of the pacemaker, is attached to the lead and placed just under the skin,
usually in the chest.

Treatment may also include medicines to control blood pressure and atrial fibrillation, as well as
lifestyle and dietary changes to reduce risk factors associated with heart attack and stroke.

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People who are eligible for receiving temporary pacemaker:

Patients likely to receive a temporary pacemaker are those who have a high risk of developing A-V
conduction failure. Patients likely to receive a permanent pacemaker include those who have:
Permanent or intermittent A-V block;
Exercise-induced A-V block;
Sinus node dysfunction;
A history of atrial fibrillation, atrial flutter, tachycardia (very rapid heartbeat) associated with
A-V dysfunction, or bradycardia associated with congestive heart failure;
A history of asystole (lack of heartbeat) with fainting;
Recurrent fainting.
Because pacemaker implantation usually is a relatively straightforward, minimally invasive procedure,
there are very few heart patients for whom receiving a pacemaker would be inappropriate.

Consideration after insertion of a pacemaker:

a. A patient's lifestyle is usually not modified to any great degree after insertion of a
pacemaker. There are a few activities that are unwise such as full contact sports and activities
that involve intense magnetic fields.

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b. The pacemaker patient may find that some types of everyday actions need to be modified.
For instance, the shoulder harness of a vehicle seatbelt may be uncomfortable if the harness
should fall across the pacemaker insertion site.

c. Any kind of an activity that involves intense magnetic fields should be avoided. This includes
activities such as arc welding possibly, with certain types of equipment [25], or maintaining
heavy equipment that may generate intense magnetic fields.

d. A 2008 U.S. study has found [26] that the magnets in some portable music player headphones
may interfere with pacemakers when placed in close proximity.

e. Some medical procedures may require the use of antibiotics to be administered before the
procedure. The patient should inform all medical personnel that the patient does have a
pacemaker. Some standard medical procedures such as the use of Magnetic resonance
imaging (MRI) may be ruled out by the patient having a pacemaker.

Complications & Risks of AV Block

Pacemaker Implantation

Any surgical procedure includes the possibility of complicationsthings that can go wrong. Typical
complications for pacemaker implants are not life threatening, but may require a repeat operation or
a longer than normal hospital stay.

Common complications include bleeding, infection, lead dislodgment, and lead or pacemaker
problems following surgery. Complications occur less than 1% of the time. Ask your doctor about
potential complications before your surgery.

Any possible complications are :

The overwhelming majority of pacemaker insertions are successful. Although complications happen
in only 1 to 2 percent of procedures, they can include:

Severe bruising or bleeding;

Formation of blood clots;

Stroke;

Heart attack;

Tearing of a blood vessel;

Puncturing of the lung or heart muscle;

Introduction of air into the space between the lung and chest wall (which could lead to an
embolism);

A lead wire dislodging from the heart;

Infection of the pocket into which the pacemaker was placed; and

Pacemaker malfunction such as loss of capture (i.e., the ability to pace the heart), abnormal
pacing rate, undersensing, and oversensing) are rare occurrences.

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People with pacemakers are at a higher risk of blood infections than people without pacemakers

Prevention from AV Block

Not all arrhythmias are preventable. Practicing heart-healthy living may help to prevent or slow heart
disease, which may help you avoid developing an arrhythmia or slow its progression.

Do

Drink plenty of water - eight to 10 glasses a day

Eat a heart-healthy diet

Eliminate unnecessary stress

Exercise regularly - especially aerobic activity like walking, cycling, jogging, or swimming

Maintain a healthy weight

See your doctor regularly

Don't

Smoke and linger where there is second-hand smoke - smoking is a leading cause of heart
disease
Drink excessive amounts of alcohol, caffeine, or sugary drinks

Ignore symptoms, which may signal heart problems

Rehabilitation of AV Block

Lifestyle measures, particularly dietary factors, are equally important in preventing heart
attacks and must be strenuously adhered to.

Prognosis of AV Block

For patients who using receiving temporary pacemaker:

Although heart block is dangerous, it can be treated effectively with a pacemaker, and it
rarely causes any long-term complications in patients who survive it

The long-term prognosis of the patients was good with 5 and 10 year actuarial survival rates.

Most people with first- and second-degree heart block don't even know they have it.
For people with third-degree block, once the heart has been restored to its normal,
dependable rhythm, most people, and live full and comfortable lives.

For patients who using receiving temporary pacemaker:

They had high risk for heart failure.

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Educational Ethic:

Patients can choose and make a decision regarding pacemaker implants. There is always indication
and contraindication for the treatment. But they can choose after considering their health status and
economic conditions.

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AV Block Treatment

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