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disease
Objective :
Indentify common cardiac problem
Understand approach in patient with heart
disease
Able to formulate complete cardiac
diagnosis
Understand basic ECG
Unterstand ECG in ACS patient
Understand acute coronary syndrome
Test case
Heart disease
Global burden
Mostly identify as CHD Atherosclerotic
heart disease
Other common cardiac problem:
Congenital heart disease
Valvular heart disease
Arrhytmias
Tumor of the heart
Misc.
Approach to disease :
Good history
Proper physical examination :
Inspection
Palpation
Percussion
Auscultation
Accurate diagnostics:
Non invasive
Invasive
History :
Identify complaints spesific to heart disease :
Dyspnea.
Chest pain.
Not always
represents
coronary
heart
Dyspnea :
Dyspnea
during
exercise.
Ortopnea
Anginal
equivalen
t.
Inspection :
Posture
Ictus cordis
Percussion :
Identify cardiac borders
Auscultation :
Identify normal heart sound.
Identify cardiac mur-mur.
Identify split.
Identify click.
Identify opening snap.
Identify extrasystole.
Identify gallop
Understand projections :
Normal heart sound :
M1 > M2 at apex (mitral / tricuspid)
M2 > M1 at base (aortic / pumonal)
Mur2 :
Systolic mur2 (Occurs prior to 1st heart
sound)
Diastolic mur2 (Occurs after 1st heart sound)
Mur2 Cont :
Things to consider:
Differentiate it with venous hum.
Amplitudes (Grade).
Radiation.
Cresendo.
Decresendo.
Cresendo-decresendo.
Spit:
Commonly seen in normal people.
Identified spesifically in pulmonary stenosis.
Opening snap :
Incomplete opening of the valve.
Identified in MS
Click :
Determines artificial or metal valve.
Gallop :
Gallop S3.
Gallop S4 (Spesifically pathognomonic for heart
failure).
Elektrokardiogram (EKG)
ECG as done
Is a recording
by Willem Einthoven
of electrical activity of heart conducted thru
ions in body to surface
Arah Defleksi
Arah impuls
Menuju Elektroda
(positif)
Arah defleksi
Ke atas (positif)
Menjauhi Elektroda
(negatif)
Ke bawah
(negatif)
Menuju kemudian
menjauhi Elektroda
Bifasik
GELOMBANG P
Menggambarkan aktivitas depolarisasi atrium
kanan dan
kiri ( dari kanan ke kiri dan ke bawah )
Karakteristik EKG :
Arah gelombang P normal :
Selalu positif di II dan selalu negatif di aVR.
Tinggi : kurang dari 3 mm (2,5 mm)
Durasi ( lebar ): kurang dari 3 mm (0,10
detik)
Kepentingan :
1. Menandakan adanya aktivitas atrium
2. Menunjukkan arah aktivitas atrium
3. Menunjukkan tanda-tanda hipertrofi
atrium
GELOMBANG Q
DEFLEKSI KE BAWAH YANG PERTAMA KOMPLEKS QRS
GELOMBANG R
GELOMBANG S
adalah defleksi negatif sesudah
gelombang R
Menggambarkan fase depolarisasi
ventrikel
Nilai normal
: akan dibahas dalam
bagian
tentang hipertrofi
Bentuk normal : akan dibahas dalam
bagian
B.B.B
Kepentingan : hampir sama dengan
gelombang R
GELOMBANG T
Menggambarkan fase repolarisasi ventrikel
Arah normal :
. Sesuai dengan arah gelombang utama kompleks
QRS
. Positif di sandapan II
Amplitudo normal :
< 10 mm di sandapan dada
< 5 mm di sandapan ekstremitas
Minimum 1 mm
Abnormal :
1. Menandakan adanya iskemia/ infark
2. Menandakan adanya kelainan elektrolit
GELOMBANG U
Asal usulnya tidak diketahui dan paling
jelas
terlihat di sandapan dada V1 - V4
Normal :
. kurang dari 2 mm
. Selalu lebih kecil dari gelombang T di
sandapan II
Abnormal :
Bila amplitudo U > 2 mm atau >T,
menandakan adanya hipokalemia
Gelombang U yang terbalik terdapat pada
iskhemia dan hipertrofi
EKG PADA
HIPOKALEMIA
INTERVAL PR
INTERVAL QRS
menggambarkan lamanya aktivitas depolarisasi
ventrikel
.
.
.
INTERVAL QT
. Jarak antara permulaan gelombang Q sampai
.
.
V.A.T.
= Ventricular Activation Time = defleksi
Intrinsik
Jarak antara permulaan gelombang Q ke puncak
gelombang R
Menggambarkan waktu yang diperlukan oleh
impuls untuk menyebar dari permukaan dalam
ventrikel (endokard) ke permukaan luar ventrikel
(epikard).
Nilai normal :
di V1 V2 < 0,03 detik
di V5 V6 < 0,05 detik
Kepentingan :
V.A.T yang memanjang terdapat pada B.B.B,
hipertrofi
ventrikel dan lain-lain.
TITIK J ( = RS T JUNCTION)
Adalah titik di mana kompleks QRS berakhir
dan segmen ST dimulai.
Kepentingan :
Sebagai titik pegangan untuk menentukan
adanya deviasi segmen ST
SEGMENT)
Rule of 300
Take the number of big boxes between
neighboring QRS complexes, and divide this
into 300. The result will be approximately
equal to the rate
Although fast, this method only works for
regular rhythms.
www.uptodate.com
(300 / 6) = 50
bpm
www.uptodate.com
(300 / ~ 4) = ~ 75
bpm
coronary arteries
Ischemia occurs when blood supply to
tissue is deficient,Causes increased lactic
acid from anaerobic metabolism
Often accompanied by angina pectoris
(chest pain)
Levine Sign Classic sign for anginal pain
13-79
Noted as cardiovascular
emergency.
Classification :
UNSTABLE Angina
NSTEMI
STEMI
Physical examination :
Systematic head to toe approach
Relates to complications :
Heart failure.
Soft S1, cardiac mur-mur
Rhales
Increased JVP
Edema of the extremities
Cardiac arrhytmias.
Irregular heart Rhythm
Diagnostic workups !
Treatment Approach :
Agresive
Anti Platelet
(double anti
platelet
recommended)
B-Blockers
ACE/ARB
Heparin / LWMH
Statin
Morfine
Heart failure.
Patient
unresponsive with
conservative
treatment
Reperfusion :
Indicated in STEMI :
Thrombolytic treatment
Stretokinases.
Atleptase.
PCI (< 12 Hours, >12 Hours)
CABG :
Patient with 3 vessels disease
Patient with 2 vessels disease and had diabetes
Prognosis :
Anatomic Groups
(Summary)
Cardiac diagnosis :
Etiology
Anatomy
Physiology
Functional class.
Test Case :
Case 1. Mrs A. 40 Yo F.
cc: Dyspnea.
History of: reccurent throat infection, (-)
hypertension or diabetes.
PE:
Edema of the extremities.
Diastolic rumble 3/6 at apex.
Systolic mur2 at 4th ICS, midsternal line
Test Case :
Case 1. Mrs A. 40 Yo F.
cc: Dyspnea.
History of: reccurent throat infection, (-)
Diagnostics :
ECG : STEMI
Troponin I (+)
WD : /
Test case 2:
Case 1. Mr A. 30 Yo M.
cc: Dyspnea.
History of: (-)reccurent throat infection , (-)
knowlegge
Prof 1:7.
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