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ACS NSTEMI KILLIP II LAPORAN KASUS

(INTERMEDIET RISK), T

DENGAN ADHF DAN


DISUSUN OLEH
PAROXYSMAL AF
LIA PRAMITA,SKED

PEMBIMBING Sp

dr. Arinta Setyasari, Sp. JP

PEMBIMBING GP

dr. Bunga
ANAMNESIS
BUSINESS STARTUP Write a Plan
NYERI DADA memberat ± This is a placeholder. Type
3 hari SMRS, nyeri di Your text here
dada kiri (diitusuk-tusuk/ SESAK hampir ± 4 bulan,
ditimpa beban) menjalar
sampai ke bahu kiri dan
memberat ± 5 hari SMRS.
Muncul saat aktivitas berat
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punggung, muncul saat seperti berjalan dan menaiki This is a placeholder. Type
Your text here
mandi atau aktivitas tangga, berbaring, dan
ringan, berkurang saat pasien lebih nyaman tidur
istirahat. saat posisi badan setengah NYERI PERUT seperti
duduk, tidur menggunakan ± Marketing
diremas ± 3Research hari SMRS,
5 bantal. Sering terbangun terasa
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dan gelisah saat malam hari. Your text
disertai here dan
mual,
keringat dingin, mudah lelah
muntah, terasa panas di
, sering pingsan , nyeri
kepala bagian belakang dan kerongkongan, dan
depan. bengkak pada kedua Set Business
kadang nyeri Goals
saat
tungkai,. menelan.
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ANAMNESIS Write a Plan
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Pasien mempunyai riwayat Your text here

penyakit jantung, hipertensi dan Pasien memiliki pola makan yanng


pernah disarankan untuk
melakukan PCI, namun pasien
Findmengomsumsi
tidak sehat, Investors
makanan berminyak seperti
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menolak. Riwayat hepatitis ± 2 gorengan-gorengaYour dan textpasien
here tidak
tahun yang lalu rutin berolahraga.

Marketing Research
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Tidak ada anggota keluarga pasien
yang mengalamai keluhan atau
penyakit seperti pasien.
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PEMERIKSAAN FISIK
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Keadaan Umum : Tampak Sakit sedang Temuan abnormal This is a placeholder. Type
Kesadaran : Compos Mentis Mata : CA(+/+) Your text here
Berat Badan : 52 kg Leher : hepatojugular refluks (+), JVP
Tinggi Badan : 160 cm 5 + 4 cm H2O Find Investors
Status Gizi : Normal (BMI: 20,31) Paru : ronkhi basah (+/+)
Tekanan Darah : 140/100 mmHg This is a placeholder. Type
Jantung : Batas pinggang jantung pada
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Denyut Nadi : 76 x/menit, Ireguler ICS III linea parasternalis sinistra, batas
Frekuensi Napas : 27 x/menit jantung kanan pada ICS III linea
Temperatur : 36,7’C
Saturasi O2 : 98% Marketing Research
parasternalis dextra, batas jantung kiri
pada ICS VI linea Axillaris Anterior, kesan
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melebar ke lateral Your text here
Abdomen: nyeri tekan (+) di epigastrium
dan kuadran kanan atas, hepar dan
limpa tidak teraba
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Ekstrimitas : edema piting pada tungkai
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+/+, CRT <2 detik Your text here
PEMERIKSAAN
BUSINESS STARTUP PENUNJANG
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Hemoglobin : 12,3 g/dl Creatinin : 0,7 mg/dl
Eritrosit : 4,6 x 106/µl Troponin I : 0,03 ng/ml
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Trigliserida : 56 mg/dl
Leukosit : 7000/µl This is a placeholder. Type
Your text here
Hematokrit : 36,7 % LDL Kolesterol : 82 mg/dl
Trombosit : 203. 000/µl Gula Darah Sewaktu : 103 mg/dl
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PT : 14,9 detik This is a placeholder. Type
MCV : 79,3 fl Your text here

MCH : 26,6 pg APTT: 26,4 detik


MCHC : 33,5 g/dl INR : 1,19 Set Business Goals
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RDW : 15,9 % Your text here
BUSINESSPEMERIKSAAN
STARTUP PENUNJANG
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BUSINESSPEMERIKSAAN
STARTUP PENUNJANG
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Irama : Irama sinus


Frekuensi: 83 bpm regular Find Investors
Axis : Normal (tidak ada deviasi)
ThisIrama sinusType
is a placeholder. dengan
Gelombang P : Normal Your text here83 bpm
frekuensi
PR Interval : Normal regular, left
Kompleks QRS : Normal ventrikel
Interval RR : Regular Marketing
hipertrofi, Research
dengan
RVH/LVH : LVH T inversi
This di lead
is a placeholder. Type II,
Segmen ST : Normal III,Your
AVF, text V5,
here V6.
Gelombang T : T inversi di lead II, III,
aVF, V5, V6
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BUSINESSPEMERIKSAAN
STARTUP PENUNJANG
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Tulang dan jaringan lunak intak,
tidak tampakThis fraktur. CorType
is a placeholder.
Your text here
membesar ke lateral kiri
kranialisasi (+), kalsifikasi aorta
(-) sinus kiri kanan tajam dan
Marketing
diafragma kiri kanan dalam Research
batas
normal. Hilus paru tampak
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a placeholder. Type
Your text here
corakan bronkovaskular
bertambah, tampak infiltrat di
kedua paru
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Kesan kardiomegali Goals
curiga
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dengan edema Your text here
paru.
BUSINESS
RESUME STARTUP
MEDIS Write a Plan
• Pr (61 th) nyeri dada sebelah kiri yang memberat ± 3 This
hariis a placeholder. Type
SMRS, seperti
Your text here
ditusuk/ditimpa beban, menjalar sampai ke punggung, muncul saat
aktivitas ringan, berkurang saat istirahat.
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• Sesak yang memberat ± 5 hari SMRS, dirasakan saat Thisberjalan, menaiki
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tangga, berbaring. tidur dengan ± 5 bantal, sering terbangun di malam
hari, mudah lelah, kadang keringat dingin, dan pingsan. Ditemukan
edema kedua tungkai
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• Tekanan darah 140/100 mmHg, denyut nadi 76 x/ This is a placeholder. Type
menit regular,
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frekuensi napas 27 x/menit. Temperatur 36,7oC.

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BUSINESSRESUME
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MEDIS..... Write a Plan
• Pada mata didapatkan konjungtiva anemis. This is a placeholder. Type
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• Pada leher pasien didapatkan JVP 5+4 cmH2O distensi vena (+), hepatojugular
reflex (+).
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• Pemeriksaan thorax pada inspeksi tampak sela iga melebar, terdengar rhonki pada
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lapang paru. Your text here

• Pada perkusi jantung kesan melebar ke lateral.

• Auskultasi jantung pasien tidak didapatkan murmur. Pada Marketing


palpasi abdomen Research
didapatkan nyeri tekan (+) di epigastrium, dan kuadran kanan atas. This is a placeholder. Type
Your text here
• Pada pemeriksaan laboratorium didapatkan peningkatan troponin I (0,03 ng/dl),

• Hasil EKG ditemukan left ventrikel hipertrofi , dengan gelombang T inversi di lead
II, III, AVF, V5, V6. Set Business Goals
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• Hasil dari foto thorax ditemukan kardiomegali, dan edema paru.
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DIAGNOSIS Write a Plan
Diagnosa Klinis: ACS NSTEMI Killip II (Intermediet
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risk), ADHF prec. sicter ACS

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Diagnosis Anatomi: Iskemik inferior lateral
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Diagnosis Etiologi: Hipertensi, CAD


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Diagnosis Tambahan: AF Paroksismal, HHD

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BUSINESSPENATALAKSANAAN
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NON FARMAKOLOGI This is a placeholder. Type
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FARMAKOLOGI
1.Bed rest posisi kepala 30o
2. Diet rendah garam < 2 gram/hari 1. Injeksi Lovenox Find
2 x 0,6Investors
cc
3. Restriksi cairan 1,5 liter/hari 2. Injeksi Furosemid 2 x 40 mg
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4. Target balance cairan 500 cc- 3. PO. Aptor 1 x 100 mg Your text here
1000cc/24 jam 4. PO. Clopidogrel 1 x 75
5. PO. Nopril 1 x 5 mg
6. PO. Bisoprolol Marketing
1 x 1.25 mg Research
7. PO. Nitrokaf 2 x 2.5Thismg sublingual
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8. PO. Atorvastatin 20 mgYour text here
9. PO. Lansoprazole 1 x 30 mg

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Quo ad vitam : Dubia ad bonam Your text here
Quo ad sanactionam : Dubia ad malam
Quo ad functionam : Dubia ad malam
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PEMBAHASAN KASUS T
BUSINESS
SKA STARTUP Write a Plan
STEMI, This is a placeholder. Type
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NSTEMI,
UAP Find Investors
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Algoritma evaluasi dan tatalaksana SKA1


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NSTEMI  depresi segmen ST ≥ 0,5 mm di V1-V3 dan ≥ 1 mm di sandapan
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lainnya. Selain itu dapat juga dijumpai elevasi segmen ST tidak persisten (<20
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menit), dengan amplitudo lebih rendah dari elevasi segmen ST pada STEMI.

Inversi gelombang T yang simetris ≥ 2 mm semakin memperkuat dugaan


NSTEMI. Set Business Goals
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BUSINESS STARTUP
BIOMARKER Kadar troponin pada pasien infark miokard akut
Write3 a– 4Plan
meningkat di dalam darah perifer jam setelah
JANTUNG awitan infark dan menetap sampai 2 minggu
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meningkat dalam
waktu 4 hingga 6
jam, mencapai
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saat 12
jam, danType
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sampai 2 hari
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Pada hasil EKG pasien ini ditemukan gelombang T inversi (tanpa ST elevasi)
Settroponin
pada sadapan II, III, aVF, V5 dan V6, dengan peningkatan Business Goals0,03
sebesar
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ng/ml, sehingga diagnosis NSTEMI inferior lateral dapat ditegakkan.
Your text here
BUSINESS STARTUP Write a Plan
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Tabel Skor TIMI untuk APTS dan IMA-NEST Your text here
Parameter
Usia > 65 tahun 1
Lebih dari 3 faktor resiko 1
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Angiografi koroner sebelumnya menunjukkan 1 PadaThis
pasien ini, memiliki
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stenosis > 50 % skor TIMI 3
Intermediet risk.
Penggunaan aspirin dalam 7 hari terakhir 1
Setidaknya 2 episode nyeri saat istirahat dalam 24 1
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jam terakhir
Berdasarkan Klasifikasi
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Deviasi ST > 1 mm saat tiba 1 Your text here
GRACE pasien ini memiliki
Peningkatan biomarka jantung (CK, troponin) 1 skor 126 sehingga
*Faktor resiko : hipertensi, DM, merokok, riwayat dalam keluarga, dikategorikan dalam
dislipidemia Set Business
intermediet risk Goals
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Rekomendasi
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obat anti-
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iskemis fase
akut pada ACS This is a placeholder. Type
Your text here
NSTEMI

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This is a placeholder. Type
Your text•hereBeta bloker
• Calcium
Channel
Marketing Research Bloker (CCB)
• Nitrat
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• Dual
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antiplatelet
• Antikoagulan
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• Statin
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BUSINESS STARTUP
Penilaian faktor risiko terjadinya stroke pada AF (Skor
CHA2DS2-VASc)6 Write a Plan
Tabel 2.8. HAS-BLED Score untuk
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HURUF KONDISI SCORE
risiko perdarahan Your text here
C Gagal Jantung Kongestif (1) 1
H Hipertensi (1) 1 Hipertensi tidak terkontrol 0

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A Usia 65-74(1) 0 Fungsi ginjal/hati abnormal 0

A Usia ≥ 75 (2) 0 Stroke 0


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D Diabetes mellitus (1) 0 Predisposisi perdarahan 0
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S Adanya Stroke atau TIA (2) 0 Labil INR 0

VA Penyakit vaskular (1) 1 Usia >65 tahun 0

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Sc Jenis Kelamin :Perempuan (1) 1 Konsumsi obat (aspirin, NSAID) atau alkohol 1

TOTAL 4 Total 1
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Pada pasien didapatkan hasil CHA2DS2-VASc ≥ 2 yang mana direkomendasikan


untuk pemberian antikoagulan oral dan HAS-BLED score 1. maka tidak perlu
perhatian khusus, pengawasan berkala Set Business Goals
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BUSINESSGAGAL
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ADHF  suatu kondsi dimana
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perburukan klinis dari gagal jantung
GAGAL JANTUNG  adanya
gangguan struktural dan fungsional
dari jantung. Dapat berupa Find Investors
Gejala klinis yang timbul dapat timbul
secara tiba-tiba ataupun secara
gangguan fungsi diastolik atau perlahan This is a placeholder. Type
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sistolik, gangguan irama jantung,
atau ketidaksesuaian preload dan Penyebab dekompensasi adalah
afterload. volume overload, ketidakpatuhan
 tipe sistolik dengan penurunan Marketing Research
minum obat (poor compliance),adanya
ejection fraction (reduced This is a placeholder. Type
infark miokard, ritme jantung Your textyang
here
ejection fraction/rEF) irreguler, infeksi dan penyakit tiroid
 tipe diastolik dengan ejection
fraction baik (preserved ejection
fraction/pEF) Set Business Goals
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Klasifikasi
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Klasifikasi berdasarkan kapasitas fungsional (NYHA)

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Memiliki risiko tinggi untuk berkembang menjadi gagal Tidak terdapat batasan dalam melakukan aktifitas fisik. Aktifitas
jantung. Tidak terdapat gangguan struktural atau fungsional fisik sehari-hari tidak menimbulkan kelelahan, palpitasi atau
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atau gejala
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Stadium B Kelas II Your text here
Telah terbentuk penyakit struktur jantung yang Terdapat batasan aktifitas ringan. Tidak terdapat keluhan saat
berhubungan dengan perkembangan gagal jantung, tidak istrahat, namun aktifitas fisik sehari-hari menimbulkan
terdapat tanda atau gejala Marketing Research
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Gagal jantung yang simtomatik berhubungan dengan Terdapat batasan aktifitas bermakna.YourTidak
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terdapat keluhan
penyakit struktural jantung yang mendasari saat istrahat, tetapi aktfitas fisik ringan menyebabkan kelelahan,
palpitasi atau sesak
Stadium D Kelas IV
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Penyakit jantung struktural lanjut serta gejala gagal jantung Tidak dapat melakukan aktifitas
This is fisik tanpa keluhan.
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yang sangat bermakna saat istrahat walaupun sudah gejala saat istrahat. Keluhan meningkat Your text
saathere
melakukan aktifitas
mendapat terapi medis maksimal (refrakter)
Klasifikasi
BUSINESSForrester
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Kongesti (-) This isKongesti
a placeholder.(+)
Type
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edema paru, orthopnoe /
PND, edema perifer,
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vena jugular,
hepatomegaly, asites,
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refluks Yourhepatojugular
text here

Hipoperfusi (-) Warm - Dry Marketing


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Hipoperfusi (+) Cold – Dry Your text
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– Wet
Akral dingin, oliguria,
delirium, pusing,
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Kompensasi
Neurohorm
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onal
Terhadap
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Curah
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Gagal

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BUSINESS
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Kriteria Minor
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Paroxysmal nocturnal Edema ekstremitas This is a placeholder. Type
KRITERIA FRAMINGHAM
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dyspnea
Distensi vena leher Batuk malam hari
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Hepatojugular refluks Dyspnea d’effort pasien ini memiliki 5
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kriteria mayor
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Peninggian vena jugularis Hepatomegaly dan 2 kriteria minor
Kardiomegali Efusi pleura
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1/3 dari normal

Edema paru akut Takikardia


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ALUR DIAGNOSIS GAGAL
JANTUNG

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ALUR DIAGNOSIS
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TERAPI FARMAKOLOGI
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Pada pasien ini fibrilasi
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atrium yang dialami
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adalah fibrilasi atrium
paroksismal
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KESIMPULAN Your text here

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Berdasarkan hasil anamnesis, pasien datang dengan keluhan kedua kaki bengkak,
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sesak napas dan nyeri dada. Sesak napas dan nyeri dada dirasakan melakukan
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aktivitas. Hasil pemeriksaan fisik dan penunjang foto thorax (kardiomegali, dan
curiga edema paru). Diagnosis klinis yaitu ACS NSTEMI Killip II (Intermediet risk),
dengan ADHF prec. sicter ACS dan Paroxysmal AF,
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1. Pedoman Tatalaksana Sindrom Koroner Akut. Edisi Keempat. Perhimpunan Dokter Spesialis Kardiovaskular

2. BUSINESS STARTUP
Indonesia. 2018
Lilly LS. Acute Coronary Syndrome. Rhe JW, Sabatine MS and Lilly LS editor in: Write a Plan Heart Disease:
Pathophysiologyof
A Collaborative Project Of Medical Students And Faculty. 6th Ed. Philadelphia: Lippincott Williams & Wilkins.
2016 This is a placeholder. Type
3. ESC Guidelines for the management of acute coronary syndromes in patients presenting Your text here
without persistent ST-
segment elevation. Europe Heart Journal. 2016;37(3):267–315
4. Perhimpunan dokter spesialis kardiovaskular Indonesia 2015. Pedoman tatalaksana sindrom koroner akut.
PERKI; 2015 Find Investors
5. Pedoman Tatalaksana Fibrilasi Atrium. Edisi Pertama. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia
2014. This is a placeholder. Type
6. Deirdre A.L. Use of the CHA2DS2-VASc and HAS-BLED scores to Aid Decision Making Yourfor
textTrombophylaxis
here in
Nonvalvular Atrial Fibrilation. CirculationAHA. UK. 2012
7. Griffin, Brian; Kapadia, Samir; Rimmerman, Curtis. Cardiology Board Review Second Edition. Cleveland Clinic;
2013
8. Joseph SM, Cedars AM, Ewald GA, Geltman EM, Mann DL. Acute Decompensated Marketing Research
Heart Failure: Contemporary
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Nikoo MH, Amir A, Jorat MV. LBBB: State-of-the-Art Criteria. Int Cardio Res J. 2013 Jun; 7(2): 39-40.
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13. American Heart Association. 2013 ACC/ AHA Guideline on the Assesment of Cardiovascular Risk. Circulation.
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