2.3 referring my patient - dr. arief wibisono sp.jp (slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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Arief Wibisono , MD
What Do I Have to Dofor Reffering My Patient for
Better Treatment
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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%
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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ESC Guidelines
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
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REFERRAL AND PCI HOSPITALS
1. Symptom onset
2. Medical contact
3. ECG
4. Decision
5. Door to needle
6. Door to departure
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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The prehospital 12-lead ECG is a
critical tool in identifying and
diagnosing a STEMI patient and
shortening the time to treatment
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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ECG Finding
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8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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Treatment Time Goal
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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Delays in diagnosis and risk stratification
Support and training for health professionals at :
• Interpretation of d ECGs
• ACLS
• Workshop and courses esp ACS
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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• Improved lines of communication and health
professional roles and responsibilities
• Interventional cardiology centres operating as
24/7
Lack of system co-ordination and integration
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8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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Specific needs for high-risk groups, including
disadvantaged population groups
Spreading of outreach cardiologistImprove the confidence and knowledge of GP in peripheral
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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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
8/18/2019 2.3 Referring My Patient - Dr. Arief Wibisono Sp.jp (Slide)
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"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
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