Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
64. The Management of Severe Bleeding in Acute Limb Ischemia (ALI) and Coronary Artery Disease (CAD)
1K Bayu K, 2T Wasyanto
1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University Surakarta
2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University / Dr. Moewardi Hospital, Surakarta, Indonesia
Background: ALI is characterized by sudden decrease in arterial perfusion of the limb and requiring urgent management. The combination of Lower Extremities Artery Disease (LEAD) and CAD is associated with heightened ischemic risk.
Case illustration: A 67‐yo man was presented with left and right leg pain as the chief complaint within 4‐
days with history of type‐2 diabetes and smoking. We found BP 130/70 mmHg, HR 76x/min, RR 20x/min, SpO2 100%, and temperature of 37ºC. Pulsation of the right femoral diminished, no pulsation of the right popliteal, anterior tibialis, and posterior tibialis arteries. ECG obtained anteroseptal Old Myocardial Infarction (OMI). Doppler showed ALI right inferior extremity on external illiaca artery. Digital Subtraction Angiography (DSA) showed occlusion total on right external illiaca artery.. Echocardiography showed Regional Wall Motion Abnormalities (RWMA), EF 20‐26%. Patient was diagnosed with ALI Rutherford III pro amputation trans tibia right cruris and anteroseptal OMI. After being amputated he had bleeding in his right leg, melena and hematuria. Laboratory showed anemia 8,8 g/dl, prolonged APTT 97,5 second, then given RBC transfusion, Aspirin, Clopidogrel and Warfarin stopped. Consider the triple therapy to dual therapy with clopidogrel and warfarin. Patients with clinical of ALI should be addressed to emergency center with vascular team for diagnosis and management. Antiplatelet agents are used in patients with LEAD to prevent limb related and general CV events. DAPT may be considered in patients with multiple coronary vessel disease diabetic patients with incomplete revascularization. In patients with LEAD, DAPT was associated with MI and high bleeding risk. In these patient DAPT therapy in LEAD patient increased the bleeding risk, the definitive therapy is needed.
Conclusion: Specific management is needed in patient with severe bleeding. Stopping DAPT, OAC, and RBC transfusion in these patient can make the condition better to away the life threatening bleeding.
Keywords: Acute limb ischemia, severe bleeding
Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
65. The Management of Severe Bleeding in Acute Limb Ischemia (ALI) and Coronary Artery Disease (CAD)
1K Bayu K, 2T Wasyanto
1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University Surakarta
2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University / Dr. Moewardi Hospital, Surakarta, Indonesia
Background: ALI is characterized by sudden decrease in arterial perfusion of the limb and requiring urgent management. The combination of Lower Extremities Artery Disease (LEAD) and CAD is associated with heightened ischemic risk.
Case illustration: A 67‐yo man was presented with left and right leg pain as the chief complaint within 4‐
days with history of type‐2 diabetes and smoking. We found BP 130/70 mmHg, HR 76x/min, RR 20x/min, SpO2 100%, and temperature of 37ºC. Pulsation of the right femoral diminished, no pulsation of the right popliteal, anterior tibialis, and posterior tibialis arteries. ECG obtained anteroseptal Old Myocardial Infarction (OMI). Doppler showed ALI right inferior extremity on external illiaca artery. Digital Subtraction Angiography (DSA) showed occlusion total on right external illiaca artery.. Echocardiography showed Regional Wall Motion Abnormalities (RWMA), EF 20‐26%. Patient was diagnosed with ALI Rutherford III pro amputation trans tibia right cruris and anteroseptal OMI. After being amputated he had bleeding in his right leg, melena and hematuria. Laboratory showed anemia 8,8 g/dl, prolonged APTT 97,5 second, then given RBC transfusion, Aspirin, Clopidogrel and Warfarin stopped. Consider the triple therapy to dual therapy with clopidogrel and warfarin.
Discussion: Patients with clinical of ALI should be addressed to emergency center with vascular team for diagnosis and management. Antiplatelet agents are used in patients with LEAD to prevent limb related and general CV events. DAPT may be considered in patients with multiple coronary vessel disease diabetic patients with incomplete revascularization. In patients with LEAD, DAPT was associated with MI and high bleeding risk. In these patient DAPT therapy in LEAD patient increased the bleeding risk, the definitive therapy is needed.
Conclusion: Specific management is needed in patient with severe bleeding. Stopping DAPT, OAC, and RBC transfusion in these patient can make the condition better to away the life threatening bleeding.
Keywords: Acute limb ischemia, severe bleeding
Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
66. Eisenmenger’s Syndrome in a 12‐years‐old Girl Suffering Ebstein’s Anomaly and Atrial Septal Defect with Spiked Helmet ECG Pattern: A Case Report
S.N. Kadafi1, A.A. Purnomo2, A. Adhyatma3, D. Setiadi4,1General Practitioner at RAA Soewondo General Hospital, Pati, Indonesia; 2General Practitioner at Sunan Kudus Islamic Hospital, Kudus, Indonesia;
3General Practitioner at Wiradadi Husada General Hospital, Banyumas, Indonesia;4Cardiologist at Sunan Kudus Islamic Hospital, Kudus, Indonesia
Background: Ebstein’s anomaly (EA) is rare congenital heart disease. It might be associated with atrial septal defect (ASD). If untreated, both conditions might develope Eisenmenger’s syndrome (ES) and arrhythmias in which mortality remains high. We hereby try to emphasize on how detecting critically‐ill patient using potential novel ECG marker called the spiked helmet pattern.
Case Illustration And Discussion: A 12‐year‐old girl came to hospital with dyspnea and cyanosis on her lips. No previous cardiac diseases recorded. Her blood pressure was 106/68mmHg. She had tachypnea, tachycardia and 39% oxygen saturation. Physical examination found central cyanosis, hepatomegaly, increased jugular venous pressure and systolic ejection murmur on tricuspid area. Electrocardiography showed SVT with spiked helmet pattern on inferior and anterolateral leads. Chest x‐ray suggested cardiomegaly. Echocardiography showed tricuspid regurgitation, atrial septal defect and Ebstein’s anomaly. Her hemoglobin was high. Patient treated with digoxin, diuretic and oxygen therapy.
Unfortunately, the patient passed away on the third day of admission.
EA affects the tricuspid valve with right ventricular myopathy. Dilatation of right atrium and right ventricle associated with atrioventricular accessory pathways generating SVT. Untreated ASD may precipitate ES resulting in cyanosis and heart failure. Erythrocytosis occured secondary to chronic cyanosis.
The spiked helmet pattern described as ST‐segment elevation with the upward shift starting before the QRS complex. Several reports stated that it was associated with critically‐ill patient but the mechanism remains unknown.
Conclusion: Undiagnosed EA patients with ASD could lead to ES and arrhythmias with high mortality.
Spiked helmet ECG pattern could be a warning indicator of critically‐ill patient.
KEYWORD: Ebstein’s anomaly, ASD, Eisenmenger’s syndrome, spiked helmet pattern
Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
67. Thrombolysis with Streptokinase in STEMI Patient Who Have Received Fondaparinux Anticoagulant Injection Therapy: A Case Report
M. Mahbubi1 S.N Kadafi2 A. Megawati3,1Cardiologist at RSUD RAA Soewondo, Pati, Indonesia; 2 General Practitioner at RSUD RAA Soeowondo Pati, Indonesia; 3General Practitioner at RSU Fastabiq Sehat PKU
Muhammadiyah, Pati, Indonesia
Background Myocardial infarction (MI) is a common disease with high mortality rate worldwide. The principal management for the ST elevation subtype of MI (STEMI) is immediate revascularization either with the primary percutaneous coronary intervention (PCI) or with the thrombolytic agents. Fibrinolytic therapy is an important reperfusion strategy in settings where primary PCI cannot be offered. Fibrinolytic therapy is recommended within 12 hours of symptoms onset if primary PCI cannot be performed within 120 minutes from STEMI diagnosis.
Case Illustration And Discussion A 47‐years‐old man, with a chest pain 4 hour before going on ER. The blood presure was 100/60 without a sign of shock, and ECG was present inferoposterior STEMI with depression of ST segment in V1‐V3. Before referred to our hospital, parenteral anticoagulant (fondaparinux) was given in other hospital 2 hours before. Our hospital was not a PCI center, and time that needed to reach PCI center was more than 120 minutes. Fibrinolysis strategy was the option. A sreptokinase just given full dose for 60 minutes. During trombolytic therapy, there was no bleeding complication. But the patient suddenly experienced cardiogenic shock, Killip IV. The vital sign was decrease, BP was 70/50, HR 52x/sec, with dypsnea, rhonkhi and followed by cardiopulmonary arrest in pulseless electrical activity. CPR and intubation was given almost 30 minutes but eventually patient died in asystole. Cardiogenic shock continues to be the most common cause of death in patients hospitalized with acute myocardial infarction.
Conclusion A full dose of Streptokinase can be given to MI patients whom have given intravenous anticoagulant therapy before because there was no specific guideline that explain it, although there is no relative nor absolute contra‐indications in this patient
Keywords : Thrombolytic, Anticoagulant, Acute Myocardial Infarction
Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
68. Aortic Dissection in Marfan Syndrome Patient Diagnosed Using echocardiography in Limited Resources Setting
S. Adiwinata, G.E.H. Reppi
Department of Cardiology and Vascular Medicine, GMIM Bethesda Tomohon Hospital, Manado, Indonesia
Background Marfan Syndrome (MS) is a rare autosomal dominant disorder with acute aortic dissection (AD) as the most fatal complication. CT‐angiography (CTA) is the imaging test of choice; however, not every Indonesia hospitals have CT‐scan, here we reported a case of MS patient with acute AD diagnosed using transthoracic‐echocardiography (TTE).
Case Illustration A 17‐year‐old male visited our emergency department with a chief complaint of shortness of breath since 3 days ago. He also complained chest pain that occurred once a week since the last 3 months. On physical examination, his BP 110/60 mmHg, HR 110 bpm and RR 24 bpm. He had several features of MS. His Revised Ghent Nosology score was 7. His lung and heart sounds were normal. No family history of MS or other heart disease was reported. A‐12‐lead‐electrocardiography showed sinus tachycardia with left ventricular hypertrophy. The next day, patient suddenly complained chest and abdominal pain with BP of right arm 115/60 mmHg and 110/60 mmHg on left arm, normal chest and abdominal examinations. He underwent TTE testing with the result global hypokinetic, LVEF 25%, aortic dilatation (sinus valsava) 6.73 cm and intimal flap up to abdominal aorta. The patient was urgently referred to tertiary hospital.
TTE may be used as initial modality in diagnosing AD, if CTA is not available. The classic finding of AD on echocardiography is demonstration of intimal flap presence that divides aorta into two lumens.
Previously reported, TTE has sensitivity 78‐90% and 31‐55% for diagnosing ascending and descending AD, respectively. Several windows views may be utilized for aorta assessment. However, several limitations made negative TTE does not rule out AD.
Conclusion AD is a fatal complication among MS patients. TTE may be used as the initial imaging modality when AD is clinically suspected in emergency setting and CTA is not available.
Keywords: Marfan Syndrome; Aortic Dissection; Grown‐Up Congenital Heart Disease; Echocardiography
Indonesian Journal of Cardiology
Indonesian J Cardiol 2020:41:suppl_A pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.1075
69. THE SPECTRUM OF ACUTE CORONARY SYNDROME IN 61 YEARS OLD MAN