Penyakit

Henti Jantung Mendadak

pada Usia Muda
Sudden Cardiac Arrest
&
Sudden Cardiac Death

•  Sudden cardiac arrest (SCA):
–  Sudden cessation of normal cardiac activity with
haemodynamic collapse.

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.


•  Sudden cardiac death (SCD):
–  Sudden natural death presumed to be of cardiac
cause that occurs within 1 h of onset of symptoms
in witnessed cases, and within 24 h of last being
seen alive when it is unwitnessed.
–  SCD in autopsied cases is defined as the natural
unexpected death of unknown or cardiac cause.

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

OUR OBLIGATION AS CLINICIANS
TREAT SUDDEN CARDIAC ARREST
&
PREVENT SUDDEN CARDIAC DEATH
Emergency Treatment of SCA
Prevention of SCD
 Epidemiology
•  SCD
–  approximately 50% of all cardiovascular deaths, with
up to 50% being the first manifestation of cardiac
disease.
–  Males higher SCD rates vs females
–  Incidence increasing with age;
•  infancy and childhood à 1/100 000 person-years
•  middle-aged individuals (5th to 6th decade of life) 50/100
000 person-years
•  Octogenarian à 200/100 000 person-years.

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.
 Epidemiology
•  Etiology of SCD
–  In the young predominance of primary electric
diseases and cardiomyopathies, as well as
myocarditis, and coronary anomalies (<30-35
years of age)
–  > 4th decade of life predominance of CAD (acute
coronary syndromes) & structural heart disease

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

 Cardiomyopathy
•  Definition of cardiomyopathy
–  structural and functional abnormalities of the
ventricular myocardium that are unexplained by
flow limiting coronary artery disease or abnormal
loading conditions.
•  Most common à hypertrophic
cardiomyopathy (HCM); est. prevalence
≈1:500 persons

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

Elliott et.al. European Heart Journal (2014) 35, 2733–2779
 Other Cardiomyopathies
•  Dilated cardiomyopathy
•  Arrhythmogenic right ventricular
cardiomyopathy
•  Left ventricular non-compaction
•  Restrictive cardiomyopathy

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

 Hypertrophic Cardiomyopathy
•  Hypertrophic cardiomyopathy à
–  a genetic disorder that is characterized by left
ventricular hypertrophy unexplained by
secondary causes (loading condition, etc.) and
–  a nondilated left ventricle with preserved or
increased ejection fraction.

Marian et.al.CircRes.2017;121:749-770
 Hypertrophic Cardiomyopathy
Diagnosis
•  left ventricular hypertrophy (LVH) : end-
diastolic ventricular septal thickness in adults
≥13 mm (ESC > 15 mm), occurring in the
absence of abnormal loading conditions or
other secondary causes.

Marian et.al.CircRes.2017;121:749-770
 Hypertrophic Cardiomyopathy
•  Treatment
–  Risk stratify for SCD; high risk à Implantable
Cardioverter Defibrillator (ICD)
–  Asymptomatic à no specific drugs
–  Obstructive HCM with exertional dyspnea à Beta
blockers, Verapamil, Dysopiramide (negative
inotropy) if refractory surgical myectomy or
alcohol septal ablation (ASA)

Maron et al.J Am Coll Cardiol 2022;79:390–414

 Ilustrasi Kasus 1

•  Laki-laki usia 32 tahun berobat ke poli
•  Keluhan utama : Sesak napas dan mudah lelah
sejak 2 bulan
 Ilustrasi Kasus 1
•  Sesak napas dan mudah lelah bila beraktvitas
•  Keluhan disertai dengan rasa seperti akan
pingsan terutama bila melakukan aktivitas
yang lebih berat.
•  Tidak ada riwayat merokok, hipertensi,
diabetes melitus, penyakit jantung bawaan
•  Tidak ada riwayat keluarga meninggal
mendadak di usia muda
 Ilustrasi Kasus 1
Physical exam.
•  GCS 15
•  BP: 120/80 mmHg; HR : 90 bpm; Resp. rate : 24
x/mnt; Temp : afebrile
•  Neck vein not distended
•  S1-S2 normal regular, systolic murmur grade 3/6
LLSB
•  No rales, crackles or wheeze
•  No pedal edema
ECG
 Assessment
1.  Dyspnea on exertion
2.  LVH
3.  Near syncope
 Follow up
•  Echocardiography :
 Follow up
•  Echocardiography
 Follow up :
Implantable Cardioverter Defibrillator
Primary Electrical Disease aka Cardiac
Channelopathies
•  Primary electrical diseases or
channelopathies:
–  inherited genetic alterations of the cell ionic and
electrical behavior leading to various cardiac
arrhythmias carrying the risk of sudden death
•  Most common à Long QT syndrome
(congenital LQTS); est. prevalence ≈1:2000
persons

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

Maury et.al.Minerva Cardioangiol.2010 Aug;58(4):449-83.
 Other Cardiac Channelopathies
•  Brugada syndrome
•  Catecholaminergic polymorphic ventricular
tachycardia
•  Early repolarization syndromes
•  Andersen–Tawil syndrome Type 1
•  Short QT syndromes
•  Idiopathic ventricular fibrillation

Zeppenfeld et.al. Eur Heart J. 2022 Oct 21;43(40):3997-4126.

 Ilustrasi Kasus 2

•  Laki-laki usia 19 tahun dibawa ke IGD
•  Keluhan Utama : Pingsan dan kejang 2 jam
yang lalu
 Ilustrasi Kasus 2
•  Pasien 2 jam yang lalu secara tiba-tiba tidak
sadarkan diri.
•  Saksi mata yang menyaksikan mengatakan
pasien terlihat mengalami kejang-kejang dan
kemudian sadar kembali beberapa menit
kemudian.
•  Pasien sedang bermain sepak bola.
•  Tidak ada keluhan nyeri dada, berdebar-debar
maupun sesak nafas.
 Ilustrasi Kasus 2
•  Tidak memiliki riwayat penyakit jantung
bawaan, diabetes, hipertensi
•  Pasien tidak merokok.
 Ilustrasi Kasus 2
Physical exam.
•  GCS 15
•  BP: 110/70 mmHg; HR : 80bpm; Resp. rate :
20 x/mnt; Temp : afebrile
•  Neck vein not distended
•  S1-S2 normal regular, no murmur or gallop
•  No rales, crackles or wheeze
•  No pedal edema
 Ilustrasi Kasus
•  Assessment?
•  Discharge (outpatient) or need further
observation?

 Follow up
•  Saat observasi di ICCU pasien mengalami
penurunan kesadaran, nadi sulit dinilai

Monitor EKG
ECG 12 lead??
 Follow up
•  Defibrilasi DC shock 200 j

 Management
•  Bolus MgSO4 IV 2 gr dilanjutkan MgSO4 infus
drip
•  Non-selective beta blocker (propranolol)
initiated
Lab : Lab pasca koreksi
•  Na/K/Cl : 140/ 3.7/98 •  Na/K/Cl : 138/ 4.4/103
•  Ca ion : 1.10 (1.01-1.31) •  Mg : 2.31 (1.7-2.55)
•  Mg : 1.8 (1.7-2.55)
 Overdrive Pacing

Trans venous pacing :

•  Meningkatkan heart
rate 90-100 bpm
•  Overdrive pacing sesuai
indikasi

 Follow up
•  Electrical storm à resolved
•  ICD implanted
 Take Home Message
•  Penyebab tersering henti jantung mendadak usia
> 40 tahun
–  ACS (CAD)
–  Diseksi aorta
•  Penyebab tersering henti jantung mendadak usia
muda (<30-35 tahun):
–  Kardiomiopati (HCM, ARVC, DCM, HNDCM etc)
–  Channelopathies (LQTS, Brs, CPVT, short QT, ERS,
Idiopathic VF)
–  Anomali koroner
–  Myocarditis
 Take Home Message
•  Kardiomiopati tersering à HCM
•  Channelopathy tersering à LQTS
•  Pasien usia muda dengan presentasi klinis
syncope perlu diobservasi (rawat à inpatient)
untuk menyingkirkan kemungkinan
arrhythmic/cardiac syncope

 Take Home Message
•  ECG monitor dan bila perlu EKG serial perlu
dilakukan untuk pemantauan/diagnosis etiologi
(ukur QTc, evaluasi perubahan segmen ST di V1-
V3, LVH criteria, ARVD criteria sesuai klinis
pasien)
•  Evaluasi obat-obatan yang dapat memanjangkan
QT interval pada pasien dengan LQTS
•  Stop/hindari obat-obatan yang dapat
meningkatkan interval QT pada LQTS
•  Tatalaksana cardiac arrest atau tachycardia à
ACLS