CURRICULUM VITAE

ARMAND RONALD
RUHUKAIL, MD, FIHA
PRESENT POSITION
General Cardiologist
• Government General Hospital (RSUD 45 Kuningan)
• RS Hasna Medika Palimanan
• RS Hasna Medika Kuningan
 CURRICULUM VITAE
ARMAND RONALD
RUHUKAIL, MD, FIHA
EDUCATION
• Desember 22,1973, Elementary School, SDN Indrapura II, Surabaya,
East Java Province, Indonesia
• November 22, 1976, Junior High School, SMPN II, Surabaya, East
Java Province, Indonesia
• Mei 8, 1980, Senior High School, SMAN I Yogyakarta, Yogya City,
Special Province of Yogyakarta, Indonesia
• February 19, 1985, University Degree, Faculty of Medicine, Sebelas
Maret University Surakarta, Solo
• Juli 28, 1987 MD, General Practitioner, Faculty of Medicine, Sebelas
Maret University Surakarta, Solo
• Januari 23, 2001, Cardiologist, Faculty of Medicine, Indonesia
University, Jakarta, Indonesia
 CURRICULUM VITAE
ARMAND RONALD
RUHUKAIL, MD, FIHA
PROFESSIONAL WORKING EXPERIENCE AND TEACHING POSITION
• 1987- 1988 : Rig, Off Shore Doctor in several oil company coordinated by BKKA
Pertamina (Indonesia Petroleum Corporation), Located in Off Shore and On Shore
Indonesia Area
• 1988- 1995 : Medical Doctor and Chief of Community Head Center of 8 Community
Health Center in 8 Distric of Kuningan Distric, West Java Province, Indonesia
• 1996- 2001 : Cardiology Resident in Cardiology Department, Medical Faculty, Indonesia
University, Jakarta Province, Indonesia
• 2001- 2002 : Cardiologist in Badak LNG Hospital, Bontang, East Kaltim Province,
Indonesia
• 2002 - Present time : Cardiologist in Arjawinangun Hospital, Cirebon Distric, West Java ,
Indonesia
• 2003 – Present Time : Cardiologist in Goverment Kuningan General Hospital, RSUD 45,
Kuningan Distric, West Java Province, Indonesia
• 2001- 2018 : Cardiologist in Hasna Medika Cardiac Hospital, Palimanan Cirebon Distric,
West Java Province : Cardiologist in Sekar Kamulyan Catholic Hospital, Kuningan
Distric, West Java Province, Indonesia
 CURRICULUM VITAE
ARMAND RONALD
RUHUKAIL, MD, FIHA
MEMBERSHIP/ACTIVITIES IN PROFESSIONAL AND
SCIENTIFIC SOCIETIES
• 1988 Member of Indonesian Medical Assaciation
• 1995 Young Member of Indonesian Heart Association
• 2001 Member of Indonesian Heart Association
• 2001 Member of Indonesia Heart Association, Cirebon
Branch
• 2013 Member of Indonesian Society of
Echocardiography
 CURRICULUM VITAE
ARMAND RONALD
RUHUKAIL, MD, FIHA
NATIONAL AND INTERNATIONAL PRESENTATION, TEACHING AND LECTURES
• Participant in many Symphosium, Workshop regional and local area of
indonesia,interest in Cardiology, Diabetologia and others
• Speaker in National Congress of Indonesia Heart Association, Hosted by Semarang
Branch, Semarang , December 11 -15, 1998
• Speaker of Basic Life Support , fire and Patient Evacuation in Arjawinangun Cirebon
District Hospital, October 2003
• Speaker of ECG Course, IDI Kab Cirebon, Des 2007 and August 2008
• Speaker of ECG Workshop, Perki Cirebon, 2008
• Speaker 0f ECG Workshop, IDI Kuningan, 2008
• Speaker of ECG Workshop, IDI Brebes, 2008
• Speaker of ECG Workshop, Perki Cirebon, 2011
• Speaker in One Day Symphosium of Diagnose and Treatment of Heart Failure, Perki
Cirebon, 2011
• Speaker of ECG Workshop, Cirebon Cardiology Update, Perki Cirebon 2012
• Speaker of ECG Workshop in One Day Symphosium (ODS) , Perki Cirebon 2013
 ACUTE
CORONARY
SYNDROME
 WHAT Case study Definitions

WE’LL
COVER Complications
Clinical
features and
differentiating

IN NEXT
ACS

30 Management ECGs

MINS…
CASE STUDY – MR
FB
A 54 year old gentleman presents to A&E with chest
pain…
 CASE STUDY
Seorang pasien laki-laki umur 54th datang dengan
keluhan nyeri dada, nyeri dada dirasakan seperti
tertimpa beban berat, terasa tidak nyaman, seperti
diremas, disertai keringat dingin dan perasaan mau mati,
nyeri berlangsung selama 30 menit, dan timbul saat
istirahat, nyeri menjalar ke leher , punggung belakang
dan bahu kiri, nyeri tidak dipengaruhi oleh perubahan
poisisi

Pasien gemuk dan pekerjaanya supir truk

Pasien perokok aktif selama >30thn
Memiliki DM tipe 2 dan HTN tidak terkontrol

Ayah dari pasien meninggal tiba-tiba di umur 50th.

 WHAT DO YOU WANT TO
ASK HIM?

1 2 3 4 5 6 7

30minute
history of
He looks PMHx of Takes FHx Smoked limited
very pale, hypertensi 40
metfor includes
central
‘crushing’
clammy on and
father cigarette exerci
and hyperchol min
chest pain
radiating to sweaty, esterolae dying of s a day
for the
se
his jaw and and has mia MI aged
left arm, vomited past 35
10/10 twice 50 years
 WHAT ARE HIS RISK
 Smoking
FACTORS?
 Increasing age

 Obesity  Gender (male)

 Diet  Family History

 Lack of exercise

 High serum cholesterol

 ? Hypertension

 ?Diabetes
 WHAT ARE HIS RISK
FACTORS?

Lack of
Smoking Obesity Diet
exercise

High serum ? Increasing

?Diabetes
cholesterol Hypertension age

Gender Family
(male) History
HOW WOULD YOU FIX
HIM?
 CASE STUDY – MR FB

Initial management in acute setting?

MONA Reperfusion BB and ACEi

Long-term management?
Aspirin, Clopidogrel, Statin, modification of lifestyle…..
SO,,,,, THE CASE IS ACUTE
CORONARY SYNDROME
 WHAT IS ACUTE CORONARY
SYNDROME?
Stable Angina
Unstable Angina NSTEMI STEMI

Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene
Braunwald.—10th edition.
 DEFINITIONS

Unstable angina: NSTEMI: STEMI:

• An unprovoked or • Chest pain • Sustained chest

prolonged suggestive of AMI pain suggestive of
episode of chest • Non-specific ECG AMI
pain raising changes (ST • Acute ST elevation
suspicion of acute depression/T or new LBBB
myocardial inversion/normal)
infarction (AMI) • Laboratory tests
• Without definite showing release of
ECG or laboratory troponins
evidence

European Heart Journal (2012) 33, 2551–2567 doi:10.1093/eurheartj/ehs184

PATHOPHYS
(ENOUGH TO
GET BY..)
• Atherosclerosis
• Epithelial injury
• Migration of
monocytes/macrophages
• LDL lipids consumed 
foam cells
• Growth factors  smooth
muscle, collagen,
proteoglycans
• Atheromatous plaque
forms

Pathophysiology of heart disease (Lilly) Pathophysiology o heart disease : a collaborative

project o medical students and aculty / editor, Leonard S. Lilly. — Sixth edition.
 CLINICAL FEATURES
 Tachycardia or
 Chest pain bradycardia
 Nausea

• Dyspnoea  Heart murmurs

 Palpitations
 Sweaty

 Hypotension or  Vomiting
hypertension
 Pallor
 Syncope
 Asymptomatic/silent

 Indigestion
 Acute confusion  Fever
Pathophysiology of heart disease (Lilly) Pathophysiology o heart disease : a collaborative project o medical students and aculty / editor, Leonard S. Lilly. — Sixth
edition.
 DISTINGUISHING
FEATURES

• SA: • UA: • NSTEMI: • STEMI:

plaque platelet platelet complete
formation adhesion aggregation occlusion

 Precipitated by • At rest or minimal exertion

stress or exertion
• Lasts >20 minutes
 Lasts <20 minutes
• Often accompanied by other s/s
 Relieved by GTN or • Poor GTN relief
resting
Pathophysiology of heart disease (Lilly) Pathophysiology o heart disease : a collaborative project o medical students and aculty / editor, Leonard S. Lilly. — Sixth
edition.
 RISK FACTORS

Modifiable Non-Modifiable
• Smoking • Increasing age
• Obesity • Gender (male)
• Diet • Ethnicity
• Lack of exercise • Family History
• High serum cholesterol • ?Diabetes
• Hypertension
• ? Diabetes
Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene
Braunwald.—10th edition.
 DIFFERENTIAL DIAGNOSIS
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain

GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GERD • Trauma
• Pancreatitis

Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene
Braunwald.—10th edition.
 INVESTIGATIONS
Bedside Obs, ECG,
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase,
CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T
depression * Possible T wave waves
inversion * New LBBB
* T inversion (hours)
* Q waves (days)
* ST elevation is >1mm in limb leads and >2mm in chest leads

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320
 ECG IN ACS
UAP NSTEMI VS STEMI

normal

STEMI

NSTEMI

NSTEMI
 ECG
IN NSTEMI AND UNSTABLE
ANGINA
 ECG
IN NSTEMI AND UNSTABLE ANGINA
• Maybe Normal
• Typically cause ST Depression
• Frequently accompanied by negative T
• ST Depresion DO NOT reflect the ischemia area

So ST depreesion in lead II, III, AVF does not imply that

ischemia located in the inferior wall.
 ECG
IN NSTEMI AND UNSTABLE ANGINA
Ischemic ST depression are characterized by a horizontal
or downsloping ST
ECG FINDING
IN
STEMI
 IMPORTANT ECG
FINDINGS IN STEMI
• ST elevations
Measured in the J point and the elevation must be
significant in at least 2 contiguous ECG leads

Contiguous leads :
II, III, AVF
1, AVL
V1-V6
V1-V2
V3-V4
WAIT WHAT IS J POINT?
 IMPORTANT ECG
FINDINGS IN STEMI
• In patients with STEMI the ECG leads displaying ST
segment elevations actually reflects the ischemic area
IMPORTANT ECG FINDINGS
IN STEMI

STEMI
IMPORTANT ECG FINDINGS IN
STEMI

STEMI
IMPORTANT ECG FINDINGS IN
STEMI

NOT STEMI
ECG CHANGES IN STEMI
(TIMELINE)
Pathophysiology of heart disease (Lilly) Pathophysiology o heart disease : a collaborative project o medical students and aculty / editor, Leonard S. Lilly. — Sixth
edition.

WHERE IS THE PROBLEM?

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
 CRITERIA DIAGNOSIS FOR ACUTE
MYOCARDIAL INFARCTION
(WHO)
A diagnosis of myocardial infarction is based on the
following three components:

• Symptoms
• Cardiac troponins rises
• ECG :
ST elevations 2 of 3
ST depressions
T wave invertion
Pathological Q wave
 MANAGEMENT

A Patent?
B Oxygen (aim for sats 94-98%), auscultate, RR
C IV access (+/-fluids), HR, BP
D GCS, pupils, cap blood glucose
E Expose

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320
 COMMON ACS
MANAGEMENT
Morphine (5-10mg slow IV injection)

Oxygen (titrate sats to need)

Nitrates - GTN spray (400mcg = 1 spray) or tablet (1mg)

Aspirin (300mg chewed)

Plus an antiemetic i.e.

Metoclopramide 10mg IV

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320
 MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI

Dose morphin : 2-5 mg IV, repeated every 5 minutes

max dose 30mg
MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI
 MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI

Dose
MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI
 MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI

LMWH Fondaparinux (arixtra) dose 1 x 2.5mg

Low Molecular
Weight Heparin Enoxaparin (Lovenox) dose 2 x 1mg/KGBB
 MANAGEMENT OF UNSTABLE
ANGINA & NSTEMI

LMWH i.e.
Consider
Enoxaparin Clopidogrel
Beta blocker - Nitrates – coronary
1mg/kg BD or 300mg
atenolol 5mg usually IV angiography
Fondaparinux loading dose
within 72 hr
2.5mg OD

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–
315, https://doi.org/10.1093/eurheartj/ehv320
 SCORING SYSTEMS
GRACE scoring TIMI
• Predicts 6/12 mortality in • Risk of cardiac events in
NSTEMI patients next 30 days
• Age • Age >65
• HR and systolic BP • Known coronary artery
• Killip class (CCF, disease
pulmonary oedema, • Aspirin in last 7/7
shock) • Severe angina (>2 in
• Cardiac arrest on 24hr)
admission • ST deviation >1mm
• Elevated cardiac • Elevated troponins
markers • > CAD risk factors
• ST segment change
European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–
315, https://doi.org/10.1093/eurheartj/ehv320
 STEMI
MANAGEMENT
TIME IS MUSCLE
Percutaneous coronary intervention (Primary PCI)
•‘Call to balloon time’ of 120 minutes
•Requires clopidogrel 600mg loading dose
•Rescue PCI after failed thrombolysis

Thrombolysis
•Streptokinase / alteplase / tenecteplase…
•Contraindications
•Clopidogrel 600mg loading dose AND LMWH

Beta blocker i.e. Atenolol

ACE inhibitor i.e. Lisinopril

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320
DOSE OF ANTIPLATELET AND ANTI
COAGULANT CO-THERAPIES
 FIBRINOLYTIC THERAPY
• It is recommended within 12 h onset without
contraindication if PCI cannot be performed.
• A fibrin-spesific agent (tenecteplase, alteplase,
reteplase).

It should start in pre hospital

primary PCI
setting

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 2015

uidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation2012
Contraindications to Fibrinolytic Therapy

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation2012
 DOSE OF ANTICOAGULANT

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation2012
DOSES OF FIBRINOLYTICS AGENTS
59
European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320

LONGER-TERM
MANAGEMENT
Continuous ECG monitoring
as inpatient/ CCU

Aspirin 75mg OD (lifelong)

Clopidogrel 75mg (1 year)

Beta blocker (1 year -

lifelong)

ACE inhibitor

Statin

Modification of risk factors

 COMPLICATIONS

Early <72hr Late

• Death • Ventricular wall rupture
• Cardiogenic shock • Valvular regurgitation
• Heart failure • Ventricular aneurysms
• Ventricular arrhythmia • Cardiac tamponade
• Myocardial rupture • Dresslers syndrome
• Thromboembolism • Thromboembolism

European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320
 SUMMARY

Don’t forget
Know your
to learn what Senior review
Structured acute
you think you ECG often is always the
approach management
already right answer
– MONA
know!
THANK YOU