Curiculum Vitae

• Nama : dr. NANDA NURKUSUMASARI, SpJP-

FIHA
• Jenis Kelamin : PEREMPUAN
• Agama : ISLAM
• Status : BELUM MENIKAH
• Alamat Rumah : JL. TARUMANEGARA III NO 31,
BANYUANYAR RT 04 RW VI, SURAKARTA, 57137
• Email : dr.nanda.nn@gmail.com
Riwayat Pendidikan
• SDN Banyuanyar III Surakarta : 1993 –
1999
• SLTP Negeri 1 Surakarta : 1999 - 2001
• SMA Negeri 1 Surakarta : 2001 – 2004
• Fakultas Kedokteran UGM (S1 + Profesi) : 2005 –
2010
• PPDS Ilmu Penyakit Jantung dan Pembuluh Darah FK
UGM : 2013 – Februari 2017
 Makalah
INA Echo 2014, di Jakarta. Judul:
Alteration of Right Ventricular Pressure
and Function After Mitral Valve
Replacement In Adult Mitral Stenosis
Patients In Dr. Sardjito General Hospital
Yogyakarta (2nd winner)
JCU, 2015, Yogyakarta: Diagnostic Test
Value Mean Pulmonary Arterial
Pressure by Transthoracal
Echocardiography in Adult Secundum
Atrial Septal Defect Patients in Dr.
Sardjito Hospital.
Wecoc, 2014, Jakarta: Fisrt Degree
Relative of Patent Ductus Arteriosus
Recurrency, A Case Report.
JCU - 3rd InaPrevent, 2017, Yogyakarta:
Diagnostic Value Of Addition First One
Minute Abnormal Heart Rate Recovery
After Exercise Treadmill Test In
Moderate Risk Duke Treadmill Score To
Detect Severe Coronary Artery Lesion In
Patient Suspected Stable Coronary
Artery Disease (3rd winner)
 Pekerjaan
• Dokter Internship Puskesmas Paduraksa, Pemalang : 2011 – 2012
• Dokter Internship RSUD M. Ashari, Pemalang : 2011 – 2012
• Dokter Umum di RS Puri Husada, Yogyakarta : 2012 -- 2013
• Asisten Penelitian di Bagian Tulip, RSUP DR. Sardjito, Yogyakarta : 2012 -- 2013
• Dokter SpJP Fulltimer RS PKU Muhammadiyah Solo : 2017 – sekarang
• Instruktur ACLS : 2017 – sekarang
• Anggota PERKI cabang Solo : 2017 - sekarang

Lain-lain
• Speaker in Interactive Corner at 26th
Asmiha, 2017: STEMI in Myasthenia Gravis
Patient
• Mederator in Clinical Updates 2017
ACUTE PULMONARY
EMBOLISM
DIAGNOSIS AND CURRENT
MANAGEMENT
 Epidemiology

Difficult to determine
Third most frequent
because it remain
cardiovascular disease,
asymptomatic, or first
incidence 100-200 per
presentation may be sudden
100.000 inhabitants
cardiac death

34% represented with

sudden fatal PE, 595 deaths
from PE, only 7% who died Lethal but
correctly diagnosed of PREVENTABLE
317.000 deaths over 454.4
million in Europe
 Acquired Risk Factors
Age
Smoking
Hyperchromocysteinemia (less commonly inherited
secondary to a mutation in methylentetrahydrofolate
reductase)
Malignancy
Antiphopholipid antibody Syndrome
Obesity
Risk
Oral contraceptive pills or hormone replacement therapy Factors
Atherosclerotic disease
Personal or family history of Venous thromboembolism
Recent trauma, surgery, or hospitalization
Acute infection
Long-haul air travel
Pacemaker or implantable cardiac defibrilator leads and
indwelling venous cathethers
 Risk Factors

Prothrombin
gene
mutation
Deficiency of
Factor V
Antithrombin
Leiden
III, protein C
Mutation
or protein S

Inherite
d Risk
Factors
 Sources of Thrombosis

Thrombosis (Thrombo-embolic) that originates in the venous

system and embolizes to the pulmonary arterial circulation
• DVT in veins of leg above the knee (>90%) Lower extremity : 70% cases of PE
• DVT elsewhere (pelvic, arm, calf veins, etc.)
• Cardiac thrombi

Air embolism Fat embolism

Clinical Suspected

Not
SPECIFIC
Haemodynamic
Consequances
Hemodynamic Status

Key factors contributing

to haemodynamic
collapse in acute
pulmonary embolism

European Heart Journal (2014) 35, 3033–3080 doi:10.1093/eurheartj/ehu283

 Diagnosis

Initial risk stratification of acute PE

 When CTPA is
performed?
Shock or hypotensive
(SBP drop  40 mmHg for > 15 minutes) not by another caused
 CTPA or Echo

Feeling defect by CTPA or

McConnel sign by echo

Therapy:
Reperfusion (thrombectomy and/or thrombolysis)

European Heart Journal (2014) 35, 3033–3080 doi:10.1093/eurheartj/ehu283

 When CTPA is
performed?

• Normotensive
• Well’s Score Probability
- High  CTPA
- Low/intermediate
+ D-dimer positive  CTPA
Non High
Feeling defect by CTPA
Risk

sPESI

Treatment
European Heart Journal (2014) 35, 3033–3080 doi:10.1093/eurheartj/ehu283
 Variables Points

Previous acute DVT or PE +1.5

Recent surgery or immobilization +1.5
Cancer +1

Haemoptysis +1
Well’s score Heart Rate >100 beats/min +1.5
Clinical signs of DVT +3
Alternative diagnosis less likely -3
than PE
Low 0 -1
Intermediate 2 -6
High 7
PE unlikely 0-4
PE likely >4
European Heart Journal (2014) 35, 3033–3080 doi:10.1093/eurheartj/ehu283
 D-dimer Test for aPE

•≥ 500 mg/dl but •< 500 mg/dl 

could be False rule out acute
Positives . PE
Positive Negative
Value Value

False Positives:
•Pregnant Patients •Hemmorrhage
•Post-partum < 1 week •CVA
•Malignancy •AMI
•Surgery within 1 week •Collagen Vascular
•Advanced age > 80 years Diseases
•Sepsis •Hepatic Impairment
•DVT
 aPE confirmed
(CTPA feeling
defect)

for Non-High Risk

 Simplified Pulmonary Embolism
Severity Index (sPESI)

Variables Points
Age > 80 years 1
Cancer 1
Chronic Cardiopulmonary Disease
1

Pulse rate  110 b.p.m 1

Systolic Blood Pressure < 100 mmHg 1

Saturation <90% 1
Low risk 0
Intermediate 1
 sPESI

RV dysfunction
Lab Trop T or I

Int-High Int-Low Risk

Risk A or B
A+B Not both

thrombectomy A/C, A/C,

and/or
thrombolysis hospitalized discharged
 Acute RV Dysfunction by Echo
McConnell’s Sign
(RV Apex normal and RV Basal hypokinetic)
Normal kinetic in
Apex

RV LV

Hypo kinetic
basal
 Chronic RV Dysfunction by Echo

RV Hypokinetic:
LV
TAPSE < 1.6 cm
Hypo without TR
TAPSE < 2 cm with TR
kinetic
basal
 Troponin T or I

• Normal: < 14 ng/L

• Border line: 14 - 53 ng/L  serial test
Troponin T • Definitive:  53 ng/L

• Normal:<0.02ng/mL
• Border line: 0.02 – 0.1 ng/mL  serial test
Troponin I • Definitive:  0.1 ng/mL
Management
Management
 Conclusion

Acute pulmonary How to diagnose

embolism is a and manage
lethal condition acute pulmonary
but preventable embolism are
disease very challenging
THANK YOU