Dr. Nanda

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
Wecoc, 2014, Jakarta: Fisrt Degree
and Function After Mitral Valve
Relative of Patent Ductus Arteriosus
Replacement In Adult Mitral Stenosis
Recurrency, A Case Report.
Patients In Dr. Sardjito General Hospital
Yogyakarta (2nd winner)
JCU - 3rd InaPrevent, 2017, Yogyakarta:

JCU, 2015, Yogyakarta: Diagnostic Test Diagnostic Value Of Addition First One
Value Mean Pulmonary Arterial Minute Abnormal Heart Rate Recovery
Pressure by Transthoracal After Exercise Treadmill Test In
Echocardiography in Adult Secundum Moderate Risk Duke Treadmill Score To
Atrial Septal Defect Patients in Dr. Detect Severe Coronary Artery Lesion In
Sardjito Hospital. 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)

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
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
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

Dr. Nanda

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Curiculum Vitae

• Nama : dr. NANDA NURKUSUMASARI, SpJP-

INA Echo 2014, di Jakarta. Judul:

JCU - 3rd InaPrevent, 2017, Yogyakarta:

34% represented with

Thrombosis (Thrombo-embolic) that originates in the venous

Air embolism Fat embolism

Key factors contributing

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

Initial risk stratification of acute PE

Feeling defect by CTPA or

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

Previous acute DVT or PE +1.5

•≥ 500 mg/dl but •< 500 mg/dl 

for Non-High Risk

Pulse rate  110 b.p.m 1

Int-High Int-Low Risk

thrombectomy A/C, A/C,

• Normal: < 14 ng/L

Acute pulmonary How to diagnose

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