(14) Ischemic Heart Disease (ACS) Thn Lalu

8/15/2019 (14) Ischemic Heart Disease (ACS) Thn Lalu

1/40

Ischemic Heart Ds

IK Rina

Kardiologi/P Dalam

FK UNUD

RS Sanglah Denpasar


2/40

PENDAHULUANFaktor Resiko PJK:

- Hipertensi

- Diabetes Melitus

- Dislipidemia

- Merokok

- dll

Injuryendotelium

Disfungsi endotil

ATEROSKLEROSIS

(Hipotesisresponse-to-injury)

PJK


3/40

• Gaya hemodinamik (shear stress, tekanan• ipid (oksidasi D!• "iperglikemia

• "iperins#linemia• $erokok• In%eksi (&ir#s, 'akteria!• "iperhomosistemia• Kelainan im#n

• De%isiensi estrogen pada anita pas)a menopa#se• "ipoksia, iskemia

Kontri'#tor in*#ri endotel


4/40

AtherogenesisAtherogenesis

LDLLDL

LDLLDL Mildly Oxidized LDLMildly Oxidized LDL

Extensively LDL OxidizedExtensively LDL Oxidized

CytokineCytokine

GHGH

LumenLumen

EndothelilEndothelil

!ntim!ntim

MediMedi

Adhesion Mole"uleAdhesion Mole"ule

MCP#$MCP#$

MC%&MC%&

'issue &"tor'issue &"tor

PA!#$PA!#$

M"ro(hgeM"ro(hge&om "ell&om "ell

Mono"yteMono"yte

Migrtion "ellsMigrtion "ells

Current O(inion in Li(idology $))*+,-./0#./1Current O(inion in Li(idology $))*+,-./0#./1


5/40


6/40

Sketsa Progresifitas Lesi Tipe I - VI


7/40

CONDITIONS AFFECTING :

MYOCARDIAL MYOCARDIAL

OXYGEN DEMAND OXYGEN SUPPLY

Exercise Atheroscl.obstructio

Tach!car"ia #or. $asospasm

H!pertesio Platelet aggregatio

H!permetabolic state H!potesio

LV%T obstructio H!poxia

Aemia


8/40

SUPPLY ====== DEMAND

&&''&&

IS#HE(IA

(etabolic Vasoacti$e LV E#) Pai

abormalit! substaces "!sfuctio ab.


9/40

MECHANISM CLINICAL

CORRELATES

• *ixe" lesio Stable agia

Ischemia

• Pure $asospasm Variat agia ma! be

silet• #ombiatio (ixe" agia

• Platelet aggregatio +stable agia

thrombosis

pla,ue rupture (!ocar"ial ifarctio


10/40

CARDINAL MANIFESTATIONS OF

CAD

. AS(PT%(ATI#

/. A0)I0A - STA1LE

- VA2IA0T 3 4 P2I05(ETAL 4 6

- +0STA1LE

7. I0*A2#TI%0 - A#+TE

- P%ST-(I STATE

8. HEA2T *AIL+2E 9 IS#HE(I# (%PATH

:. A22HTH(IAS

;. S+DDE0 DEATH


11/40

TREATMENT

. (o"ificatio of risk factors

/. (o"ificatio of acti$it! patter

7. Drugs <

- ati-ischemic < itrates

1-blockers #a-atagoists

- ati-platelets < aspiri

ticlopi"ie etc - ati trombi < hepari' L=( Hep.

8. P#I 9 relate" proce"ures

:. Surger!


12/40

(%DI*I#ATI%0 %* 2IS> *A#T%2S

• H!pertesio• #igarette smokig

• %besit!

• H!perlipi"emia

- pre$etig progressio ' promotig

regressio of atherosclerosis


13/40

Agia Pectoris

Trasiet iskhemia miokar" ok #ADstenosis/pla+#e, spasme, anomali

(aifestasi <

SP

UP - Ne onset, progresi&e, rest, post in%ar)tion!

T!pical Agia <

. Nyeri dada - tertekan/tersayat 0 12 mnt,

s#' sternal radiasi - dag#, leher, lengan kiri3. Faktor mod#lasi - e4ertion/stress, istirahat hilang.

At!pical Agia


14/40

Dasar Diagosis +AP

0!eri "a"a khas<

D#rasi 5 lama

6riger - 'e'an %isik ringan/istirahat/tid#r Nitrat - nyeri hilang 7

Perubaha ST ?T

#>(1 ? LDH ormal


15/40

SAP - spirin, Nitrat, 883, 33 )ath

+AP - spirin, he/%ra4i/nadroparin, nitrat, 33, 883 )ath

A(I - spirin, he/%ra4i/nadroparin, aspirin, nitrat, 33

@ trombolitik (Streptase! )ath

Terapi pa"a agia pektoris

A(I < dari 9 ge*ala

1. Nyeri Dada Khas In%ark

. Per#'ahan :KG

9. Kadar :n;im Kardiak 'ermakna


16/40

Si"roma >oroer Akut

S>A


17/40

Radiation of pain??


18/40


19/40

A#S

0o ST Ele$atio ST Ele$atio

0o- Ba$e (I+stable

agia

Ba$e

A(I

Spectrum of ACS

Ph!sical examiatioC E#) moitorigC 1loo" samplesPh!sical examiatioC E#) moitorigC 1loo" samples


20/40

Manaement of ACS

A#S

0o ST Ele$atio ST Ele$atio

Thrombolysis Primary PCI


21/40


22/40


23/40


24/40

SINDROMA KORONER AKUT (SKA)

APTS

I(A

STE(I ' 0STE(I ' o

S#D


25/40


26/40

Implikasi patofisiologi oklusi koroer akut


27/40


28/40


29/40


30/40

Normal Arterial WallNormal Arterial Wall

Lumen

Media:

Smooth muscle cell

Matrix proteins

Internal elastic membrane

Endothelium

Intima:

External elastic membrane


31/40

Historical Model of At!eroenesis

healthy subclinical symptomatic

Threshold

Decades Years-Months Months-Days

la!ue

Intima

Media"umen

• Stable an#ina• Stable pla!ues $ith narro$in#• Simple dia#nostic %E&'( an#io#raphy)• *are MI• Easy to treat

Antischkow N. Beitr Path Anat Allg Path 1913;56:379-404.


32/40

"e# Paradim

healthy subclinical symptomatic

Threshold

Decades Years-Months Months-Days

Intima

Media

la!uela!ue

Thrombus

"umen

• +nstable an#ina• +nstable pla!ue no narro$in#• Di,,icult to dia#nose %I+S( M*I)• .re!uent MI $ith sudden death• Easy to pre/ent

$ i % ! i ' d t A


33/40

$main %ec!ni&ues 'sed to Assess

At!erosclerosis

( !nvsive te"hni2ues ) !ntrvs"ulr ultrsound 3!4U%5

) Coronry ngiogr(hy

( Non#invsive te"hni2ues ) Mgneti" resonn"e imging 3M6!5

) Com(uted tomogr(hy 3C'5

) Ultrsound 37#mode5

$ntra*ascular 'ltrasound +$,'S S!o#in


34/40

$ntra*ascular 'ltrasound +$,'S S!o#in

At!eromatous Pla&ue

Reproduced ro! Circulation "001;012:604#616$ with per!ission ro! %ippincott &i''i(!s ) &i'kins.

An#io#ram I+S

atheroma

normal/essel

C A i !

http://circ.ahajournals.org/content/vol103/issue4/images/large/hc0415065004.jpeg


35/40

Coronar. Aniorap!.

of Stenotic Coronar. Arter.

3

Arro$ indicates atherosclerosis %stenosis) o, the coronary artery


36/40

Se!a "as#$#as# ACS

:&al#asi UP

"istori, P4/ %isik, :KG, :n;ym kardiak

ST ele$asi

S#sp A(I

0o ST ele$asi

:n;ym < :8G serial

:n;ym A(I (@! :n;ym $I (-!

+AP #hest pai o car"iac


37/40

Pegelolaa A(I

$I = 1*am > S6 ele&asi /333

spirin, heparin

Syok/edema par# Trombolitik 3@6 6rom'olitik (?!

#ath'P#I


38/40

)oal < 7 mt

Door to ee"lePend AP ti'a di R:

:8G ST ele$asi

I"ikasi kotra trombolitik

3leeding akti% Ry stroke

6D 5 1@A/11A 3edah ma*or = 'l

Penyakit 'erat lainnya

TrombolitikStrept%#&ase

1,2 *#ta #nit

/BA menit

Primer P#I

Stroke

Risiko 'leeding

Syok kardiogenik

mt

mt

mtNo Ces


39/40

Treatmet of A#S

2e"uce a" pre$et thrombosis

2e"uce $asocostrictio 9

(!ocar"ial ox!ge "ema"

2epair e"othelial iFur! 9

2e$erse "!sfuctio

StabiliGe pla,ue


40/40

(14) Ischemic Heart Disease (ACS) Thn Lalu

Documents

Transcript of (14) Ischemic Heart Disease (ACS) Thn Lalu