Acute Coronary Syndrome 052014
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Transcript of Acute Coronary Syndrome 052014
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Acute Coronary Syndrome
Sindroma Koroner Akut
Dr M.Diah, SpPD-KKV, FCIC, FINASIM
Departemen KardiologiInstalasi Kateterisasi Jantung
Divisi Kardiologi Departemen Ilmu Penyakit Dalam
FKUNSYAH/RSUZA BANDA ACEH
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MUHMMAD DIAH
SD, SMP, SMA Bireuen
Dokter Umum: FK UNSRI Palembang
Internist : FK UNSRI, Palembang
Konsultan Kardiovaskuler: RCSM-RSMH Kolegium
Intervensi Jantung:
- Angiografi : 2011 (RSCM)
- Fellow Intervention Clinical Cardiologi (FCIC)
Institut Jantung Negara (IJN). Kuala Lumpur
- Sertifikasi Intervensi Cardiologi Tk III (Koleguim)
Pekerjaan:Staf Departemen Kardiologi RSUZA/FK UNSYIAH
Staf Subdivisi Kardiologi Bag Penyakit Dalam RSUZA.FK
UNSYIAH
Ka Instalasi Kateterisasi Jantung RSUZA Banda Aceh
Staf SP2 Kardiologi, Bagian Peny Dalam RSMH/FK UNSRI
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3
DEFINISI
Suatu sindroma klinik yang menandakanadanya iskemia miokard akut, terdiri dari :
Infark miokard akut Q wave (STEMI)
Infark miokard akut non-Q (NSTEMI)
Angina pektoris tidak stabil (UAP)
Ketiga kondisi ini sangat berkaitan erat, berbeda
hanya dalam derajat beratnya iskemi dan
luasnya miokard yang mengalami nekrosis.
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4
PATOGENESIS
Umumnya disebabkan oleh aterosklerosis
koroner
Plak aterosklerosis ruptur terbentuktrombus diatas ateroma yang secara akut
menyumbat lumen koroner
Apabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan
nekrosis
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Uncontrollable
Sex
Hereditary
Race
Age
Controllable
High blood pressure
High blood cholesterol
Smoking
Physical activity
Obesity
Diabetes
Stress and anger
Risk Factors
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CAD
Atherosclerosis
Risk Factors
( ,BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
The cardiovascular continuum of events
DYSLIPIDEMIA
Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
Myocardial
Ischemia
plaque
Ischemia = oxygen supply
and demand imbalance
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CAD
Atherosclerosis
Risk Factors
( ,BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
The cardiovascular continuum of events
DYSLIPIDEMIA
Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
Myocardial
Ischemia
Coronary
Thrombosis
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CAD
Atherosclerosis
Risk Factors
( ,BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
The cardiovascular continuum of events
DYSLIPIDEMIA
Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
Myocardial
Ischemia
Coronary
Thrombosis
ACS
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Stable anginaPlaque ruptureCoronary thrombosisUA/NSTEMISTEMI
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PenyempitanPembuluh darah
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Clinical Spectrum of Acute Coronary Syndrome
Acute Coronary Syndrome
Non-ST Segment
Elevation
ST SegmentElevation
Unstable
Angina Pectoris
Non-Q-wave Q-wave
Acute Myocardial Infarction
STEMI
NSTEMI
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Unstable
AnginaSTEMINSTEMI
Non occlusive
thrombus
Non specificECG
Normal
cardiac
enzymes
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
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Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
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HISTORY
PRODROMAL SYMPTOMS
History very valuable to establish D/. Prodoma : chest discomfort
unstable angina1/3 symptoms for 1 4 wks
20% symptoms for < 24 hrs
Malaise, exhaustion
NATURE OF PAIN Most patients
severe prolonged, 30 minutes - hours Constricting, crushing, oppressing, compressing
heavy weight or squeezing in chest
Choking, vise-like, heavy pain or stabbing, knife-like, boring or
burning discomfort
Location : retrosternal, spreading frequently to both sides of the
chest with predilection to the left side
Often pain radiates down ulnar aspect of left arm, producing
tingling sensation in left wrist, hand and fingers
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NATURE OF PAIN
SOME INSTANCES : pain begins in epigastrium, and simulates
abdominal disorder
Sometimes pain radiates to shoulders, upper extremities, neck, jaw
and interscapular region favoring the left side
Elderly : no chest pain but acute left ventricular failure and chest
tightness or marked weakness or syncope
Pain arises from nerve endings in ischemic or injured, but not necrotic,
myocardium
OTHER SYMPTOMS
50% nausea or vomiting in transmural infarctsOccasionally diarrhea, profound weakness, dizziness, palpitation, cold
perspiration, sense of impending doom
Occasionally : cerebral embolism or systemic arterial embolism
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Pain Patterns with MyocardialIschemia
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Anamnesis untuk UAP
3 kategori presentasi klinik UAP:
Angina saat istirahat (resting angina)
Angina awitan baru (new onset angina)
Angina yang bertambah berat (increasingangina)
Riwayat penyakit dahulu :
Riwayat angina on effort, infark atauoperasi pintas
Riwayat penggunaan nitrogliserin
Identifikasi faktor-faktor risiko
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PHYSICAL EXAMINATION
GENERAL APPEARANCE
Anxious, considerable distress, restless, Levine sign (fistsign: costricting, pressing pain typical of angina pectoris)
LV failure & symp. stimulation : cold perspiration, pallor,dyspnea, cough with frothy pink or blood-streakedsputum.
Shock : cool, clammy skin, facial pallor, cyanosis,confusion or disorientation
HEART RATEVariable depending on underlying rhythm and degree or
ventr. failure
Most commonly, HR 100 110/min; > 95% patients :
VPBs within first 4 hours
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BLOOD PRESSURE
Majority normotensive, but syst. BP may decline and diast.
BP may riseHalf of pts with inferior MI parasympathetic stimulation
: hypotension, bradycardia or both (Bezold Jarischreflex)
half of pts with anterior MI, sympathetic excess :hypertension, tachycardia or both
TEMPERATURE AND RESPIRATION
Most pts with extensive MI fever within 24-48 hrs, feverresolves by 4thor 5thday
Respiration due to anxiety and pain, in LV failure : resp.rate correlates with degree of heart failure
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JUGULAR VENOUS PULSE
JVP usually normal
RV infarction : marked jug. venous distension
CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction
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CHEST
LV failure and/or LV compliance : moist rales
Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification
Class I : patients free of rales or S3
II : rales < 50% lung fields +/- S3
III : rales > 50% lung fields, frequently
pulm. edema
IV : cardiogenic shock
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Pemeriksaan Penunjang
Pemeriksaan EKG
Gambaran EKG infark miokard akut Q-wave (STEMI) :
Elevasi segmen ST 1 mm pada 2 sadapanextremitas
Atau 2 mm pada 2 sadapan prekordial yangberurutan
Atau gambaran LBBB baru atau diduga baru
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ST-segment elevation
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Gambaran EKG infark miokard akut non-Q-
wave (NSTEMI)atau angina pektoris tidak
stabil (UAP) :
Depresi segment ST atau gelombang T
terbalik pada 2 sadapan berurutan Inversi gelombang T minimal 1 mm pada 2
sadapan atau lebih yang berurutan.
Perubahan segment ST saat keluhan dan
kembali normal saat keluhan hilang sangat menyokong UAP
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ST-segment depression
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T-wave inversion
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Current-of-injury patterns with acuteischemia
ELEKTROKARDIOGRAM
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Pemeriksaan Penanda Jantung/Enzim jantung
(Cardiac Markers):
Yang lazim adalah CKMB, dapat pula troponin T (TnT)
atau troponin I (TnI)
Peningkatan marka jantung akan terlihat pada infark
miokard akut Q-wave (STEMI) dan non-Q-wave
(NSTEMI)
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Plot of the appearance of cardiac markers inblood versus time after onset of symptoms
A myoglobin C CK-MB
B troponin D troponin in UA
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1. Diseksi aorta
2. Perikarditis
3. Nyeri angina atipikal pada kardiomiopati
hipertrofi
4. Penyakit esofageal, GI atas atau traktus biliaris
5. Penyakit paru-paru : pneumotoraks, emboli,
pleuritis
6. Sindroma hiperventilasi7. Gangguan dinding dada : muskuloskeletal,
neurogen
8. Psikogen
Diagnosis Banding
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KRITERIA DIAGNOSTIK (WHO) :
1. Klinis : keluhan terbanyak adalah nyeri dada
2. Perubahan gambaran EKG :
Dengan elevasi segmen ST : STEMI
Tanpa elevasi segmen ST : UAP, NSTEMI
3. Peningkatan kadar enzim jantung :
1. Kadar CK, CK-MB
2. Kadar Troponin I/ Troponin T
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Kasus 1
Laki-laki, usia 50 tahun Nyeri dada semakin memberat sejak 7 jam
sebelum masuk rumah sakit
Riwayat nyeri sebelumnya (-) FR : merokok, HT dan DM tidak diketahui
Riw Keluarga : PJK (+)
PF : CM, TD=140/90 mmHg
Cor dan Pulmo : dalam batas normalAbdomen : dalam batas normal
Ekstremitas : edema -/-
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Kasus 1
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Interpretasi EKG ?
a. STEMI Anterior dan NSTEMI
Inferior
b. STEMI Anteroseptal dan OMIInferior
c. STEMI Anteroseptald. NSTEMI Inferior
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STEMI Anteroseptal
Terdapat perubahan pada segmen STberupaelevasi yang merupakan terjadinyaacuteinjury di anteroseptal ( leads V1-V4)
Dengan atau tanpa perubahan resiprokalberupa depresi segmen ST pada sandapaninferolateral
Gamb EKG : Acute Injury pada sandapan V1-V3 :
Elevasi segmen ST upsloping Gel T yang tinggi
Perubahan resiprokal pada sandapan II,III-aVF
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Kasus 1
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Interpretasi EKG ?
a. STEMI Anterior dan NSTEMI
Inferior
b. STEMI Anteroseptal dan OMIInferior
c. STEMI Anteroseptald. NSTEMI Inferior
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Kasus 2
Laki-laki, 36 tahun
Nyeri dada hebat sejak40 menit sebelum
datang ke IGD rumah sakit
FR : tidak jelas. Kadar lipid belum diperiksa
PF : CM. TD = 130/90 mmHg
Lain-lain dalam batas normal
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Kasus 2
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Interpretasi EKG ?
a. NSTEMI Anterior dan Inferior
b. STEMI Anterior Ekstensif/Luas
c. STEMI Anterior Ekstensif/Luas dengan
Ventricular ectopic beats
d. STEMI Anteroseptal
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STEMI Anterior Ekstensif/Luas dengan
Ventricular Ectopic beats
Terdapat perubahan berupa elevasi segmenST yang menunjukkan terdapatnya acuteinjury pada hampir seluruh sandapananterior (V1-V6) dan I-aVL
Dengan atau tanpa perubahan resiprokalpada berupa depresi segmen ST padasandapan inferior
Gamb EKG : Gambaran HIPERAKUT : jam-jam pertama infark
Peningkatan tinggi gel R
Elevasi ST upsloping
Gel T yang lebar dan tinggi
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Kasus 2
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Interpretasi EKG ?
a. NSTEMI Anterior dan Inferior
b. STEMI Anterior Ekstensif/Luas
c. STEMI Anterior Ekstensif/Luas dengan
Ventricular ectopic beats
d. STEMI Anteroseptal
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Kasus 3
Wanita, 67 tahun
Nyeri dada semakin memberat sejak3 jam
FR : riw DM (+)
PF : CM. TD = 140/90 mmHg
Lab :
GDS = 250 mg/dL Troponin T (-), CK dan CK-MB dalam batas normal
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Kasus 3
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Interpretasi EKG ?
a.OMI Anteroseptal
b.NSTEMI Inferior
c.STEMI Anteroseptal
d.STEMI Lateral
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STEMI Lateral
Terdapat perubahan pada segmen ST berupaelevasidi sandapan lateral (V4-V6) dan I-aVL
Dengan atau tanpa perubahan resiprokal berupadepresisegmen ST pada sandapan inferior
Gamb EKG : Gamb acute injury pada sandapan V4-V6 dan I-aVL :
Elevasi ST upsloping
Gel T yang tinggi
Perubahan resiprokal pada sandapan inferior (leads III
dan aVF) Kemungkinan terdapat infark lama di daerah
anteroseptal :poor R wave progression
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Kasus 3
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Interpretasi EKG ?
a.OMI Anteroseptal
b.NSTEMI Inferior
c.STEMI Anteroseptal
d.STEMI Lateral
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Kasus 4
Laki-laki, usia 60 tahun
Nyeri dada beberapa jam sebelum masuk RS
(onset tidak jelas)
FR : DM (+)
PF : CM. TD = 80/50 mmHg
Cor dan Pulmo dalam batas normal
Lain-lain tidak ditemukan kelainan
Lab : Troponin T (+)
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Kasus 4
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Interpretasi EKG
a. STEMI Inferior
b. STEMI Inferior dan Infark Ventrikel
Kananc. NSTEMI Inferior dan Infark Ventrikel
Kanan
d. Infark Ventrikel Kanan
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STEMI Inferior
dengan Infark Ventrikel Kanan
Perubahan pada segmen ST di daerah inferior(leads II, III dan aVF) berupa elevasi,menunjukkan terjadinya acute injury .
Infark inferior sering berhubungan dan Infark padaVentrikel Kanan. Ditandai dengan elevasisegmenST > 1 mm pada sandapan V4R .
Gamb EKG : Incomplete RBBB Infark miokard inferior akut
Infark ventrikel kanan akut Perubahan resiprokal pada berupa depresi ST pada
sandapan anterior Junctional Premature Beat (JPB) Ventricular Premature Beat pada sandapan V4-V6
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Kasus 4
JPB
VES
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Interpretasi EKG
a. STEMI Inferior
b. STEMI Inferior dan Infark Ventrikel
Kananc. NSTEMI Inferior dan Infark Ventrikel
Kanan
d. Infark Ventrikel Kanan
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Interpretasi EKG :
Curiga iskemi/infark inferior, harus dilakukanpemeriksaan ventrikel kanandan posterior
Gejala klinis tidak khas pada pasien DM dan usialanjut
Komplikasi infark inferiordan infark ventrikelkanan :
infark inferior : blok pada AV node
infark ventrikel kanan : gangguan
hemodinamik
EVOLUSI EKG PADA STEMI
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EVOLUSI EKG PADA STEMI
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EVOLUSI EKG
ELECTROCARDIOGRAPHIC HIGHLIGHTS
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Anatomic
Region
Coronary Artery Descriptive
Leads
Anterior wallAnteroseptal
Anteroseptal Lateral
Septal wall
Inferior wall
Inferior and RV
Inferoposterior
Posterior wall
Lateral wall
Anterolateral
Inferolateral
posterolateral
LADLAD
Proximal LAD
LAD
RCA; LCX
Proximal RCA
RCA; LCX
RCA; LCX
LAD
LAD; LCX
LAD; LCX
LAD; LCX
V3 and V4V1 to V4
V1-V6, I and aVL
V1 and V2
II, III and aVF
II, III, aVF, V1, V2
and V3R-V6R
II, III, aVF, V1,
V2 and V7-V9
V1, V2 and V7-V9
V5, V6, I and aVL
V3-V6, I and aVL
II, III, aVF, I, aVL,
V5 and V6
V1, V2, V7 to V9,
V5, V6, I and aVL
ELECTROCARDIOGRAPHIC HIGHLIGHTS
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Kasus 5
Laki-laki, usia 42 tahun
Nyeri dada yang memberat sejak 2 hari
sebelum datang ke IGD
RPD : infark miokard akut 1 tahun yang lalu,
belum dilakukan intervensi selain obat-obatan
FR : merokok
PF : CM. TD = 130/80 mmHg
Lain-lain dalam batas normal
Kasus 5
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Interpretasi EKG ?
a. Angina Pektoris Stabil
b. Angina Pektoris tidak Stabil (UAP)
c. Angina pasca infark
d. NSTEMI Anteroseptal
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Deep and symmetr ical T waveinvers ion pada sandapan anterior
(V1-V5, I-aVL)
Inversi gelombang T seringkalimerupakan perubahan yang non-
spesifik kecuali inversi yang
bentuknya dalam dan simetris
Kasus 5
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Interpretasi EKG ?
a. Angina Pektoris Stabil
b. Angina Pektoris tidak Stabil (UAP)
c. Angina pasca infark
d. NSTEMI Anteroseptal
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Manajemen
The cardiovascular continuum of events
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ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
( ,BP, DM,Insulin Resistance, Platelets,
Fibrinogen, etc)Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
DYSLIPIDEMIA
Arrhythmia and
Loss of Muscle
Remodeling
Ventricular
Dilatation
Congestive
Heart Failure
End-stage Heart
Disease
DELAY TO THERAPY
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DELAY TO THERAPY
1. From onset of symptoms to patient recognition
2. Out-hospital transport
3. In-hospital evaluation
ISCHEMIC CHEST PAIN ALGORYTHM
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ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
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ISCHEMIC CHEST PAIN
TYPICAL ANGINA EQUIVALENT ANGINA
1. CHEST DISCOMFORT
2. LOCATION
3. RADIATION
4. UNLIKELINESS
1. NO CHEST DISCOMFORT
2. LOCATION
3. INDIGESTION
4. UNEXPLAINED WEAKNESS
5. DIAPORESIS
6. SHORTNESS OF BREATH
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Chest discomfort suggestive of ischemia
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Immediate ED assessment and immediate ED general treatment
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
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Chest discomfort suggestive of ischemia
Immediate ED assessment ( 10 min)Vital sign
Oxygen saturation
Obtain IV access
Obtain ECG 12 lead
Brief history and physical exam
Check contraindication for fibrinolytic
Initial serum cardiac markers
Initial electrolyte and coagulation
study
Portable chest x-ray ( 30 minutes)
Immediate ED general treatment
O2 at 4 L/min (maintain O2 sat 90%)
Aspirin 160-325 mg
Nitroglycerin SL, spray, or IV
Morphine IV 2-4 mg repeated every
5-10 minutes (if pain not relieved
with nitroglycerine)
Memory: MONAgreets all patients
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
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Review initial 12 lead ECG
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Acute coronary syndrome algorithm
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ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
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ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
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ST-depression or
dynamic T-wave
inversion stronglysuspicious for injury
(UA/NSTEMI)
ST elevation or new or
presumably new LBBB
strongly suspicious forinjury (STEMI)
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Normal or non-
diagnostic changes
in ST-segment or T-waves (intermediate/
low-risk UA)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
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Start adjunctive treatment
Normal or non-
diagnostic changes
in ST-segment or T-waves (intermediate/
low-risk UA)
ST-depression or
dynamic T-wave
inversion stronglysuspicious for injury
(UA/NSTEMI)
ST elevation or new or
presumably new LBBB
strongly suspicious forinjury (STEMI)
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
ADJUNCTIVE TREATMENT
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1. Beta-adrenergic receptor blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)
ADJUNCTIVE TREATMENT
(Do not delay reperfusion)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
Ch t di f t ti f i h i
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Start adjunctive treatment
Normal or non-
diagnostic changes in
ST-segment or T-
waves
ST-depression or dynamic
T-wave inversion strongly
suspicious for injury
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Time from onset of
symptoms
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin
12 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Acute coronary syndrome algorithm
Chest discomfort s ggesti e of ischemia
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Time from onset of
symptoms
- Reperfusion strategy: PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin
12 hours
Start adjunctive treatment
Normal or non-
diagnostic changes in
ST-segment or T-
waves
ST-depression or dynamic
T-wave inversion strongly
suspicious for injury
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
Adj ncti e t eatment
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Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors
-Adrenoreceptor blockers Clopidogrel
Adjunctive treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia
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Time from onset of
symptoms
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
12 hours
Start adjunctive treatment
Normal or non-
diagnostic changes in
ST-segment or T-
waves
ST-depression or dynamic
T-wave inversion strongly
suspicious for injury
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
12 hrs Admit to monitored bed
Assess risk status
-High risk: early invasive
strategy
-Continue ASA, heparin,
ACE-I, statin
VERY HIGH-RISK PATIENT
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VERY HIGH RISK PATIENT
1. Refractory chest pain
2. Recurrent/persistent ST deviation
3. Ventricular tachycardia
4. Hemodynamic instability
5. Sign of pump failure
6. Shock within 48 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia
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2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Time from onset of
symptoms
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
12 hours
12 hrs
Start adjunctive treatment
Normal or non-
diagnostic changes in
ST-segment or T-
waves
ST-depression or dynamic
T-wave inversion strongly
suspicious for injury
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Start adjunctive treatment
Admit to monitored bed
Assess risk status
-High risk: early invasivestrategy
-Continue ASA, heparin,
ACE-I, statin
Develops high or
intermediate risk criteria
or troponin-positive
Monitored bed in ED
Develops high or
intermediate risk criteria
or troponin-positive
No evidence of ischemia and MI: discharge with follow-up
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Pengobatan Pasca Perawatan
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89
Obat-obat untuk mengontrol keluhan iskemiaharus dilanjutkan
Aspirin Beta-blocker
ACE inhibitor
Berhenti merokok
Pertahankan BB optimal
Aktivitas fisik sesuai dengan hasil treadmill
Diet
Rendah lemak jenuh dengan kolesterol, bila perludengan target LDL < 100 mg/dL
Pengendalian hipertensi
Pengendalian ketat gula darah pada penderita DM
Modifikasi Faktor Risiko
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Get regular medical checkups.
Control your blood pressure.Check your cholesterol.
Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.Manage stress.
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Thank you for your attention