Kuliah SKA

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MI 1

Acute Coronary

Syndromes

®

Bag / SMF Ilmu Penyakit Dalam

FK Universitas Islam Sultan Agung

Semarang

2010



What is Acute Coronary Syndrome(ACS) ?

Acute Coronary Syndrome is when occlusion ofone or more of the coronary arteries occurs,usually following plaque rupture, resulting in

decreased oxygen supply to the heart muscle. ACS is the largest cause of death in U.S. Over 1

million people will have Myocardial Infarctions

this year; almost half will be fatal. Majority of mortality associated with ST

Elevation Myocardial Infarction (STEMI).



Acute Coronary Syndrome



Dimana Rasa Nyeri Dirasakan??



Acute Coronary Syndrome

Ischemic Discomfort

Unstable Symptoms

No ST-segment

elevation

ST-segment

elevation

Unstable Non-Q Q-Wave

angina AMI AMI

ECG

Cardiac

marker

History

Physical Exam



CAD Causes

Type Comments

Atherosclerosis Most common cause. Risk factors: hypertension,

hypercholesterolemia, diabetes mellitus, smoking, family history of

atherosclerosis.

Spasm Coronary artery vasospasm can occur in any population but is most

prevalent in Japanese. Vasoconstriction appears to be mediated by

histamine, serotonin, catecholamines, and endothelium-derived

factors. Because spasm can occur at any time, the chest pain is

often not exertion-related.

Emboli Rare cause of coronary artery disease. Can occur from vegetationsin patients with endocarditis.

Congenital Congenital coronary artery abnormalities are present in 1 to 2% of

the population. However, only a small fraction of these

abnormalities cause symptomatic ischemia.

6DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:

http://www.accesspharmacy.com



Pembuluh darah yang mengalami aterosklerosis & trombosis



Thrombus Formation and ACS

UA NQMI STE-MI

Plaque Disruption/Fissure/Erosion

Thrombus Formation

Non-ST-Segment Elevation AcuteCoronary Syndrome (ACS)

ST-SegmentElevation

Acute

Coronary

Syndrome

(ACS)

Old

Terminology:

NewTerminology:



Expanding Risk Factors

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Low HDL < 40

Elevated LDL / TG

Family History—

eventin first degree relative

>55 male/65 female

Age-- > 45 for male/55

for female

Chronic Kidney Disease

Lack of regular physicalactivity

Obesity

Lack of Etoh intake

Lack of diet rich infruit, veggies, fiber



Diagnosis Acute Coroner

Syndrome At least 2 of the

following

Ischemic symptoms Diagnostic ECG

changes

Serum cardiacmarker elevations



Unstable Angina - Definition

angina at rest (> 20 minutes)

new-onset (< 2 months) exertional angina

(at least CCSC III in severity) recent (< 2 months) acceleration of angina

(increase in severity of at least one CCSC

class to at least CCSC class III)

Agency for Health Care Policy Research - 1994

Canadian Cardiovascular Society Classification



Unstable Angina and Non-Q-

Wave Myocardial Infarction Evaluation and

management similar

Preliminary diagnosis Clinical symptoms

Risk factors

Electrocardiogram

Cardiac enzymes Assess short-term

risks



Unstable Angina

precipitating factors

Inappropriate tachycardia

anemia, fever, hypoxia, tachyarrhythmias,

thyrotoxicosis

High afterload aortic valve stenosis, LVH

High preload

high cardiac output, chamber dilatation

Inotropic state

sympathomimetic drugs, cocaine intoxication



TIMI Risk Score for Non – ST-Segment Elevation Acute Coronary Syndromes

Past Medical History Clinical Presentation

Age >65 years ST-segment depression (>0.5 mm)

>3 Risk factors for CAD >2 episodes of chest discomfort in the past 24 hrs

Hypercholesterolemia Positive biochemical marker for infarctiona

HTN

TM

Smoking

Family history of premature CHD

50% stenosis of coronary artery)

Use of aspirin within the past 7 days

Using the TIMI Risk Score

One point is assigned for each of the seven medical history and clinical presentation findings. The score (point)

total is calculated, and the patient is assigned a risk for experiencing the composite end point of death, myocardialinfarction or urgent need for revascularization as follows:

High Risk Medium Risk Low Risk

TIMI risk score 5 – 7 points TIMI risk score 3 – 4 points TIMI risk score 0 – 2 points

15

aTroponin I, troponin T, or creatinine kinase MB greater than the MI detection limit.

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:

http://www.accesspharmacy.com



Adverse Ischemic Events in Patients

with NSTE-ACS

Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk

score for unstable angina/non-ST elevation MI: a method for prognostication and

therapeutic decision making. JAMA.. 2000;284:835-842. Copyright © 2000, American

Medical Association. All rights reserved.

4.7 8.3

13.2

19.9 26.2

40.9

0

10

20

30

40

50

0/1 2 3 4 5 6/7

Number of Risk Factors

D e

a t h ,

M I , o r U r g e n t

R e

v a s c u l a r i z a t i o n

( % )



Unstable Angina

Therapeutic Goals

Therapeutic Goals

Reduce myocardial ischemia

Control of symptoms Prevention of MI and death

Medical Management

Anti-ischemic therapy Anti-thrombotic therapy



Unstable Angina

Medical Therapy

Anti-ischemic therapy

nitrates, beta blockers, calcium antagonists

Anti-thrombotic therapy Anti-platelet therapy

aspirin, ticlopidine, clopidogrel,

GP IIb/IIIa inhibitors

Anti-coagulant therapy

heparin, low molecular weight heparin (LMWH),

warfarin, hirudin, hirulog



Myocardial Infarction

Occlusion of coronary artery by thrombus

Progression of necrosis with time

Diagnosis

Clinical symptoms

Electrocardiogram

Cardiac enzymes



Ischemic Heart Disease

• angina, aortic stenosis

Nonischemic Cardiovascular Disease

• pericarditis, aortic dissection

Gastrointestinal

•

esophageal spasm, gastritis, pancreatitis,cholecystitis

Pulmonary

• pulmonary embolism, pneumothorax,

pleurisy

Differential Diagnosis



Acute Inferior Wall MI

http://homepages.enterprise.net/djenkins/ecghome.html



ST-Segment Elevation MI



BAGAIMANA GUIDELINES MENURUT ESC & ACC-AHA

GUIDELINE PENANGANAN PASIEN

ACS NON STENT



Diagnosa, penatalaksanaan dan persiapan/pre hospital oleh EMS :

- Monitor, support ABC. Persiapan untuk CPR dan defibrilasi

- Berikan oksigen, aspirin, nitroglycerin dan morphine bila dibutuhkan

- Jika tersedia, periksa ECG 12 lead, jika terdapat ST-Elevasi :

• Hubungi rumah sakit yang dituju dengan DX pasien

• Mulai membuat fibrinolytic checklist

- RS yang dituju harus menyaiapkan “Mobilize Hospital Resources” untuk

merespon pasien STEMI

Diagnosa cepat oleh Emergency Departemen Penatalaksanaan umum cepat oleh E.D(<10min)

- Check vital signs, evaluasi saturasi O2 - Morphin IV jika nyeri tidak berkurang

dengan - Pasang IV line nitroglycerin- ECG 12 lead - O2 4 L/mnt, pertahankan saturasi O2 >90%

- Anamnese singkat, terarah, pemeriksaan fisik - Nitroglycerin SL atau spray atau IV - Periksa awal level cardiac marker, elektrolit - Aspirin 160 samapai 325 mg (jika tidak Dan faal hemostatis diberikan oleh EMS)

- Periksa Rontgen dada (<30 m)

Nyeri dada (kecurigaan ischemia)

ACC/AHA ACLS ACS Algorithm 2006

1

2

3

4



Ulang pemeriksaan ECG 12lead

ST Elevasi atau LBBB baruatau diasumsikan baru;

dicurigai kuat ST-Elevasi MI(STEMI)

ST depresi atau T inverted;dicurigai kuat suatu ischemia

Resiko tinggi unstable angina/ Non ST Elevation MI

(AU/NSTEMI)

Normal atau tidak ada perubahansegmen ST atau gelombang T

Resiko rendah atau sedang untuk unstable angina

Mulai terapi tambahansesuai indikasi. Janganmenunda reperfusi -Clopidogrel --adrenergic reseptorblockers

-Heparin (UFH or LMWH)

Mulai terapi tambahan sesuaiindikasi

-Clopidogrel

-Nitroglycerin

--adrenergic reseptor blockers

-Heparin (UFH or LMWH)

-Glycoprotein IIb/IIIa inhibitor

Berlanjut memenuhi kriteriasedang atau tinggi (tabel

3,4)atau troponin positive?

Onset gejala < 12 jam Opname di ruangan dgn

“monitoring bed” Tentukan status resiko

Pertimbangkan opname di EDchest paint unit atau

“monitored bed” di ED

Lanjutkan dengan :

Serial cardiac marker(termasuk troponin)

Ulang ECG, monitor segmenST

Pertimbangan stress test

Strategi reperfusi:

Terapi ditetapkanberdasarkan keadaan pasiendan center criteria

Menyadari tujuan terapireperfusi: Door-to-balloon inflation(PCI) = 90 mnt

Door-to-needle (fibrinolysis)= 30 mnt

Lanjutkan dengan terapi:

ACE inhibitor/angiotensireceptor blocker (ARB) 24

jam dari onset HMG CoA reductase inhibitor(statin therapy)

Pasien High-risk: Refractory ischemic chest pain

Recurrent/persistent STdeviation

Ventricular tachycardia

Hemodynamic tachycardia Signs of pump failure

Strategi invasive awal termasuk kateterisasi & revaskularisasipenderita IMA dgn syok dlm 48

jam

Lanjutkan pemberian ASA,heparin & terapi lain sesuaiindikasi:

ACE inhibitor / ARB

HMG CoA reductase inhibitor(statin therapy)

Tidak pada resiko tinggi:penentuan penggolongan resikodari cardiology

Berlanjut memenuhikriteria resiko tinggi atau

sedang (tabel 3,4)atau

troponin-positive

Jika tidak ada ischemiaatau infare, maka dapatpulang dengan rencanakontrol

4

5 9

10

11

12

6

7

8

13

14

15

16

17

CRUSADE



5,95%

5,16% 4,97%

4,16%

6,33%

5,07%4,63%

4,17%

0

1

2

3

4

5

6

7

≤25% 25%–50% 50%–75% ≥75%

Hospital Composite Quality Quartiles

Adjusted

Unadjusted

Kepatuhan pada Guidelines

Menurunkan angka Mortality di Rumah Sakit

CRUSADE is a national quality improvement initiative of the Duke Clinical Research Institute. Partial funding for CRUSADE is provided by the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.

CRUSADE Data Q3 2006. Cumulative CRUSADE data through September 2003.Duke Clinical Research Institute. Available at: http://www.crusadeqi.com. Accessed February 13, 2007.

I n - h o s p i t a l M o r t a l i t y ( % )

Increased Adherence to Guidelines Decreases Mortality

CRUSADE

Definite Indications for



Definite Indications for

Thrombolytic Therapy

Consistent Clinical Syndrome

Chest pain, new arrhythmia, unexplained

hypotension or pulmonary edema

Diagnostic ECG

ST elevation 1 mm in 2 contiguous

leads or new left bundle-branch block

Less than 12 hours since onset of pain



Absolute Contraindications for

Thrombolytic Therapy History of hemorrhagic stroke

Stroke or CVA within 1 year

Allergy to the agent

Surgery or trauma in past 2wks

Known intracranial neoplasm Suspected aortic dissection

Active internal bleeding(except menstruation)

e a ve on ra n ca ons or



e a ve on ra n ca ons or Thrombolytic Therapy

Active peptic ulcer disease Significant hepatic dysfunction

Severe uncontrolled hypertension (> 180/110

mmHg ) History of chronic severe hypertensoin

Current anticoagulant use

Recent trauma ( within 2-4 weeks) Pregnancy

Allergy or prior exposure to streptokinase



Continuing Therapy

Heparin infusion after thrombolysis

(except after streptokinase)

Aspirin daily

Nitroglycerin for 24- 48 hours

-blocker unless contraindicated

Angiotensin-converting enzyme (ACE)

inhibitor within first 24 hours



Summary

UA NSTEMI AMI

Simptom Angineus 20 mnt/> Berat > 30 mnt

Sign + + + & > berat

EKG ST elevasi/depresi

T: pos tinggi &simetris /neg dalam

ST depresi

menetap > dlm &lama

T : neg dalam

Hiperakut T

ST elevasiQ patologis

Marker CKMB ( - )

Tropinin + / -

CKMB positif

Troponin - / +

CKMB ( + )

Troponin + / -



Pengobatan Cepat pada SKA

Oksigenisasi 2-3 l/mnt dg kanul

Aspirin 160 – 300 mg dikunyah

diberikan pada semua pasien SKA

Clopidogrel 300 mg Nitrogliserin (SL) 5 mg, jika sakit dada

tetap berlanjut dapat diulang setiap 5

menit sampai 3 kali pemberian ”tidak boleh diberikan pada pasien

dengan hipotensi”.

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