Up Date on Acute Coronary Syndrome Management
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Transcript of Up Date on Acute Coronary Syndrome Management
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SymCARD 4 th
2014
Up Date on Acute Coronary Syndrome
Management
Dr . Muhammad Fadil, SpJP
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Pendahuluan
• Sindrom Koroner Akut (SKA) Meningkatkan angka perawatan dan Kematian di seluruh dunia
• Saat ini Penanganan SKA sudah mengalami banyak kemajuan dibanding 2 dekade terakhir
Marso SP, et al. Comparison of Myocardial Reperfusion in Patients Undergoing Percutaneous Coronary Intervention in ST-Segment Elevation Acute Myocardial Infarction With Versus Without Diabetes Mellitus. Am J Cardiol 2007;100: 206-210
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Klasifikasi SKA
ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2011
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Nyeri Dada Khas Infark
•Nyeri dada Angina Saat Istirahat (>20 Menit)
•Nyeri dada angina Pertama Kali (de Nuvo) dengan tingkatan CCS III
•Cresendo Angina
•Angina Paska Infark
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Elektrokardiografi
The most important Serial EKG is routinelyClassify ACSDetermine severity and
prognosis
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Elevasi Segmen ST pada J Point pada 2 lead yg berhubungan
≥0.25 mV Pada laki-laki dibawah 40th ≥0.2 mV pada laki-laki diatas 40th, or ≥0.15 mV
pada wanita di lead V2–V3 dan/atau ≥0.1 mV pada lead lainnya
Depresi Segmen ST horizontal/downsloping baru ≥ 0.1 mV pada 2 lead yg berhubunganT Inverted ≥ 0.1 mV
ESC Guidelines for the management of acute myocardial infarction in patients presentingwith ST-segment elevation. 2011.
STEMI
NSTEMI/UAP
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Marka Jantung
• Pada pasien dg SKA Peningkatan enzinm Troponin terjadi 4 jam setelah onset gejala
• Troponin dapat bertahan selama 2 minggu didalam darah
• Pemeriksaan serial harus dilakukan dlm 6-12 jam jika pemeriksaan pertama negatifPemeriksaan CKMB atau Troponin T sangat bermanfaat utk mendiagnosis SKA
ESC Guidelines for the management of Acute Coronary Syndrome in patients without persistent ST Elevation.2012
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Angiography Coroner
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Bagaimana Penanganan SKA?
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Tirah Baring (Kelas 1C)
Oksigen utk pasien dg Saturasi<95% atau distres nafas(I-C)
Suplemen Oksigen diberikan utk semua SKA dlm 6 jam pertama tanpa mempertimbangkan Saturasi (IIa-C)
Aspirin tanpa salut 160-320 mg pd semua ps yg toleran thdp Aspirin (I-C)
Clopidogrel dosis awal 300 mg, dilanjutkan 75 mg/hari(I-C)
Tindakan Umum & Langkah Awal
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Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
Suplemen Oksigen diberikan utk semua SKA dlm 6 jam pertama tanpa mempertimbangkan Saturasi (IIa-C)5
Anti Iskemik: NTG spray/tab (I-C), Morfin sulfat 1-5 mg IV dpt diulang setiap 10-30 menit (IIa-B)5
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Persangkaan SKA
Non Kardiak
Angina Stabil (Kronik)
Kemungkinan SKA
Definitif SKA
• EKG: Normal atau nondiagnostik
• Marka Jantung awal: Normal
Observasi 12 jam setelah awitan Angina
• Angina tdk berulang
• EKG:tdk berubah• Marka
jantung:Normal
NEGATIFDiagnostik: Bukan SKA atau Resiko rendah SKA
POSITIFDiagnosis: Definitif atau sangat mungkin SKA
• Angina berulang,atau• EKG: perubahan ST
dan/atau gelombang T
• Marka Jantung : positif
Definitif SKA
Terapi NSTEMI
Tanpa Elevasi segmen ST
Elevasi segemen ST (STEMI) atau LBBB
Baru
• Perubahan ST dan/atau
• Gelombang T• Angina berlanjut• Marka Jantung Positif• Hemodinamik
abnormal
Evaluasi terapi reperfusi
Pemantauan rawat Jalan
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
Algoritma evaluasi dan tatalaksana SKA
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Terapi Reperfusi pada STEMI
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.DIDO = door-in-door-out
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Jika Waktu yang dibutuhkan untuk mecapai RS dg Fasilitas PCI > 2jam Lakukan Fibrinolitik Di RS anda !
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Kontra Indikasi FibrinolitikKontraindikasi Absolut Kontraindikasi Relatif
Stroke hemoragik atau stroke yg penyebabnya blm diketahui dg awitan kapanpun
Transient Ischaemic Attact(TIA) dlm 6 bulan terakhir
Stroke iskemik 6 bulan terakhir Pemakaian antikoagulan oral
Kerusakan sistem syaraf sentral dan neoplasma
Kehamilan atau dalam 1 minggu post-partum
Trauma operasi/trauma kepala yg berat dalam 3 minggu terakhir
Resusitasi traumatik
Penyakit perdarahan Hipertensi refrakter (TDS >180 mmHg)
Diseksi aorta Penyakit hati lanjutInfeksi endokartis
Ultus peptikum yang aktif
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Regimen Fibrinolitik untuk Infark Miokard Akut
Agen Dosis Awal Ko Terapi Antitrombotik
Kontraindikasi spesifik
Streptokinase (Sk) 1,5 juta U dalam 100 ml dextrose 5% atau dlm larutan salin 0,9% dlm 30-60 menit
Heparin iv selama 24-48 jam
Sebelum SK atau Anistreptase
Alteplase (tPA) Bolus 15mg IV0,75 mg/kg selama 30 menit, kemudian 0,5 mg/kg selama 60 mrnitDosis total tidak lebih dari 100 mg
Heparin IV selama 24-48 jam
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Anti Iskemik
Penyekat Beta (Beta Blocker) (Kelas I-B)Nitrat (Kelas I-C)
Calcium Channel Blocker (CCB) (Kelas I-B)
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Anti Platelet
Aspirin : dosis loading 150-300 mg, dosis pemeliharaan 75-100 mg
Ticagrelor: dosis loading 180 mg,dosis pemeliharaan 2x90 mg
Clopidogrel: Dosis loading 300 mg, dosis pemeliharaan 75 mg/hari
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Anti Platelet
Aspirin : dosis loading 150-300 mg, dosis pemeliharaan 75-100 mg
Ticagrelor: dosis loading 180 mg,dosis pemeliharaan 2x90 mg
Clopidogrel: Dosis loading 300 mg, dosis pemeliharaan 75 mg/hari
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Ace Inhibitor(Mengurangi remodelling,menurunkan angka kematian pasca-infark)
Captopril : 2-3 x 6,25-50 mg
Ramipril : 2,5-10 mg/hari dalam 1 atau 2 dosisLisinopril: 2,5-20 mg/hari dalam 1 dosis
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Statin
Harus diberikan pada setiap pasien SKA (tanpa kontraindikasi)Anti inflamasi dan stabilisasi Plak (Kelas I-A)Terapi statin dosis tinggi hendaknya dimulai sblm pasien keluar RS, target LDL<100 mg/dL (Kelas I-A)
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi NSTEMI
Anti Koagulan (HARUS DITAMBAHKAN pd terapi Antiplatelet Secepat Mungkin)
Fundaparinuks : 2,5 mg subkutan (Kelas I-A)
Enoksaparin : 1 mg/kg,dua kali sehari (Kelas I-B)
UFH :Bolus i.v 60 u/g,dosis mak 4000 U, Infus i.v 12 U/kg selama 24-48 jam dg dosis maksimal 1000 U/jam, Target aPTT 1,5 – 2x Kontrol (Kelas I-C)
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Terapi Reperfusi pada NSTEMIRekomendasi Kelas rekomendasi Level
Urgent PCI (<2 jam)
Angiography segera dilakukan (<2 jam) pd pasien dengan:Angina refrakter Gagal JantungAritmia ventrikel yg mengancamHemodinamik tdk stabil
I C
Early Invasive (<24 jam)
Pada pasien dengan Skor GRACE > 140 atau dengan paling tidak 1 kriteria resiko tinggi
I A
Invasive Strategy (72 jam setelah presentasi)
1 kriteria resiko tinggiGejala rekuren
I A
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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Grace Score
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SKA
Anti Platelet
Anti Koagulan
Resiko Perdarahan↑
Mencegah Trombosis Lebih
Lanjut
Prognosis Baik Prognosis Buruk
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Hubungan Perdarahan dengan Angka Kematian
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20,078 Patients
12,092 Patients
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Cum
ulat
ive
Haz
ard
0.0
0.01
0.02
0.03
0 3 6 9 12 15 18 21 24 27 30
HR: 0.83 95% CI: 0.71-0.97p=0.02
Enoxaparin
Fondaparinux
0.04
Fondaparinux Significantly Reduced Mortality vs. Enoxaparin up to Day 30
1. ArixtraTM PI BPOM GDS04/IPI04 (23 January 2007).1. Salim Yusuf, et al. Comparison of Fondaparinux and Enoxaprine in Acute Coronary Syndrome.
The fifth organization to assess strategies in Acute Ischemic Syndrome investigator. N Egl J Med 2006:354:1446-76.
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Fondaparinux Reduced the Rate of the Composite of Death, MI or Stroke up to 6 Months
0.0
Days0 20 40 60 80 100 120 140 160 180
Cum
ulat
ive
Haz
ard
HR: 0.8995% CI: 0.82-0.97 p=0.007
Enoxaparin
Fondaparinux
0.02
0.04
0.06
0.08
0.10
0.12
0.14
1. ArixtraTM PI BPOM GDS04/IPI04 (23 January 2007).1. Salim Yusuf, et al. Comparison of Fondaparinux and Enoxaprine in Acute Coronary Syndrome.
The fifth organization to assess strategies in Acute Ischemic Syndrome investigator. N Egl J Med 2006:354:1446-76.
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Cum
ulat
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Haz
ard
0.0
0.01
0.02
0.03
0.04
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HR: 0.52 95% CI: 0.44-0.61 p<0.001
Enoxaparin
Fondaparinux
Fondaparinux Patients Experienced Half the Rate of Major Bleeding Than Enoxaparin Patients at Day 9
(Primary Safety)
1. ArixtraTM PI BPOM GDS04/IPI04 (23 January 2007).1. Salim Yusuf, et al. Comparison of Fondaparinux and Enoxaprine in Acute Coronary Syndrome.
The fifth organization to assess strategies in Acute Ischemic Syndrome investigator. N Egl J Med 2006:354:1446-76.
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Kesimpulan• SKA merupakan merupakan penyebab utama kematian mendadak di dunia
• Diagnosis dan tatalaksana meliputi, Pemberian antiplatelet, anti iskemik, antikoagulan, statin dan Ace inhibitor, Terapi Revaskularisasi (PCI atau Fibrinolitik) untuk STEMI
• Perdarahan Merupakan resiko yg mungkin tjd selama terapi SKA
• Fundaparinuk Secara keseluruhan memiliki profil keamanan berbanding risiko yg paling baik (Kelas I-A)
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Terimakasih