3 Acute Coronary Syndrome
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Acute Coronary Syndrome
Sindroma Koroner Akut
Toni Mustahsani Aprami, dr., SpPD, SpJP
Department of Cardiology and Vascular Medicine
Division of Cardiovascular, Department of Internal Medicine
Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung
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DEFINISISuatu sindroma klinik yang menandakan
adanya 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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PATOGENESIS• Umumnya disebabkan oleh
aterosklerosis koroner
• Plak aterosklerosis ruptur terbentuk trombus 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 SyndromeAcute Coronary Syndrome
Non-ST SegmentNon-ST SegmentElevationElevation
ST SegmentST SegmentElevationElevation
UnstableUnstableAngina PectorisAngina Pectoris
Non-Q-waveNon-Q-wave Q-waveQ-wave
Acute Myocardial InfarctionAcute Myocardial Infarction
STEMISTEMI
NSTEMINSTEMI
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Unstable
Angina STEMI
NSTEMINSTEMI
Non Non occlusive occlusive thrombusthrombus
Non specific Non specific ECGECG
Normal Normal cardiac cardiac enzymesenzymes
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis
ST depression +/- T wave inversion on ECG
Elevated cardiac enzymes
Complete thrombus Complete thrombus occlusionocclusion
ST elevations on ST elevations on ECG or new LBBBECG or new LBBB
Elevated cardiac Elevated cardiac enzymesenzymes
More severe More severe symptomssymptoms
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Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
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HISTORYPRODROMAL SYMPTOMS
History very valuable to establish D/. Prodoma : chest discomfort – unstable angina
1/3 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 infarcts
Occasionally 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 Myocardial Ischemia
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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
(increasing angina)
• Riwayat penyakit dahulu : Riwayat angina on effort, infark atau
operasi pintas Riwayat penggunaan nitrogliserin Identifikasi faktor-faktor risiko
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PHYSICAL EXAMINATIONGENERAL APPEARANCEAnxious, considerable distress, restless, fist on chest
(Levine sign)LV failure & symp. stimulation : cold perspiration, pallor,
dyspnea, cough with frothy pink or blood-streaked sputum.
Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientation
HEART RATEVariable depending on underlying rhythm and degree or
ventr. failureMost commonly, HR 100 – 110/min; > 95% patients :
VPB’s within first 4 hours
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BLOOD PRESSUREMajority normotensive, but syst. BP may decline and diast.
BP may rise Half of pts with inferior MI parasympathetic stimulation
: hypotension, bradycardia or both (Bezold – Jarisch reflex)
half of pts with anterior MI, sympathetic excess : hypertension, tachycardia or both
TEMPERATURE AND RESPIRATIONMost pts with extensive MI fever within 24-48 hrs, fever
resolves by 4th or 5th dayRespiration 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 sadapan extremitas
Atau 2 mm pada 2 sadapan prekordial yang berurutan
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 acute ischemia
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 in blood versus time after onset of symptoms
A myoglobin C CK-MBB 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 hiperventilasi
7. Gangguan dinding dada : muskuloskeletal, neurogen
8. Psikogen
Diagnosis Banding
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Manajemen
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ACS
Coronary Thrombosis
Myocardial Ischemia
CAD
Atherosclerosis
Risk Factors( , BP, DM,
Insulin Resistance, Platelets, Fibrinogen, etc)
Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
The cardiovascular continuum of events
DYSLIPIDEMIA
Arrhythmia andLoss of Muscle
Remodeling
Ventricular Dilatation
Congestive Heart Failure
End-stage Heart Disease
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DELAY TO THERAPY
1. From onset of symptoms to patient recognition
2. Out-hospital transport
3. In-hospital evaluation
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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
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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: “MONA” greets all patients
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
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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
Acute coronary syndrome algorithm
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
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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
Acute coronary syndrome algorithm
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
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ST-depression or dynamic T-wave
inversion strongly suspicious for injury
(UA/NSTEMI)
ST elevation or new or presumably new LBBB strongly suspicious for
injury (STEMI)
Acute coronary syndrome algorithm
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
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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 strongly suspicious for injury
(UA/NSTEMI)
ST elevation or new or presumably new LBBB strongly suspicious for
injury (STEMI)
Acute coronary syndrome algorithm
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
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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
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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
Acute coronary syndrome algorithm
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
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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
Acute coronary syndrome algorithm
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
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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
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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
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
12 hrs Admit to monitored bedAssess risk status
- High risk: early invasive strategy- Continue ASA, heparin, ACE-I, statin
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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
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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
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Start adjunctive treatment
Admit to monitored bedAssess risk status
- High risk: early invasive strategy- 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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Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan
Aspirin Beta-blocker ACE inhibitor
Pengobatan Pasca Perawatan
Berhenti merokok Pertahankan BB optimal Aktivitas fisik sesuai dengan hasil treadmill Diet Rendah lemak jenuh dengan kolesterol, bila
perlu dengan 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.
•Don’t smoke.
•Exercise regularly.
•Maintain a healthy weight.
•Eat a heart-healthy diet.
•Manage stress.
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Thank you for your attentionThank you for your attention
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Anamnesis• Nyeri dada atau nyeri epigastrium hebat yang
mengarah pada iskemia miokard : Seperti dihimpit benda berat Terasa tercekik Rasa ditekan, ditinju, ditikam Rasa terbakarBiasanya dirasakan dibelakang stenum seluruh
dada terutama kiri, dapat ke tengkuk, rahang, bahu,
punggung, lengan kiri atau kedua lengan
• Terutama laki-laki > 35 tahun dan Wanita > 40 tahun
• Seringkali disertai mual atau muntah, dapat pula rasa tidak enak disertai sesak nafas, lemah, penurunan kesadaran, dan keringat banyak
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Pemeriksaan Fisik
• Biasanya penderita tampak cemas, gelisah, pucat, dan keringat dingin
• Periksa tanda-tanda vital : Denyut nadi cepat, reguler tetapi dapat pula
bradi atau tachycardia, irama ireguler Tekanan darah biasanya normal bila belum
terjadi komplikasi, dapat pula terjadi hipo atau hipertensi
Bunyi jantung dapat terdengar redup S3 dapat terdengar bila kerusakan miokard
luas Paru-paru dapat terdengar ronkhi basah dan
atau wheezing yang menandakan terjadinya bendungan paru tergantung ada tidaknya gangguan fungsi ventrikel kiri