MI 2

Acute CoronarySyndromes

Acute CoronarySyndromes

®

Bag / SMF Ilmu Penyakit DalamFK Universitas Islam Sultan Agung

Semarang2014

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 indecreased oxygen supply to the heart muscle.ACS is the largest cause of death in U.S. Over 1million people will have Myocardial Infarctionsthis year; almost half will be fatal.Majority of mortality associated with STElevation Myocardial Infarction (STEMI).

Acute Coronary Syndrome

Dimana Rasa Nyeri Dirasakan??

CAD CausesType Comments

Atherosclerosis Most common cause. Risk factors: hypertension,hypercholesterolemia, diabetes mellitus, smoking, family history ofatherosclerosis.

Spasm Coronary artery vasospasm can occur in any population but is mostprevalent in Japanese. Vasoconstriction appears to be mediated byhistamine, serotonin, catecholamines, and endothelium-derivedfactors. Because spasm can occur at any time, the chest pain isoften 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% ofthe population. However, only a small fraction of theseabnormalities 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-SegmentElevationAcuteCoronarySyndrome(ACS)

OldTerminology:

NewTerminology:

Expanding Risk FactorsSmokingHypertensionDiabetes MellitusDyslipidemia Low HDL < 40 Elevated LDL / TG

Family History—eventin first degree relative>55 male/65 female

Age-- > 45 for male/55for female

Chronic Kidney Disease Lack of regular physical

activity Obesity Lack of diet rich in

fruit, veggies, fiber

Chest pain

11

ECG

Troponin rise /fall

Bio-chemistry

Diagnosis

STEMI NSTEMIAdapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366

ST segmentST depressionST elevation

Troponinnormal

UA

Diagnosis Acute CoronerSyndrome

At least 2 of thefollowing

Ischemic symptomsDiagnostic ECG

changesSerum cardiac

marker elevations

Unstable Angina -Definition

angina at rest (> 20 minutes)new-onset (< 2 months) exertionalangina (at least CCSC III in severity)recent (< 2 months) acceleration ofangina (increase in severity of at leastone CCSC class to at least CCSC classIII)

Agency for Health Care Policy Research - 1994Canadian Cardiovascular Society Classification

Unstable Angina andNon-Q-Wave Myocardial

InfarctionEvaluation andmanagement similarPreliminary diagnosis Clinical symptoms Risk factors Electrocardiogram Cardiac enzymes

Assess short-termrisks

Unstable Anginaprecipitating factors

Inappropriate tachycardia anemia, fever, hypoxia, tachyarrhythmias,

thyrotoxicosisHigh afterload aortic valve stenosis, LVH

High preload high cardiac output, chamber dilatation

Inotropic state sympathomimetic drugs, cocaine intoxication

GRACE REGISTRYHigher mortality 6months afterdischarge inNSTEMI vs STEMI

NSTEMI

STEMI

UA

NSTEMI

STEMI

UA

Fox KAA et al. BMJ 2006;333:1091-1094

Risk Stratification is important in NSTE-ACSManagement

TIMI SCORETIMI SCORE GRACE SCOREGRACE SCORE

recommended as thepreferred classification toapply on admission and atdischarge in daily clinical

routine practice

recommended as thepreferred classification toapply on admission and atdischarge in daily clinical

routine practice

Less accurate in predictingevents but its simplicity

makes it useful and widelyaccepted

Less accurate in predictingevents but its simplicity

makes it useful and widelyaccepted

Hamm W et al. European Heart Journal 2007; 28:1598–1660; Hamm CW et al. Eur Heart J2011;32:2999 – 3054

CLINICAL CONDITIONCLINICAL CONDITION1

2 3

• Relevant rise or fall in troponin• Dynamic ST- or T-wave changes

(symptomatic or silent)• GRACE Score > 140

• Diabetes mellitus• Renal insufficiency(eGFR <60 mL/min/1.73 m²)

• LVEF < 40% or congestive HF• Early post infarction angina• Prior PCI• Prior CABG• GRACE risk score 109 - 140

HIGH RISKHIGH RISK VERY HIGH RISKVERY HIGH RISK

• Haemodynamic instability orcardiogenic shock

• Recurrent or ongoing chestpain refractory to medicaltreatment

• Life-threatening arrhythmiasor cardiac arrest

• Mechanical complications ofMI

• Acute heart failure• Recurrent dynamic ST-T

wave changes, particularlywith intermittent ST-elevation

Intermediete RISKIntermediete RISK

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

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

21

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

GRACE RISK SCOREAge ( Years ) Point< 40 040 – 49 850 – 59 3660 – 69 5570 – 79 73> 80 91

Heart Rate< 70 070 – 89 790 – 109 13110 – 149 23150 – 199 36> 200 46

Systolic BP (mmHg )< 80 6380 – 99 58100 – 119 47120 – 139 37140 – 159 26160 – 199 11> 200 0

Creatinin (mg/dl)0,0 – 0,39 20,4 – 0,79 50,8 – 1,19 81,2 – 1,59 111,6 – 1,99 140,2 – 3,99 23> 4 31Killip class

Class I 0Class II 20Class III 39Class IV 59

Cardiac arrest at admission 43Elevated cardiac marker 15ST segmen deviation 30

Total possible score is 258

Bleeding risk score – CRUSADE SCORE

Hamm CW et al. Eur Heart J 2011;32:2999 – 3054

Very low < 20 ; low (21–30) ; moderate (31– 40);high (41–50); very high (50)

Unstable AnginaTherapeutic Goals

Therapeutic GoalsReduce myocardial ischemiaControl of symptomsPrevention of MI and death

Medical ManagementAnti-ischemic therapyAnti-thrombotic therapy

Unstable AnginaMedical 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 bythrombusProgression of necrosis with timeDiagnosisClinical symptomsElectrocardiogramCardiac 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 DiagnosisDifferential Diagnosis

Acute Inferior Wall MI

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

ST-Segment Elevation MI

Definite Indications forThrombolytic TherapyDefinite Indications forThrombolytic TherapyConsistent Clinical Syndrome Chest pain, new arrhythmia,

unexplained hypotension or pulmonaryedema

Diagnostic ECG ST elevation 1 mm in 2 contiguous

leads or new left bundle-branch blockLess than 12 hours since onset of pain

Consistent Clinical Syndrome Chest pain, new arrhythmia,

unexplained hypotension or pulmonaryedema

Diagnostic ECG ST elevation 1 mm in 2 contiguous

leads or new left bundle-branch blockLess than 12 hours since onset of pain

Continuing TherapyContinuing Therapy

Heparin infusion after thrombolysis(except after streptokinase)Aspirin dailyNitroglycerin for 24- 48 hours-blocker unless contraindicatedAngiotensin-converting enzyme (ACE)inhibitor within first 24 hours

Heparin infusion after thrombolysis(except after streptokinase)Aspirin dailyNitroglycerin for 24- 48 hours-blocker unless contraindicatedAngiotensin-converting enzyme (ACE)inhibitor within first 24 hours

SummaryUA NSTEMI AMI

Simptom Angineus 20 mnt/> Berat > 30 mnt

Sign + + + & > berat

EKG ST elevasi/depresiT: pos tinggi &

simetris /neg dalam

ST depresimenetap > dlm &

lamaT : neg dalam

Hiperakut TST elevasiQ patologis

Marker CKMB ( - )Tropinin + / -

CKMB positifTroponin - / +

CKMB ( + )Troponin + / -

Pengobatan Cepat pada SKA

Oksigenisasi 2-3 l/mnt dg kanulAspirin 160 – 300 mg dikunyah diberikan pada semua pasien SKAClopidogrel 300 mgNitrogliserin (SL) 5 mg, jika sakitdada tetap berlanjut dapat diulangsetiap 5 menit sampai 3 kalipemberian ” tidak bolehdiberikan pada pasien denganhipotensi”.