SIDROMA KORONER AKUT
-
Upload
ukht-marutu -
Category
Documents
-
view
226 -
download
0
Transcript of SIDROMA KORONER AKUT
-
7/31/2019 SIDROMA KORONER AKUT
1/28
UA/NSTEMI 9/00
SIDROMA KORONER AKUT
UMAR F SHIBLY
SPESIALIS JANTUNG DAN PEMBULUH DARAH
-
7/31/2019 SIDROMA KORONER AKUT
2/28
UA/NSTEMI 9/00
-
7/31/2019 SIDROMA KORONER AKUT
3/28
UA/NSTEMI 9/00 Atherosclerotic Plaque Stability
Adapted from Weissberg. Atherosclerosis. 1999;147:S3S10
DEMANDSUPPLY
-
7/31/2019 SIDROMA KORONER AKUT
4/28
UA/NSTEMI 9/00Characteristics of the
stable atherosclerotic plaque
Lipid core
Adventitia
-
7/31/2019 SIDROMA KORONER AKUT
5/28
UA/NSTEMI 9/00
-
7/31/2019 SIDROMA KORONER AKUT
6/28
UA/NSTEMI 9/00
SAKIT DADA
NON JANTUNGJANTUNG
ANGINA
STABIL TAK STABIL
ATIPIKAL
KEDARURATAN
-
7/31/2019 SIDROMA KORONER AKUT
7/28
UA/NSTEMI 9/00FEATURES NOTCHARACTERISTIC
OF MYOCARDIAL ISCHEMIA (CONTD
Pain reproduced with movement or palpationof the chest wall or arms
Very brief episodes of pain that last a fewseconds or less
Pain that radiates into the lower extremities
-
7/31/2019 SIDROMA KORONER AKUT
8/28
-
7/31/2019 SIDROMA KORONER AKUT
9/28
UA/NSTEMI 9/00UA/NSTEMI
EMERGENCY ROOM TRIAGE
Chest pain or severe epigastric pain, typical ofmyocardial ischemia or MI:
Substernal compression or crushing chest pain
Pressure, tightness, heaviness, cramping,
aching sensation Unexplained indigestion, belching, epigastric pain
Radiating pain to neck, jaw, shoulders, back or toone or both arms
Associated dyspnea, nausea and/or vomiting,diaphoresis
IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG
-
7/31/2019 SIDROMA KORONER AKUT
10/28
UA/NSTEMI 9/00UA/NSTEMI
THREE PRINCIPAL PRESENTATIONS
Rest Angina* Angina occurring at rest andprolonged, usually > 20 minutes
New-onset Angina New-onset angina of at least CCSClass III severity
Increasing Angina Previously diagnosed angina that hasbecome distinctly more frequent,longer in duration, or lower inthreshold (i.e., increased by > 1 CCS)
class to at least CCS Class III severity
BraunwaldCirculation 80:410; 1989
* Pts with NSTEMI usually present with angina at rest.
S S C O
-
7/31/2019 SIDROMA KORONER AKUT
11/28
UA/NSTEMI 9/00RISK STRATIFICATION IN
EMERGENCY DEPARTMENT
Prolonged ischemic discomfort (>20 min), ongoingrest pain, accelerating tempo of ischemia
Pulmonary edema; S3 or new rales
New MR murmurHypotension, bradycardia, tachycardia
Age >75 years
Rest pain with transient ST-segment changes
> 0.05 mV; new bundle-branch block, new
sustained VT
Elevated (e.g. TnT or TnI>0.1 ng/mL)
History
Clinical findings
ECG
Cardiac markers
HIGH RISK-FEATURES (RISK RISES WITH NUMBER)
-
7/31/2019 SIDROMA KORONER AKUT
12/28
UA/NSTEMI 9/00
ACUTE CORONARY SYNDROME
No ST Elevation ST Elevation
Unstable Angina NQMI QwMIMyocardial Infarction
NSTEMI
-
7/31/2019 SIDROMA KORONER AKUT
13/28
UA/NSTEMI 9/00
-
7/31/2019 SIDROMA KORONER AKUT
14/28
UA/NSTEMI 9/00
-
7/31/2019 SIDROMA KORONER AKUT
15/28
UA/NSTEMI 9/00
N Engl J Med. 339:436-43, 199
PURSUIT TRIAL: DEATH OR MI
Days
1
0.98
0.96
0.94
0.92
0
0.9
0.88
0.86
0.84
0.82
0.8 30 60 90 120 150 180
-
7/31/2019 SIDROMA KORONER AKUT
16/28
UA/NSTEMI 9/00RECOMMENDATION
Class I
1. Patients with suspected ACS with chestdiscomfort at rest for >20 min, hemodynamic
instability, or recent syncope or presyncopeshould be referred immediately to an ED or aspecialized chest pain unit.
Other patients with a suspected ACS may beseen initially in an ED, a chest pain unit, oran outpatient facility.
-
7/31/2019 SIDROMA KORONER AKUT
17/28
UA/NSTEMI 9/00ANTI - ISCHEMIC Rx
Class I1. Bed rest with continuous ECG monitoring in pts with
ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.3. Supplemental O2 for pts with hypoxemia, cyanosis or
respiratory distress; finger pulse oximetry or arterialblood gas determination to confirm SaO2>90%.
4. Morphine sulfate IV when symptoms are not immediatelyrelieved with NTG or when acute pulmonary congestionand/or severe agitation is present.
-
7/31/2019 SIDROMA KORONER AKUT
18/28
UA/NSTEMI 9/00ANTI - ISCHEMIC Rx (contd)
Class I5. A -blocker with the first dose administered IV if there
is ongoing chest pain, followed by oral administration.
6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or
diltiazem) as initial therapy in pts with continuing orfrequently recurring ischemia when -blocker iscontraindicated.
7. An ACEI when hypertension persists despite treatment
with NTG and a -blocker in pts with LV systolicdysfunction or congestive heart failure and in ACSpatients with diabetes.
-
7/31/2019 SIDROMA KORONER AKUT
19/28
UA/NSTEMI 9/00ANTIPLATELET Rx
Class I1. Administer ASA as soon as possible after
presentation and continue indefinitely.
2. A thienopyridine (clopidogrel or ticlopidine) in pts
unable to take ASA.
3. Add IV UFH or subcutaneous LMWH to antiplatelettherapy with ASA, clopidogrel, or ticlopidine.
4. Add platelet GP IIb/IIIa receptor antagonist in ptswith continuing ischemia or with other high-riskfeatures and in pts in whom early PCI is planned.
-
7/31/2019 SIDROMA KORONER AKUT
20/28
UA/NSTEMI 9/00ANTIPLATELET Rx
Class I
Definite ACS with continuingPossible ACS Likely/Definite ACS Ischemia or Other High-Risk
Features or planned PCI
Aspirin Aspirin Aspirin+ +
Subcutaneous LMWH IV heparin/LMWHor
IV heparin IV platelet GP IIb/IIIa antagoni
+
BIOCHEMICAL CARDIAC MARKERS IN
-
7/31/2019 SIDROMA KORONER AKUT
21/28
UA/NSTEMI 9/00BIOCHEMICAL CARDIAC MARKERS IN
PTS WITH SUSPECTED ACS WITHOUT ST
CK-MB
1. Rapid, cost-
efficient, accurateassays
2. Ability to detectearly reinfarction
Myoglobin
1. High sensitivity
2. Useful in earlydetection of MI
3. Detection ofreperfusion
4. Most useful inruling out MI
Troponins
1. Powerful for stratificatio
2. Greater sensitivity andspecificity than CK-MB
3. Detection of recent MI uto 2 weeks after onset
4. Useful for selection oftherapy
5. Detection of reperfusion
Advantages
COCAINE
-
7/31/2019 SIDROMA KORONER AKUT
22/28
UA/NSTEMI 9/00COCAINE
CLINICAL CHARACTERISTICS
Ischemic chest pain
Usually male < 40 years
Cigarette smokers, but no other risk factors for
atherosclerosis
Associated with all routes of administration
Not dose dependent
Often associated with use of cigarettes and/or
alcohol
Adapted from Pitts et al.Prog. Cardiovasc. Dis. 40:65, 1997
SPECIAL GROUPS
-
7/31/2019 SIDROMA KORONER AKUT
23/28
UA/NSTEMI 9/00SPECIAL GROUPS
COCAINE
1. NTG and oral Ca2+ blocker for pts with STdeviation that accompanies ischemic chest
discomfort.
2. Immediate coronary arteriography in pts with STelevation after NTG and Ca2+ blocker;
thrombolysis if a thrombus is detected.
Class I
-
7/31/2019 SIDROMA KORONER AKUT
24/28
UA/NSTEMI 9/00ED MANAGEMENT OF UA/NSTEMI
No recurrent pain;Neg follow-up studies
Nondiagnostic ECGNormal serum cardiac markers
ObserveFollow-up at 4-8 hours: ECG, cardiac markers
Neg: nonischemicdiscomfort;low-risk UA/NSTEMI
YESNO
ST and/or T wave changesOngoing pain
+ cardiac markersHemodynamic abnormalities
Recurrent ischemic pain or+ UA/NSTEMI follow-up studies
Diagnosis of UA/NSTEMIconfirmed
ADMIT+ UA/NSTEMI confirmed
Outpatient follow-up
Evaluate
forReperfusion
ST ?
Stress study to provokeischemia prior to discharge
or as outpatient
-
7/31/2019 SIDROMA KORONER AKUT
25/28
UA/NSTEMI 9/00POST-HOSPITAL DISCHARGE CARE
A Aspirin and Anticoagulants
B Beta blockers and BloodPressure
C Cholesterol and Cigarettes
D Diet and Diabetes
E Education and Exercise
-
7/31/2019 SIDROMA KORONER AKUT
26/28
UA/NSTEMI 9/00MEDICATIONS AT HOSPITAL DISCHARG
1. Aspirin 75 to 325 mg/d
2. Clopidogrel 75 mg/qd for patients withcontraindication to ASA
3. -Blocker4. Lipid-lowering agent and diet in patients with
LDL cholesterol >130 mg/dL
5. Lipid-lowering agent if LDL cholesterol level after
diet is > 100 mg/dL6. ACEI for patients with CHF, LV dysfunction
(EF
-
7/31/2019 SIDROMA KORONER AKUT
27/28
UA/NSTEMI 9/00
1. Smoking cessation and achievement or maintenancof optimal weight, daily exercise, and diet.
2. HMG-CoA reductase inhibitor for LDL cholesterol
> 130 mg/dL.
3. Lipid-lowering agent if LDL cholesterol after diet is> 100 mg/dL.
4. Hypertension control to a BP < 130/85 mm Hg.
5. Tight control of hyperglycemia in diabetics.6. Consider referral of smokers to a smoking
cessation program.
INSTRUCTIONS AT HOSPITAL DISCHARGRISK FACTOR MODIFICATION
Class I
-
7/31/2019 SIDROMA KORONER AKUT
28/28
UA/NSTEMI 9/00