Acute Coronary Syndrome Sindroma Koroner Akut

DEFINISI
Suatu 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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Risk Factors
Uncontrollable
Sex Hereditary Race Age

Controllable
High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Stress and anger

The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance
Myocardial Ischemia

CAD

plaque
Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

Coronary Thrombosis Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

ACS
Coronary Thrombosis Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

Coronary Plaque Stable UA/NSTEMI STEMI thrombosis rupture angina

Penyempitan Pembuluh darah

Clinical Spectrum of Acute Coronary Syndrome Acute Coronary Syndrome

Non-ST Segment Elevation

ST Segment Elevation
STEMI NSTEMI

Unstable Angina Pectoris

Non-Q-wave Q-wave Acute Myocardial Infarction

Unstable Angina
Non occlusive thrombus

NSTEMI
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/T wave inversion on ECG Elevated cardiac enzymes

STEMI
Complete thrombus occlusion ST elevations on ECG or new LBBB

Non specific ECG

Normal cardiac enzymes

Elevated cardiac enzymes

More severe symptoms

Diagnosis
Anamnesis

Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi

3. Thoraks Foto

HISTORY
PRODROMAL 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 13 tingling sensation in left wrist, hand and fingers

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 operasi pintas Riwayat penggunaan nitrogliserin Identifikasi faktor-faktor risiko

atau

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PHYSICAL EXAMINATION
GENERAL APPEARANCE Anxious, considerable distress, (Levine sign) LV failure & symp. stimulation : dyspnea, cough with frothy sputum. Shock : cool, clammy skin, confusion or disorientation
restless, fist on chest cold perspiration, pallor, pink or blood-streaked facial pallor, cyanosis,

HEART RATE Variable depending on underlying rhythm and degree or ventr. failure Most commonly, HR 100 110/min; > 95% patients : VPBs within first 4 hours 17

BLOOD PRESSURE Majority 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 RESPIRATION Most pts with extensive MI fever within 24-48 hrs, fever resolves by 4th or 5th day Respiration 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 II : patients free of rales or S3 : 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

Gambaran EKG infark miokard akut non-Qwave (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

T-wave inversion

ELEKTROKARDIOGRAM
Current-of-injury patterns with acute ischemia

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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 B troponin

C CK-MB D troponin in UA

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Diagnosis Banding
1. Diseksi aorta 2. Perikarditis 3. Nyeri angina hipertrofi atipikal pada kardiomiopati

4. Penyakit esofageal, GI atas atau traktus biliaris

5. Penyakit paru-paru : pneumotoraks, emboli, pleuritis

6. Sindroma hiperventilasi

7. Gangguan neurogen
8. Psikogen

dinding

dada

muskuloskeletal,

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Manajemen

The cardiovascular continuum of events

ACS
Coronary Thrombosis Arrhythmia and Loss of Muscle

Myocardial Ischemia

Remodeling

CAD

Ventricular Dilatation Congestive Heart Failure End-stage Heart Disease

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of ischemia

ISCHEMIC CHEST PAIN

TYPICAL ANGINA

EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT 1. CHEST DISCOMFORT 2. LOCATION

2. LOCATION
3. INDIGESTION 4. UNEXPLAINED WEAKNESS 5. DIAPORESIS 6. SHORTNESS OF BREATH

3. RADIATION
4. UNLIKELINESS

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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

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

study
Portable chest x-ray ( 30 minutes)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

ST-depression or dynamic T-wave inversion strongly suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI) ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI) Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI)
Start adjunctive treatment

ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI)

Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

ADJUNCTIVE TREATMENT (Do not delay reperfusion)

1. Beta-adrenergic receptor blocker 2. Clopidogrel 3. Heparin (UFH or LMWH)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 hours of onset - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors -Adrenoreceptor blockers Clopidogrel

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 Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hrs Admit to monitored bed Assess risk status

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves Develops high or intermediate risk criteria or troponin-positive Monitored bed in ED Develops high or intermediate risk criteria or troponin-positive

Start adjunctive treatment 12 hrs Admit to monitored bed Assess risk status

No evidence of ischemia and MI: discharge with follow-up

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Pengobatan Pasca Perawatan

Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan Aspirin Beta-blocker ACE inhibitor

Modifikasi Faktor Risiko

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

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Get regular medical checkups. Control your blood pressure.

Check your cholesterol.

Dont smoke. Exercise regularly. Maintain a healthy weight. Eat a heart-healthy diet. Manage stress.

Thank you for your attention

Anamnesis
Nyeri dada atau nyeri epigastrium hebat yang mengarah pada iskemia miokard : Seperti dihimpit benda berat Terasa tercekik Rasa ditekan, ditinju, ditikam Rasa terbakar Biasanya 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 56

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 57 ventrikel kiri