Acute Coronary Syndrome PDF

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.
2
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
3
Risk Factors
Uncontrollable
Controllable
Sex
High blood pressure
Hereditary
High blood cholesterol
Race
Smoking
Age
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

Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from

ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from
Coronary
Plaque
Stable
UA/NSTEMI
STEMI
thrombosis
rupture
angina
Penyempitan
Pembuluh darah
Clinical Spectrum of Acute Coronary Syndrome

Acute Coronary Syndrome
ST Segment
Elevation
Non-ST Segment
Elevation
STEMI
NSTEMI
Unstable
Angina Pectoris
Non-Q-wave
Q-wave
Acute Myocardial Infarction
Unstable
Angina
Non occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes
NSTEMI
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
ST depression +/T wave inversion on

ECG
Elevated 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
14
Pain Patterns with Myocardial

Ischemia
15
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
16
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
18
JUGULAR VENOUS PULSE
JVP usually normal

RV infarction : marked jug. venous distension
CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction
19
CHEST
LV failure and/or LV compliance : moist rales

Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification
Class
: patients free of rales or S3
II
: rales < 50% lung fields +/- S3
III : rales > 50% lung fields, frequently

pulm. edema
IV : cardiogenic shock
20
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
21
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
25
ST-segment depression
T-wave inversion
ELEKTROKARDIOGRAM
Current-of-injury patterns with acute
ischemia
28
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)
29
Plot of the appearance of cardiac markers in

blood versus time after onset of symptoms
A
B
myoglobin
troponin
C CK-MB
D troponin in UA
30
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,
31
Manajemen

ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Arrhythmia and
Loss of Muscle
Remodeling
Ventricular
Dilatation
Congestive
Heart Failure
End-stage Heart
Disease
Adapted from
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
3. RADIATION
4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS
5. DIAPORESIS
6. SHORTNESS OF BREATH
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
Immediate ED assessment ( 10 min)
Immediate ED general treatment
Vital sign
O2 at 4 L/min (maintain O2 sat 90%)
Oxygen saturation
Aspirin 160-325 mg
Obtain IV access
Nitroglycerin SL, spray, or IV
Obtain ECG 12 lead
Morphine IV 2-4 mg repeated every
Brief history and physical exam
5-10 minutes (if pain not relieved
Check contraindication for fibrinolytic
with nitroglycerine)
Initial serum cardiac markers

Initial electrolyte and coagulation
Memory: MONA greets all patients
study
Portable chest x-ray ( 30 minutes)

Review initial 12 lead ECG

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

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


presumably new LBBB
injury (STEMI)
ST-depression or
dynamic T-wave
inversion strongly
(UA/NSTEMI)
Normal or nondiagnostic changes

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


presumably new LBBB
injury (STEMI)
ST-depression or
dynamic T-wave
inversion strongly
(UA/NSTEMI)
Normal or nondiagnostic changes

in ST-segment or Twaves (intermediate/
low-risk UA)
Start adjunctive treatment
ADJUNCTIVE TREATMENT
(Do not delay reperfusion)
1. Beta-adrenergic receptor blocker

2. Clopidogrel
3. Heparin (UFH or LMWH)


presumably new LBBB
injury
ST-depression or dynamic
T-wave inversion strongly
Normal or nondiagnostic changes in

ST-segment or Twaves

Time from onset of
symptoms
12 hours
- Reperfusion strategy: PCI (90

min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin


presumably new LBBB
injury

Time from onset of

symptoms
12 hours
- Reperfusion strategy: PCI (90 min) or

fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin
Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors
-Adrenoreceptor blockers
Clopidogrel

presumably new LBBB
injury
Time from onset of

symptoms
12 hrs

Admit to monitored bed

Assess risk status
12 hours
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
- High risk: early invasive

strategy
- Continue ASA, heparin,
ACE-I, statin
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

presumably new LBBB
injury

Develops high or
intermediate risk criteria
or troponin-positive
Time from onset of

symptoms
12 hrs
Admit to monitored bed

Assess risk status
Monitored bed in ED
12 hours
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
- High risk: early invasive

strategy
- Continue ASA, heparin,
ACE-I, statin
Develops high or
intermediate risk criteria
or troponin-positive
No evidence of ischemia and MI: discharge with follow-up

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
53
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

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Acute Coronary Syndrome

Sindroma Koroner Akut

Plak aterosklerosis ruptur terbentuk

High blood pressure

High blood cholesterol

Stress and anger

The cardiovascular continuum of events

The cardiovascular continuum of events

The cardiovascular continuum of events

Clinical Spectrum of Acute Coronary Syndrome

ST depression +/T wave inversion on

50% nausea or vomiting in transmural infarcts

Pain Patterns with Myocardial

Anamnesis untuk UAP

restless, fist on chest

cold perspiration, pallor,

JUGULAR VENOUS PULSE

JVP usually normal

Pulse alternans : severe LV dysfunction

LV failure and/or LV compliance : moist rales

: patients free of rales or S3

: rales < 50% lung fields +/- S3

III : rales > 50% lung fields, frequently

Atau 2 mm pada 2 sadapan prekordial yang

Inversi gelombang T minimal 1 mm pada 2

Pemeriksaan Penanda Jantung/Enzim jantung

Peningkatan marka jantung akan terlihat pada infark

Plot of the appearance of cardiac markers in

4. Penyakit esofageal, GI atas atau traktus biliaris

5. Penyakit paru-paru : pneumotoraks, emboli,

The cardiovascular continuum of events

1. From onset of symptoms to patient recognition

ISCHEMIC CHEST PAIN ALGORYTHM

ISCHEMIC CHEST PAIN

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min)

Immediate ED general treatment

O2 at 4 L/min (maintain O2 sat 90%)

Nitroglycerin SL, spray, or IV

Obtain ECG 12 lead

Morphine IV 2-4 mg repeated every

Brief history and physical exam

5-10 minutes (if pain not relieved

Check contraindication for fibrinolytic

Initial serum cardiac markers

Memory: MONA greets all patients

Acute coronary syndrome algorithm

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Acute coronary syndrome algorithm

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Acute coronary syndrome algorithm

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Acute coronary syndrome algorithm

Review initial 12 lead ECG

Normal or nondiagnostic changes

Acute coronary syndrome algorithm

Review initial 12 lead ECG

Normal or nondiagnostic changes

Start adjunctive treatment