How To Treat Acute Coronary

Sydrome (STEMI Patient) in Pre

and Post Hospital

Dr. Mustika Mahbubi SpJP FIHA

 Introduction
• Ischamic heart disease is the single most common
cause of death and its frequency is increasing. 1,8
million annual death in european

• Incidense of STEMI dan NSTEMI remaines constant or

increased slightly.

• The mortality in STEMI/NSTEMI pastient is influenced

by many factor, advance age, Killip clalss, time delay to
treatment, presence of emergency medical system
network, treatment strategy, history of MI, other disease
complications (DM, renal failure, etc)
• mortality remains substantial; the inhospital mortality of
unselected patients with STEMI in the national
registries of the ESC countries varies between 4 and
12%,23 1-year mortality among STEMI patients in
angiography registries is approximately 10%

• Several recent study have highlited a fall in acute and

long term-term mortality following STEMI/NSTEMI in
parallel with use of reperfusion therapy, PCI,
Antithrombotic therapy, and secondary prevention
 DISCUSSION

• How To Diagnose ACS? WHY its

Important to differentiate NSTE-ACS
and STE-ACS?
• How to Manage patient with STE-
ACS/NSTE-ACS?
• What is Fibrinolysis?
• Risk Stratification and Prognosis of
ACS?
How To Diagnose ACS?
Definition
• Sekumpulan keluhan
dan tanda klinis yang
sesuai dengan iskemia
miokardium akut yang
disebabkan oleh
trombosis/aterosklerotik
pada pembuluh darah
koroner sehingga
menyebabkan sumbatan
sebagian atau seluruh
lumen pembuluh darah
 Pathophysiology of ACS
Evolution of Coronary Thrombosis
 Clinical presentations

• Anamnesis : OPQRST (Onset,

Provocation, Quality, Radiation, Scale,
Time)
• Waspadai angina ekuivalen pada
subpopulasi tertentu seperti pasien
dengan diabetes melitus, geriatri.
 Diagnosis

1. KELUHAN NYERI DADA/ ANGINA

2. PERUBAHAN EKG (SEGMEN ST-T )
3. PERUBAHAN ENZIM JANTUNG (TROPONIN T/I)

Kriteria diagnosis SKA: terpenuhi 2

dari 3 kriteria di atas
Evolution of serum biomarkers in acute
myocardial infarction
ECG
ECG
ECG
SPECTRUM OF ACS
WHY its Important to Differentiate NSTE-
ACS and STE-ACS?

How to Manage patient with STE-

ACS/NSTE-ACS?
Universal Classification of Myocardial Infarction
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ALGORITME
Reperfusion Strategy for NSTEACS
What IS Fibrinolysis?
Reperfusion strategy
 indication of fibrinolysis

• STEMI
• New LBBB
• Onset < 12 jam, efektif < 6 jam, efektifitas
tinggi < 3 jam
• Non PCI hospital
 Preparation

1. PERSIAPAN PASIEN  INFORM CONSENT

2. CEK LIST FIBRINOLISIS, KONTRAINDIKASI?
3. PERSIAPAN OBAT DAN ALAT
STREPTOKINASE
TROLI EMERGENCY, MONITOR EKG DAN DEFIBRILATOR
LEMBAR MONITORING
4. AKSES IV  JIKA TIDAK STABIL SIAPKAN 2 JALUR
5. MONITORING  TTV DAN PAHA
6. EVALUASI  SUKSES OR FAILED?
 MONITORING

• DILAKUKAN TIAP 5-10 MENIT

• KELUHAN?
• TANDA VITAL
• KELUHAN NYERI DADA
• EKG-ARITMIA REPERFUSI
• KOMPLIKASI (perdarahan, Aritmia,
Hipotensi, Alergi)
Data fibrinolisis di RSUD RAA Soewondo
April - September
Risk Stratification and Prognosis of
ACS?
• TIMI ( Thrombolysis in Myocardial Infarction)
• GRACE (Global Registry of Acute Coronary Events)
• Killip
• Troponin
• Presentasi Klinis pasien
Monitoring and Observation
 TIMI for UAP/NSTEMI
• TIMI risk score for UAP/NSTEMI for predicting 30-day
mortality
 TIMI for STEMI
• TIMI risk score for STEMI for predicting 30-day mortality
 KILLIP
Killip classification  development of heart failure in order to predict and
stratify their risk of mortality
GRACE
Troponin
 Long term management

• Antiplatelet
• ADP selama 12 bulan kecuali high risk bleeding
• Statin  target LDL <70 mg/dl (IB)
• B-bloker terutama pada pasien dengan LVEF ≤40%
• ACE/ARB terutama LVEF ≤40%
• Antagonis aldosteron pada pasien dengan failure atau
LVEF ≤35%
• Nitrat k/p
• Diet
• Life style dan kontrol faktor resiko
 Conclusion

• Anamnesis dan pemeriksaan fisik yang terarah, MONA

dapat diberikan pada kemungkinan ACS sesegera
mungkin di layanan primer sebelum di rujuk
• Spektrum ACS (STE-ACS dan NSTE-ACS) memiliki
manajemen awal yang hampir sama tetapi dengan
strategi reperfusi dan prognosis yang berbeda sehingga
perlu dibedakan
• Pencegahan sekunder dan pengobatan jangkan panjang
penting dilakukan karena kejadian iskemik cenderung
terjadi dengan laju yang tinggi setelah fase akut.
Thank You