ACUTE CORONARY

SYNDROME

Triwedya Indra Dewi

Departemen Kardiologi dan Kedokteran Vaskular
Divisi Kardiovaskular, Departemen Ilmu Penyakit Dalam
FK-UNPAD/RS Hasan Sadikin
Bandung
BACKGROUND
Anginal pain in NSTE-ACS patients may have the
following presentations:

• Prolonged (>20 min) anginal pain at rest

• New onset (de novo) angina (class II or III of the

Canadian Cardiovascular Society classification)

• Recent destabilization of previously stable angina with

at least Canadian Cardiovascular Society Class III
angina characteristics (crescendo angina)

• Post-MI angina
 12 LEADS ECG IN <10 MINUTES
Morfin
2-4 mg slow iv bolus
repeated in 15’
Oxygen
if SaO2<94%
Nitrat
ISDN 5 mg SL up to 3x
CI if BP < 90 mmHg
Aspirin
180-325 mg non coated
“MONA greet chest pain patients at BLOOD SAMPLING (SERUM
the door” MARKER)

O’Connor, R. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Acute Coronary Syndromes. 
Circulation. 2010.
ST-segment elevation (measured at the J-point) is considered
suggestive of ongoing coronary artery acute occlusion:

• At least two contiguous leads

• 2.5 mm in men <40 years, 2 mm in men > 40years, or 1.5 mm in

women in leads V2–V3 and/or 1mm in the other leads

• Absence of left ventricular (LV) hypertrophy or left bundle branch

block LBBB
 In patients with inferior MI

• For RV infarction : record right precordial leads (V3R and V4R)

seeking ST-segment elevation ≥ 1.0 mm

• For posterior MI : V7-V9 ST-segment elevation 0.5mm

Two main ECG patterns associated with NSTEACS:

• ST segment depression
• T wave flattening or inversion

ST depression can be either upsloping, downsloping, or horizontal (see diagram

below)
• Horizontal or downsloping ST depression ≥ 0.5 mm at the J-point in ≥
2 contiguous leads indicates myocardial ischaemia
• ST depression ≥ 2 mm in ≥ 3 leads is associated with a high probability of NSTEMI
and predicts significant mortality (35% mortality at 30 days).
• Upsloping ST depression is non-specific for myocardial ischaemia.
 T wave inversion may be considered to be evidence of myocardial ischaemia if:

• At least 1 mm deep
• Present in ≥ 2 continuous leads that have dominant R waves (R/S ratio > 1)
• Dynamic — not present on old ECG or changing over time

NB. T wave inversion is only significant if seen in leads with upright QRS complexes (dominant R waves). T wave inversion is a normal variant
in leads III, aVR and V1.
Non-specific ST segment and T wave changes

• ST depression < 0.5 mm

• T wave inversion < 1 mm
• T wave flattening
• Upsloping ST depression
anti platelet
aspirin
Anticoagulant :
enoxaparine/fondaparinux/
UFH
Anti ADP :Ticagrelor or
clopidogrel

Fibrinolytic ?
REPERFUSION

ONSET <12 Hrs

Even if it is likely that fibrinolysis will be successful
(ST-segment resolution > 50% at 60–90 min;
typical reperfusion arrhythmia; and disappear- .
ance of chest pain), a strategy of routine early
angiography is recommended if there are no
contraindications.
“Do not forget” interventions in STEMI patients undergoing a primary
PCI strategy
“Do not forget” interventions in STEMI patients undergoing a successful
fibrinolysis strategy
DON’T FORGET TO PERFORM CORONARY ANGIOGRAPHY
CASE 1
• Male, 50 yo came to ER with angina since 2 hours before
admission, pain score 8/10

• The hospital is not facilitated with PCI lab, Nearest Hospital in 2

Hrs

• Previous history: HT (+), DM (+), Smoking (+)

• PF: BP 150/90, HR 60x, No specific finding

• ECG within 10 minutes at ER

ACS STEMI Anterior wall
MONA
1. Oxygen
2. Pain : ISDN 5 mg SL Reperfusion?
repeated until 3x, if PCI
persist —> NTG/ISDN or
iv Fibrinolytic
3. Morphine
4. Aspirin 160 mg chew
 STEMI onset <12 hrs
No CI for fibrinolysis

Clopidogrel 300 mg
Alteplase
Enoxaparine 30 mg iv bolus
15 minutes later 1mg/kg sc every 12 hours
until revascularization or hospital discharge
max 8 days ( the 1st two sc dose does not
exceed 100 mg)
CASE II
• Female, 60 yo came to ER with angina since 10 hours
before admission, pain score 7/10

• The hospital facilitated with PCI lab

• Previous history: Menopause, HT (+), DM(+)

• PF: BP 170/90, HR 80x, No specific finding

• ECG within 10 minutes at ER

Troponin T (+)
ACS NSTEMI
GRACE 150
MONA
1. Oxygen
2. Pain : ISDN 5 mg SL
repeated until 3x, if
persist —> NTG/ISDN PCI
iv <2 hrs
3. Morphine 24 hrs
4. Aspirin 160 mg chew 72 hrs?
Ticagrelor 180 mg, 2x90 next
day
fondaparinux 2.5 mg sc daily
European Heart Journal (2016) 37, 267–315
European Heart Journal (2016) 37, 267–315
European Heart Journal (2016) 37, 267–315
European Heart Journal (2016) 37, 267–315
European Heart Journal (2016) 37, 267–315
 BANDUNG
CITY
Area: 167.67 km2 

Population : 2,417,287
32 Hospitals 

78 Primary Health Care Centers
(Puskesmas/Pkm)

PCI capable hospital (7)

Hospital (27)
Puskesmas (78)

Acute Coronary 

Syndrome Incidence
222.3/100,000 per-year

= 2,417,287/100,000 x 222.3 = 5,374
Estimated 5,374 ACS case per-
year
50
Ref: Singapore Myocardial Infarction Registry Report No.2, 

Trends in Acute Myocardial Infarction in Singapore 2007-2012
TERIMA KASIH
From: 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with
EACTSThe Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and
of the European Association for Cardio-Thoracic Surgery (EACTS)
Eur Heart J. 2017;39(3):213-260. doi:10.1093/eurheartj/ehx419
Eur Heart J | The article has been co-published with permission in the European Heart Journal [DOI: 10.1093/eurheartj/ehx419] on behalf of the
European Society of Cardiology and European Journal of Cardio-Thoracic Surgery [DOI 10.1093/ejcts/ezx334] on behalf of the European
Association for Cardio-Thoracic Surgery. All rights reserved in respect of European Heart Journal, © European Society of Cardiology 2017. The