Intervention Procedure in

Acute Coronary Syndrome

Dr. dr. Eka Ginanjar, Sp.PD-KKV, FINASIM, FACP, FICA

Division of Cardiology, Internal Medicine Departement, Faculty of Medicine Universitas

Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Pelayanan Jantung Terpadu (PJT) RS Dr Cipto Mangunkusumo, Jakarta

 CURRICULUM VITAE
Dr. dr. Eka Ginanjar, SpPD, K-KV, FINASIM, FACP, FICA
 Education:
 Medical Doctor – FKUI 2003 Interest:
 Spesialis Penyakit Dalam (SpPD) – FKUI/RSCM 2009 Interventional Cardiology
 Clinical and Interventional Cardiology – National Heart Peripheral & Endovascular Intervention
Institute, Kuala Lumpur Malaysia 2012 Emergency Medicine
 Konsultan Kardiovaskular (KKV), FKUI/RSCM 2014 Acute Cardiovascular Care
 PhD in Medical Science – FKUI 2019 Heart Failure and Stem Cell
 Fellow/membership: Public Health and Health Economics
 Instructor for American Heart Association (AHA) BLS-ACLS Hospital Management
2010
 Fellow of Indonesian Society of Internal Medicine (FINASIM)
2012
 Fellow of American College of Physician (FACP) 2014
 Fellow of International College of Angiology (FICA) 2015
 Member of European Society of Cardiology (ESC) 2013
 Member of European Association of Percutaneous
Cardiovascular Interventions (EAPCI) 2013
 Member of Acute Cardiovascular Care Association (ACCA)
2013
 Position:
 Medical Staff and Lecturer at FKUI/RSCM
 Clinical and Interventional Cardiologist at PJT-RSCM
 Clinical and Interventional Cardiologist at RS MMC Jakarta
 General Secretary of Indonesian Society of
Cardiocereberovascular
 HEAD OF INTEGREATED HEART CENTRE (PJT) – RSCM
@Dr_EKG
 Secretary General of PAPDI
CASE
 Tn. T 40 yo
 Presented with typical chest pain since 4 hours
 Referred from RS K
 Smoker 1-2 packs per day
 Fatigue, BP 120/80 mmHg, HR 60 bpm, RR 20 x/m
WHAT SHOULD WE DO….?
 The Cardiovascular Continuum of Events

ACS
Coronary
Secondary Arrhythmia and
prevention
Thrombosis Stroke Loss of Muscle

Myocardial Remodeling
Ischemia

Ventricular
CAD Dilatation

Atherosclerosis Congestive
Heart Failure
Primary
prevention Risk Factors End-stage
( Dyslipidemia,  BP, , Heart Disease
Insulin Resistance,
Adapted from
Platelets, Fibrinogen, etc)
Dzau et al. Am Heart J. 1991;121:1244-1263
 Spectrum of Pathology and Clinical IHD

Stable angina NSTEMI STEMI

IHD= Ischaemic heart disease

ACS
NSTEMI= Non ST segment elevation myocardial infarction
STEMI= ST segment elevation acute myocardial infarction
ACS= Acute coronary syndrome

Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.

Ischemic Heart Disease
SUPPLY vs DEMAND
Initial Assessment for ACS patients

10 minutes

No need to
wait the result
REVASCULARIZATION
RISK Stratification on NSTEMI/UAP
 Case 2
 Mrs. S 45 YO
 Chest pain since 12 hours, on and off
 DM
 Trop T Negatif
Component Time Delay

In Hospital and EMS

Diagnose capabilities

Improve Public
Awareness ACS Network
CODE STEMI
 Importance for Early Reperfusion

 Reperfusion is a key strategy in Acute STEMI care

and it time dependent
 Shortening the time from symptom to reperfusion
and choosing the optimal reperfusion strategy for
STEMI patients are a great challenges in practice.
 The infarction related artery (IRA) must be opened
early, consistently, and thoroughly in order to
effectively restore myocardial perfusion

1. Zhang et al. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2011; 12(8):629-632; 2. Ibanez B et al. Eur Heart J. 2017; 00: 1–66
TIME and Myocardial Salvage
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
 Recommended / Should be Not
indicated considered recommended

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

 Recommended / Should be Not
indicated considered recommended
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
2017

A primary PCI strategy is

recommended over fibrinolysis
within indicated Timeframes
1A
CATHLAB
Percutaneus Coronary
Intervention
CASE 3
 Tn. M 54 yo.
 Chest pain since 2 hours
 History of HT, DM, Smoking
 Trop T Negatif
 The success of reperfusion in STEMI is dependent on
the time of administration

 Time delays are central in the decision-making process

 Registry data show that the 30-min DTN and 90-min

DTB time goals are extremely difficult to achieve

 Analysis of the NRMI (National Registry of Myocardial

Infarction) 3/4 data demonstrated that only 4.2% of
patients undergoing PPCI achieve a DB time 90 min

 Time delays are also crucial to determine the best

reperfusion strategy

Danchin N. J Am Coll Cardiol Intv. 2009; 2: 901– 908.

 Mortality benefit with fibrinolytics is
greatest with shortest delay to treatment

Proportional effect of fibrinolytic therapy on

35-day mortality according to treatment delay1
22 trials were
reported between Time to Fibrinolytic Control/placebo
treatment (h) better better
1983 and 1993 P=0.001 vs
0–1
and indexed in other
timepoints ≥1–2
the MEDLINE
≥2–3
information
≥3–6
system.
≥6–12
≥12–24

0 0.5 1.0 40
Odds ratio
Benefit shown for treatment delays up to 12 hours

1. Boersma E et al. Lancet 1996;348:771–775;

Timing and logistical factors influence choice
of reperfusion strategy

Time to reperfusion Healthcare resource

• Patient ability to recognize • PCI vs non-PCI capable hospitals1–3

symptoms1,2 • Dependence on operator
• Mode of transportation to the expertise/volume3
hospital • Availability of a 24/7 service1,3*
(self-presentation vs EMS)1,2 • Availability of a pre-hospital system for
• Inter-hospital transfer challenges diagnosis and treatment3,4,5
(distance, traffic patterns, climatic
conditions etc)2,3 *Patients treated during non-working hours (6 PM to 8 AM) have
a greater delay to therapy, twice the failure rate of PPCI, and a
>2-fold increased 30-day mortality rate3,6

 1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation
2013;127:e362–e425; 3. Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation
2004;110:1909–1915; 6. Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142
 Contraindications to fibrinolytic therapy1–3

ABSOLUTE RELATIVE

• Previous intracranial hemorrhage or stroke of • Transient ischemic attack in the preceding 6

unknown origin at any time month
• Ischemic stroke in the preceding 6 months • Oral anticoagulant therapy
• Central nervous system damage or neoplasms or • Pregnancy or within 1 week postpartum
arteriovenous malformation • Refractory hypertension
• Recent major trauma/surgery/head injury (within • Advanced liver disease
the preceding 3 weeks) • Infective endocarditis
• Gastrointestinal bleeding within the past mo • Active peptic ulcer
• Prolonged or traumatic resuscitation
• Known bleeding disorder (excluding menses)

• Aortic dissection
• Non-compressible punctures in the past 24 h (e.g.
liver biopsy, lumbar puncture)
• Ischemic stroke more than 6 months ago

1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042; Accessed November 6, 2017; 2. O’Gara PT et al. Circulation
2013;127:e362–e425; 3. Morse MA et al. Drugs 009;69:1945–1966
 Fibrinolytic Therapy
Specific
Drugs Dosage & Administration
Contraindication
Streptokinase 1.5 Million units over 30-60 min i.v. Previous treatment
with streptokinase
or anistreplase
Alteplase 15 mg i.v. bolus
0.75 mg/kg i.v. over 30 min (up to 50 mg)
Then 0.5 mg/kg i.v. over 60 min (up to 35 mg)

Reteplase 10 units + 10 units i.v. bolus given 30 min apart

Tenecteplase Single i.v. bolus:

(TNK-tPA) 30 mg (6000 IU) if <60 kg
35 mg (7000 IU) if <70 kg
40 mg (8000 IU) if <80 kg
45 mg (9000 IU) if <90 kg
50 mg (10000 IU) if ≥90 kg
It is recommended to reduce to half-dose in
patients
ESC Guideline. Ibanez B et al. Eur ≥75
Heart J 2017. years old
https://academic.oup.com/eurheartj/article/4095042
 Fibrinolytic Complication and it’s
management
Hypotention Allergic reaction Bleeding Arythmia
• Patient position – Mild allergic Minor Bleeding • Refer to ACLS
supine Antihistamin injection Pressure to bleeding guidelines
• Reduce or stop (difenhidramin 10 mg area
streptokinase i.v) Major Bleeding – eg • Reperfusion sign
drops Severe allergic ICH • Premature
• Provide Ringer Dexamethasone Stop streptokinase Ventricular
Lactate / NaCL injection 5 mg and refer patient for Contraction
100 ml (10 further bleeding • Idiophatic
minutes) management Ventricular Rhytm
• Stop vasodilator
drug (eg. Nitrate)
• Streptokinase
drop continue if
systolic pressure Parameter Successful Fibrinolytic Therapy
> 90 mmHg
1. Reduction of chest pain
2. Decrease ST elevation > 50%
3. Arrhythmia reperfusion
Reference : iSTEMI Indonesia Video
 Early Reperfusion Strategy in STEMI

Symptom Primary PCI Fibrinolytic

Onset
0 – 3 hours
 
3 – 12 hours
 
> 12 hours
 

Presented to PCI Routine Angiography

Hospital ± PCI
Maximum Wire crossing 60 minutes Successful Thrombolytic
Within 2-24 Hours
target
time from Presented to Non Rescue PCI
If Failed Thrombolytic
diagnosis PCI Hospital (60 -90 min after start
Wire crossing 90 minutes
thrombolytic)

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6,

2017.
 Summary
35

 Primary Management in every spectrum of CAD is very

important  from risk factor management to primary
management of acute space.
 Risk Stratification is very important step for NSTEMI/UAP
 Reperfusion is a key strategy in Acute STEMI care and it time
dependent
PPCI is preferred options for reperfusion strategy for STEMI
patients
Fibrinolytic therapy is an important reperfusion alternative
when onset chest pain < 3 hours or when primary PCI cannot
be offered in a timely manner
Important to know capabilities of each hospital before
referring STEMI patients to prevent delay
YOUR CLINICAL JUDGMENT IS VERY IMPORTANT