Acute Coronary Syndrome-1

Acute Coronary Syndrome
Mohammad Saifur Rohman, MD, PhD, FAsCC, FICA, FSCAI

Department of Cardiology and Vascular Medicine
Faculty of Medicine, Universitas Brawijaya
Outline
• Introduction: Definition, spectrum, epidemiology, problem in Indonesia
• Pathophysiology
• Diagnosis
• Management of STEMI
• Management of NSTEACS
• Complications of ACS
• Take home messages
2
Definition
• “Acute coronary syndrome” Acute coronary syndrome (ACS)
is a term used to describe a range of conditions associated
with sudden, reduced blood flow to the heart.
A Subset of CAD
3
www. Mayo clinic.org
Spectrum of Coronary Artery Disease
Stable CAD/Stable Angina à
Acute Coronary Syndrome
Chronic Coronary Syndrome
Unstable Angina NSTEMI STEMI
Davies MJ. Heart 2000; 83(3):361-366.

4
Lily LS. Pathophysiology of Heart Disease 6th ed, 2016
High Mortality dan Morbidity of CAD
• 126 Million CAD around the word and increasing to 1.845/100.000 in 20301
• One person dies every 36 seconds in the United States from cardiovascular disease.2
• CAD cause 12,2% of overall death in the world2
• 1/4 dead before reach to the hospital.2
• About 2 in 10 deaths from CAD happen in adults less than 65 years old2.
• 1/5 heart failure patient died after 12 month of diagnosis confirmation3
• Occlusion à irreversible myocardial infarction àheart failure à hospital
readmission à Poor quality of life and high cost3
1. Khan AB. et al. Cureus 2020;12: e9349

2. Virani SS. et al. Circulation. 2020;141:e139–e596.
3. Donald LJ, et al.Circulation 2010; 121:e46-e215
ACS in Indonesia
• Globalization Era and technological advances:Fast food high in calories and lack of
physical movement (sedentary) à Metabolic Diseasesà IMA.1
• In pusat jantung nasional Harapan Kita (PJNHK) Jakarta: 4 Patients/Day (10 % < 40
Years old).2
• IMA population in Indonesia is younger (55 yo.) than IMA patients in the Americas
and Europe.3
• In Saiful Anwar hopital Malang : second Highest cause of death, mortality in hospitals
of 16.6%/year (2010) and 21%/year (2011).4
•
Why it's still high ?
1. Deedwania PC. Circulation 2004: 109; 2-4.

2. Mohammad Saifur Rohman, et al. InaSH V abstract
book; 2011: 20
3. Smolina K, et al. BMJ 2012; 344:d8059.
4. Rekam medis RSSA, 2010 dan 2011.Unpublised data.
Differences Between SKA in Indonesia Vs. Developed Countries
2004
Datang-CVCU : 3.75±2.5 jam (2012)

System
SDM
X X
RS Harapan Kita: 5.78 ± 5.2 jam (2011)
RS dr Saiful Anwar: 6.32 ± 5.37 jam (2012) Penunjang

Di Indonesia
American College of
Cardiology and American
Heart Association. 2004.
Rohman, M.S., et al. Cardiovascular Summit TCTAP 2013 Korea Abstract book 2013 Guidelines for the
management of patients with
Novira, R.Y., Rohman, M.S. 21thASMIHA Program and Abstract 2012. STEMI
Outline
• Introduction
• Pathophysiology
• Diagnosis
8
Myocardial
Coronary infarction Arrhythmia & Sudden
thrombosis muscle loss cardiac death
Myocardial
Ischemia Neohormonal Remodelling
activation
CAD The Cardiovascular Ventricular

englargement
Continuum
Atherosclerosis
CVD Risk factors: CHF
LVH
Advanced age Hypertension
Male gender Diabetes mellitus End stage
Heredity Metabolic syndrome
Dyslipidemia Lack of physical activity
Heart disease
Tobacco smoking
Dzau VJ, et al. Circulation 2006; 114: 2850–2870, by modification
9
Lily LS. Pathophysiology of Heart Disease 6th ed, 2016
Atherosclerosis Timeline
Acute Coronary
Syndrome
Stable plaque Vulnerable plaque
Davies MJ. Heart 2000; 83(3):361-366.
Anderson JL, et al. Journal of the American College of Cardiology 2007; 50(7):e1-e157. 11
Libby P, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th ed, 2019
Myocardial ischemic : Imbalance of Supply and Demand
Myocardial O2 Supply Myocardial O2 Demand
O2 content
Wall stress
Coronary blood flow (P × r / 2h)
1) coronary perfusion pressure
2) coronary vascular resistance: Heart rate
• external compression
• intrinsic regulation Contractility
Angina Pectoris
Angina Pectoris
Lily LS. Pathophysiology of Heart Disease 6th ed, 2016 12
Progression of Plaque Toward Rupture
CCS ACS
14
Pathogenesis of Ischemia and Myocardial Infarction
15
16
Outline
• Introduction
• Pathophysiology
• Diagnosis
17
Diagnosis
• Anamnesis
• Physical Examination
• ECG
• Thorax
• Labs
• Imaging (non invasive)
• Invasive
18
Anamnesis
• O nset
• P recipating factors
• Q uality
• R adiation menjalar Keleher , tengan ,
du .
Gada mengalar him tentugpp
• S everity
• T ime durasi , berapa lama
19
causes should always be considered. could
2. In women presenting with chest pain, it ly to
is recommended to obtain a history that
1 B-N R
emphasizes accompanying symptoms that
medi
are more common in women with ACS.1-7 nying
breat
Chest Pain Characteristics and Corresponding Causes

Table 3. Chest Pain Characteristics and Corresponding Causes
rema
amon
with
Nature
Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, Reco
discomfort, heaviness, tightness, pressure, constriction, squeezing) (Section
1.4.2, Defining Chest Pain). 1.
Sharp chest pain that increases with inspiration and lying supine is unlikely
related to ischemic heart disease (eg, these symptoms usually occur with
acute pericarditis).
Onset and duration
Anginal symptoms gradually build in intensity over a few minutes.
Sudden onset of ripping chest pain (with radiation to the upper or lower back)
is unlikely to be anginal and is suspicious of an acute aortic syndrome.
Fleeting chest pain—of few seconds’ duration—is unlikely to be related to
Downloaded from http:/ ahajournals.org by on May 19, 2022
ischemic heart disease.

Location and radiation
Pain that can be localized to a very limited area and pain radiating to below
the umbilicus or hip are unlikely related to myocardial ischemia.
Severity
Ripping chest pain (“worse chest pain of my life”), especially when sudden
in onset and occurring in a hypertensive patient, or with a known bicuspid
aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg,
aortic dissection).
Precipitating factors
Physical exercise or emotional stress are common triggers of anginal
symptoms.
Occurrence at rest or with minimal exertion associated with anginal symp-
toms usually indicates ACS.
Positional chest pain is usually nonischemic (eg, musculoskeletal).
Relieving factors
Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia
and should not be used as a diagnostic criterion.
Associated symptoms
Common symptoms associated with myocardial ischemia include, but are 2.
not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, presyn-
cope or syncope, upper abdominal pain, or heartburn unrelated to meals
and nausea or vomiting.
Symptoms on the left or right side of the chest, stabbing, sharp pain, or
discomfort in the throat or abdomen may occur in patients with diabetes,
women, and elderly patients.
ACS indicates acute coronary syndrome.

20
Gulati M, et al. Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029
as cardiac, possibly cardiac, or noncardiac
because these terms are more specific to the fleeting, related to inspi
Index of Suspicion That Chest “Pain” Is Ischemic in
potential underlying diagnosis.
shifting locations—sugges
Origin on the Basis of Commonly Used Descriptors
Fig
Che
on
Des
21
Gulati M et al. Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029
Traditional Clinical Classification of Angina
• Typical angina (definite)

Meets all three of the following characteristics:
• substernal chest discomfort of characteristic quality and duration;
• provoked by exertion or emotional stress;
• relieved by rest and/or nitrates within minutes.
• Atypical angina (probable)
Meets two of these characteristics.
• Non-anginal chest pain
Lacks or meets only one or none of the characteristics.
22
Montalescot G, et al. European heart journal, 2013: 34(38), 2949-3003.
Typical
chest pain
Indigestion Sweating
Elderly
Women
Diabetes
Chronic renal disease
Cardiac Clinical Dementia
Nausea
arrest
presentation
Epigastric
Syncope
pain Atypical presentation
Dyspnea
23
Roffi M, et al. Society of Cardiology (ESC). European heart journal, 2016: 37(3), 267-315.
Classification of angina severity according to
the Canadian Cardiovascular Society
Ordinary activity does not cause angina such as walking and climbing stairs. Angina
Class I
with strenuous or rapid or prolonged exertion at work or recreation.
Slight limitation of ordinary activity. Angina on walking or climbing stairs rapidly,
walking or stair climbing after meals, or in cold, wind or under emotional stress, or
Class II only during the first few hours after awakening. Walking more than two blocks on
the level and climbing more than one flight of ordinary stairs at a normal pace and
in normal conditions.
Marked limitation of ordinary physical activity. Angina on walking one to two
Class III
blocksa on the level or one flight of stairs in normal conditions and at a normal pace.
Inability to carry on any physical activity without discomfort - 'angina syndrome may
Class IV
be present at rest'.
aEquivalent to 100–200 m. I 11 angina
'
us µ progress f-
-
-
- =
24
Montalescot G, et al. European heart journal, 2013: 34(38), 2949-3003.
Angina in Acute Coronary Syndrome
• Prolonged (>20 min) anginal pain at rest
• New onset (de novo) angina (CCS class II or III)
• Recent destabilization of previously stable angina with at
least CCS Class III angina characteristics (crescendo angina)
• Post-MI angina
25
Roffi M, et al. Society of Cardiology (ESC). European heart journal, 2016: 37(3), 267-315.
W
A
Y
O
sensitifita ↑
F
spesitik ↑ ↓
T
H
I
N
K
I
N
G
26
Evaluation and Diagnosis of Chest Pain
kerfasama dg lain
27
Gulati M et al. Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029
Physical Examination
• Alert-Unconscious
• BP: Hypertension-Normal-Hypoptension
• HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
• RR: Tachypnea-apnea
• Cor: Regular-iregular, murmur, gallop
• Pulmo: Normal-Rales- wheezing
• Ext: cold, pulsation, edema, etc.
Gulati et al
Physical Examination in Patients With Chest Pain

Table 4. Physical Examination in Patients With Chest Pain 2.3.
Clinical Syndrome Findings
2.3.
Emergency
Rec
ACS Diaphoresis, tachypnea, tachycardia, hypoten- Refe
sion, crackles, S3, M R murmur.2; examination sum
may be normal in uncomplicated cases
C
PE Tachycardia + dyspnea—>90% of patients; pain
with inspiration7
Aortic dissection Connective tissue disorders (eg, Marfan syn-
drome), extremity pulse differential (30% of
patients, type A>B)8
Severe pain, abrupt onset + pulse differential +
widened mediastinum on CXR >80% probabil-
ity of dissection9
Frequency of syncope >10%8, AR 40%–75%
(type A)10
Esophageal rupture Emesis, subcutaneous emphysema, pneumo-
thorax (20% patients), unilateral decreased or
absent breath sounds
Other
Noncoronary cardiac: AS: Characteristic systolic murmur, tardus or
AS, AR, HCM parvus carotid pulse
AR: Diastolic murmur at right of sternum, rapid
carotid upstroke
HCM: Increased or displaced left ventricular
impulse, prominent a wave in jugular venous 3: H
pressure, systolic murmur
Pericarditis Fever, pleuritic chest pain, increased in supine
position, friction rub
Myocarditis Fever, chest pain, heart failure, S3 Syn
Esophagitis, peptic ulcer Epigastric tenderness The
disease, gall bladder Right upper quadrant tenderness, Murphy sign
Downloaded from http:/ ahajournals.org by on May 19, 20
disease
acut
2) d
Pneumonia Fever, localized chest pain, may be pleuritic,
friction rub may be present, regional dullness to hosp
percussion, egophony and
Pneumothorax Dyspnea and pain on inspiration, unilateral ab- of th
sence of breath sounds and
Costochondritis, Tietze Tenderness of costochondral joints into
syndrome card
Herpes zoster Pain in dermatomal distribution, triggered by and
touch; characteristic rash (unilateral and derma- facil
tomal distribution)
tion
ACS indicates acute coronary syndrome; AR, aortic regurgitation; AS, aortic with
stenosis; CXR, chest x-ray; LR, likelihood ratio; HCM, hypertrophic cardiomy-
abno
opathy; M R, mitral regurgitation; PE, pulmonary embolism; and PU D, peptic
ulcer disease.
29 man
Gulati M et al. Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 case
ECG for Patients Presenting with Chest Pain
Gulati et al 2021 Chest Pain Guideline
CLINICAL STATEMENTS
AND GUIDELINES
30
ECG Criteria of STEMI
• ST-segment elevation (measured at the J-point) is considered
suggestive of ongoing coronary artery acute occlusion in the
following cases:
At least two contiguous leads with:

ST-segment elevation >2.5 mm in men <40 years, >2 mm in
men >40 years, or >1.5 mm in women in leads V2–V3
and/or
>1 mm in the other leads
31
Ibanez B, et al. European heart journal 2017; 39(2):119-177.
Eletrocardiography
32
Baltazar R, Basic and Bedside Electrocardiography, 2009
33
34
35
Chest Pain and Cardiac Testing Considerations
CLINICAL STATEMENTS
AND GUIDELINES
Figure 5. Chest Pain and Cardiac Testing Considerations 36
The choice of imaging depends on the clinical question of importance, to either a) ascertain the diagnosis of CAD and define coronary anatomy
General Approach to Risk Stratification of Patients With
Suspected ACS
37
Outline
• Introduction
• Pathophysiology
• Diagnosis
• General measure
• Mangement of STEMI
38
39
Acute Coronary Syndrome Complications
Impaired contractility Tissue necrosis Electrical Pericardial

instability inflammation
Ventricular Hypotension à Ventricular Papillary Ventricular

thrombosis ↓coronary perfusion septal muscle wall
à ↑ischemia rupture rupture rupture
Acute mitral Arrhythmias Pericarditis

regurgitation
Stroke Cardiogenic Heart failure Cardiac Lily LS. Pathophysiology of Heart Disease 6th ed, 2016
Libby P, et al. Braunwald’s Heart Disease, 11th ed, 2019
(embolism) shock tamponade 40
Complications
• LV failure • Mechanical complications:
• Ventricular septal rupture
• RV failure • Acute MR
• Cardiogenic Shock • Ventricular free wall rupture
• Ventricular aneurysm /pseudoaneurysm
• Arrhythmia • Dynamic LVOT obstruction
• Thromboembolism • Cardiac arrest

• Inflammation: • Death
• Early pericarditis
• Late pericarditis
41
Griffin BP, et al. Manual of Cardiovascular Medicine, 4th ed, 2013.
Outline
• Introduction
• Pathophysiology
• Diagnosis
• General measure
• Mangement of STEACS
42
Initial Treatment
• Oxygen
• Dual anti-platelet treatment (DAPT)
• Aspirin
• P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor, or Cangrelor)
• Nitrate (with caution in RV infarction)
• Morphine (with caution in syock)
Roffi M, et al. European heart journal 2015:ehv320.

43
44
45
46
Primary PCI
47
48
49
50
Outline
• Introduction
• Pathophysiology
• Diagnosis
• General measure
51
52
53
Outline
• Introduction
• Pathophysiology
• Diagnosis
• General measure
• Problems and solutions in Indonesia
54
CAD Problems in Indonesia
System
SDM How to Solve It?
Support Kelompok Kajian Kardiovaskuler
X X X X
Faktor Resiko à PJK Stabilà Sindrom Koroner akut à Gagal jantung à Kematian
Promosi Pencegahan: Kewaspadaan: Terapi Cepat dan Tepat Rehabilitasi

Kendalikan Faktor resiko Pasien Pencegahan
Sistem : SDM/Nakes
Penunjang
ACS Network and DETAK Application to Reduce
Delays in Faskes I and Patients levels (Pre-hospital)
50% Paham
Aplikasi
“DETAK” 4. 35±2.77 jam
Pasien Saiful
IMA (1) 9.5% pasien
Anwar
Hospital
(2) 4.08±4.63 jam
(3) 71.5% pasien
19%
pa s 16.7% Paham
ien
70 % Paham
(3.2)
(2)
7.68±5.43 jam
5 .9%
. 1 ) 1 5.33±2.78 jam
( 3
Tenaga Jejaring SKA
Pengobatan
(3.2) 55.6% Kesehatan berbasis
sendiri (PS) Whatsapp.
/RS lain
Patient delay System delay
Rohman MS, Dwi Chya, Rahmawatus, Mefetika, Prsented at ASMIHA 2012

Service System Development Plan
• 24/7 Primary PCI service
• ACS Network • Ambulance to Cath lab bypass
• Education • Workshop/training • Improving door to wire crossing/
• Seminar • Handbook door to lytic bolus time
• TV/radio • ECG Machine • National Registry (iSTEMI)/ Big Data
• Patients/Health • Emergencies drugs • Back up operasi Coronary Artery
Cadres • Early therapy By Pass Graft (CABG)
• •
Referral
Patients Faskes I
Hospital
• DETAK app (smart • Pre-hospital

phone) fibrinolytic (STEMI)
• Integrated ambulance system
• Public safety center
Take Home Messages
• ACS is a life threatening condition.
• Early diagnosis and prompt treatment can improve the
outcome.
• Delay is the main problem in Indonesian ACS patients
• Provider Awareness may reduce delay
• Shortening delay leads to a better outcome
• Collaboration among providers may solve the problems in the
future
58

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Acute Coronary Syndrome

Mohammad Saifur Rohman, MD, PhD, FAsCC, FICA, FSCAI

Davies MJ. Heart 2000; 83(3):361-366.

1. Khan AB. et al. Cureus 2020;12: e9349

1. Deedwania PC. Circulation 2004: 109; 2-4.

Datang-CVCU : 3.75±2.5 jam (2012)

RS dr Saiful Anwar: 6.32 ± 5.37 jam (2012) Penunjang

CAD The Cardiovascular Ventricular

Myocardial O2 Supply Myocardial O2 Demand

Chest Pain Characteristics and Corresponding Causes

ischemic heart disease.

ACS indicates acute coronary syndrome.

Origin on the Basis of Commonly Used Descriptors

• Typical angina (definite)

Physical Examination in Patients With Chest Pain

At least two contiguous leads with:

Impaired contractility Tissue necrosis Electrical Pericardial

Ventricular Hypotension à Ventricular Papillary Ventricular

Acute mitral Arrhythmias Pericarditis

• Thromboembolism • Cardiac arrest

Roffi M, et al. European heart journal 2015:ehv320.

Promosi Pencegahan: Kewaspadaan: Terapi Cepat dan Tepat Rehabilitasi

Rohman MS, Dwi Chya, Rahmawatus, Mefetika, Prsented at ASMIHA 2012

• DETAK app (smart • Pre-hospital

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