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Mengenali ACS: Cegah dan

tangani dg cepat dan benar

Mohammad Saifur Rohman, dr.SpJP, PhD.FICA


Mengapa Penting?

 Jantung adalah organ yang sangat vital


 Menjamin pasokan kebutuhan seluruh
organ tubuh
 Jantung memompa lebih dari 1 juta gallon
pertahun
 Berhenti ----- Death
 Pertanda awal  Kenali !
 Terlambat Irreversible (?)
Kegawatdarutan kardiak
 Cardiac arrest
 Acute coronary syndrome
 Cardiac dysrhythmias
 Acute pulmonary oedema
 Trauma – both blunt & penetrating
 Cardiogenic shock
 Aortic dissection
 Valve insufficiency
Bgm Keluhan & Tanda ?
Slide No. 3
Mengapa Harus Cepat?

 Serangan Jantung
 Proses adaptasi terhadap perubahan
yang sangat cepat
 Kompensasi
 Dekompensasi

Dapat di kenali dan diantisipasi serta dicegah


Diperbaiki? Tidak!, Dicegah? Ya !
Prevalensi SKA
 Di Amerika : kejadian Infark miokard Akut
(IMA) lebih 1 Juta/tahun
 200,000 – 300,000 pasien IMA meninggal
sebelum sampai RS
 Total : Warga negara Amerika mengalami IMA
setiap 29 detik dan meninggal setiap menit.
 Indonesia ?
 Tahun 2008: PJN Harapan Kita 7 pasien SKA ,
50-60% IMA
 !0% IMA < 40 thn
Topol EJ. CV med 2009
Data PJN HK 2008
SKA DI RSSA MALANG
AMI prevalence in Saiful Anwar General
ApaHospital
penyebab
KEMATIAN?
keterlambatan
59 patients pasien
death cases among 356 patients
datang ke RS
Penanganan di RS
The second deadliest diseases

The mortality rate was 16,6% in 2010


Seeking care behaviour pattern

Saiful
Patient
Anwar
Hospital
General
Practitioner
role

Self
PHC
Medication
Aterosklerosis  SKA
Atherogenesis
Progression of Plaque toward rupture
Progression of Plaque toward rupture
Plaque Rupture
Platelet aggregation in ruptured plaque

Platelets aggregate at the


site of rupture / erosion

Lipid core

Adventitia

Weissberg, 1999
Thrombus formation
Thrombus forms and
extends into the lumen

Thrombus

Lipid core

Adventitia
Weissberg, 1999
Plaque Rupture Toward Occlusion
Spektrum SKA
 Unstable Angina Pectoris :
(EKG normal, Trop T/I (-))
 Acute Non ST-Elevation Myocardial Infarction
(NSTEMI) :
(EKG normal/ST depresi/T inversi dan Trop
T/I (+))
 Acute ST-Elevation Myocardial Infarction
(STEMI) :
EKG ST elevasi dan Trop T/I(+)
Bagaimana Diagnosa SKA ?
Membedakan Nyeri dada: SKA?

 1. Cardiac or non cardiac


 2. Cardiac : Ischemic non Ischemic
 3. Ischemic : Coronary non Coronary
 4. Angina pektoris stabil atau SKA
Nyeri (tidak enak) dada ….. ?
 Sifat :Berat/ tertindih (pressure, tightness, or heaviness,
strangling, constricting, or compression), Panas
(burning) ; Masuk angin, Sesak,”maag”
 Lokasi: Di dada kiri/tengah tidak bisa ditunjuk
 Penjalaran : ke bahu/lengan, leher, dagu,
 belakang,epigastrium
 Lama : 5-30’
 Pencetus :aktifitas/stres/dingin
 Berkurang: Nitrat/Istirahat
 Tidak khas: Pingsan/kejang/tidak sadar/berdebar

ESC guidelines for SAP 2006


ESC AMI ST elevation guidelines 2008
Angina Pectoris
 A syndrome resulting from myocardial
ischemia
 Demand and supply imbalance
 Careful history taking; mode of onset,
location, quality of pain, duration, precipitating
factors, pattern of disappearance, risk factor,
etc
Angina Pectoris
 A syndrome resulting from myocardial
ischemia
 Demand and supply imbalance
 Careful history taking; mode of onset,
location, quality of pain, duration, precipitating
factors, pattern of disappearance, risk factor,
etc
Hati-hati : Angina Equivalent

 Indigestion, belching, dyspnea


 DM, wanita, manula (post operative)
 Didapatkan 5% dari ACS
 2% dipulangkan ternyata ACS

Braunwalds Heart Disease 8th Ed 2008


DD Chest pain

Ischemic
 Stenosis Aorta
 Regurgitasi Aorta
 Hypertrophic Cardiomyopathy
 Angina pada Hypertensi
 Hipertensi pulmonal berat

11th ed Hurst’s the heart 2005


DD Chest Pain

Non Ischemic
 Diseksi Aorta
 Pericarditis
 Mitral valve prolaps

11th ed Hurst’s the heart 2005


DD Chest Pain

Gastro intestinal
 Esophageal spasm/reflux/rupture
 Peptic Ulcer

Neuromusculoskeletal
 Costochondritis
 Herpes zoster
 Chest wall pain dan tenderness etc
11th ed Hurst’s the heart 2005
DD chest pain

Pulmonary
 Pulmonary emboli
 Pneumothorax
 Penumonia with pleural involvement
Pleurisy
Psychogenic
 Axiety/depression/cardiac psychosis etc

11th ed Hurst’s the heart 2005


Non Angina Pain

 Hanya terasa pada sebagian kecil dada


kiri/kanan (bisa di tunjuk)
 Berkahir berjam jam sampai berhari hari.
 Biasanya tidak berkurang dengan
nitrogliserin
 Mungkin dicetuskan oleh debaran.

ESC guidelines for SAP 2006


ESC AMI ST elevation guidelines 2008
Nyeri dada khas SKA
 Angina awitan baru derajat 3 menurut
klasifikasi kanada kardiovaskuler group
( nyeri dada timbul pada aktifitas ringan
sehari-hari)
 Angina saat istirahat > 20 menit
 Perburukan derajat angina menjadi derajat
3 dalam beberapa hari – 1 bln terakhir
(Crescendo angina)
 Atypical
Pemeriksaan Fisik

 Sadar-Koma
 TD: Hypertensi-Normal-Hypoptensi
 HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
 RR: Tachypnea-apnea
 Cor: Regular-iregular, murmur, gallop
 Pulmo: Normal-Rales- wheezing
 Ext: dingin/hangat, edema+/-, etc.
EKG

 Secepat mungkin – 10’ setelah pasien tiba


 Diulang apabila meragukan adanya
kenaikan segmen ST (ST televasi)
 Bandingkan denga EKG sebelumnya
 Pasang monitor EKG
EKG : Gambaran aktifitas listrik jantung
EKG pada SKA

EKG dapat menentukan adanya:


 Old/Recent/Acute infarction
 Pericarditis
 Arrhythmias
 Pembesaran jantung
Gambaran EKG pada Iskemik/IMA
UAP/Acute NSTEMI
Acute NSTEMI
Acute STEMI- Evolution
Acute STEMI-Q wave
Occluded artery
Anterior STEMI

ECG demonstrates large anterior infarction


Inferior STEMI
Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6


with precordial ST depression
Inferior STEMI
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF


EKG
 Gangguan Irama
 Infark baru atau lama
 Perikarditis
 Pembesaran jantung dll
1st degree

2nd degree Type 1


2nd degree Type II

3rd degree
Ventricular Tachycardia (VT)
Ventricular Tachycardia (V T)

 Unable to determine rhythm


 Regular ventricular rate (100-250)
 No P waves present
 QRS complex > 0.10 sec
Ventricular Fibrillation (VF)

Coarse

Fine
Peningkatan Enzym jantung

 Troponin T/Troponin I
 CKMB
Chest x-ray

CTR 62%
Aorta elongation
Po normal
Cardiac Waist (+)
Apex lat downward
Congestion (+)
Non Invasif
Invasif
Universal Definition of Myocardial Infarction

Diagnosa AMI ditegakkan apabila min memenuhi 2


dari kriteria:
 Gejala Ischemic
 Perubahan EKG
 Kenaikan/penurunan Troponin T/I
Stratifikasi Resiko

High risk Intermediate risk Low risk


Angina saat Istirahat Angina > 20 kurang Angina dengan aktivitas
dengan istirahat
ALO Riwayat CVD
LBBB/RBBB baru Ada Q, ST depresi
ENZYME (+) Sedikit meningkat ENZYM (-)
MR ATAU S3 Baru,
HYPOTENSI, Usia > 70 tahun
BRADIKARDI,
TAKIKARDI. VT
ST DEPRESI> 0.5 T inversi EKG TETAP
Prinsip Terapi

 Cepat (time responsif), obati penyebab 


buka sumbatan
 Terlambat: Fatal
 Monitor ketat tanda vital sejak awal
 Antisipasi dini tanda tanda perburukan dan
komplikasi
Terapi Awal SKA

 Atasi keadaan kegawat daruratan :


asistol, apney, syock, lung edema,
gagal jantung dll.
 Terapi reperfusi : PCI, Fibrinolitik,
heparin
 Antiischemic
 Terapi komorbid; hipertensi, DM, dll
Pentingnya Reperfusi

 Sumbatan total15-30 menit tanpa


kolateral IMA
 Reperfusion  selamatkan miorkard
 Kematian1 bulan: 25-30% 4-6% dengan
reperfusi (PCI, fibrinolytic, antithombotic)

ESC AMI ST elevation guidelines 2008


Kerusakan Miokard Irreversibel

 Miokard tidak mengalami regenerasi


 Terlambat/tidak dibuka  Miokard mati 
Gagal Jantung  rawat ulang  biaya
besar, kualitas hidup kurang baik
 Obat gagal Jantung hanya mencegah
perburukan, tidak memperbaiki miokard
yang mati/infark
 Alternatif terapi : Stem cell
The time is muscle
Terapi NSTEMI

 O2
 Bed rest
 Pain killer
 Nitrate and anti-ischemia
 Antiplatelet : Aspirin, Clopidogrel
 Heparin
 HTN
 Hyperglicemia
 Treat the complication etc
Terapi STEMI

 O2
 Bed rest
 Pain killer
 Nitrate and anti-ischemia
 Antiplatelet : Aspirin, Clopidogrel
 Fibrinolytic time to neddle : 30 m/PCI
 HTN
 Hyperglicemia
 Treat the complication etc
Fibrinolitik
 Manfaat bila onset < 12 jam, optimal bila onset <
3 jam
 Bila dikirim ke RS dengan PCI > 90 menit,
fibrinolitik
 Konsep baru : Fibrinolitik di Ambulan menuju RS
 Perhatikan kontraindikasi fibrinolitik
 Awasi ketat komplikasi fibrinolitik seperti
perdarahan, stroke, syok dll
 Perhatikan tanda tanda keberhasilan: nyeri
hilang, ST elevasi turun >50%, Junctional
VES(+), bila gagal rescue PCI
Kontra Indikasi Absolut

 Any prior ICH


 Known structural cerebral vascular lesion (eg, AVM)
 Known malignant intracranial neoplasm (primary or
metastatic)
 Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours
 Suspected aortic dissection
 Active bleeding or bleeding diathesis (excluding menses)
 Significant closed head or facial trauma within 3 months
Kontra Indikasi Relatif
 History of chronic severe, poorly controlled hypertension
 Severe uncontrolled hypertension on presentation (SBP greater than
180 mm Hg or DBP greater than 110 mm Hg)†
 History of prior ischemic stroke greater than 3 months, dementia, or
known intracranial pathology not covered in contraindications
 Traumatic or prolonged (greater than 10 minutes) CPR or major
surgery (less than 3 weeks)
 Recent (within 2 to 4 weeks) internal bleeding
 Noncompressible vascular punctures
 For streptokinase/anistreplase: prior exposure (more than 5 days
ago) or prior allergic reaction to these agents
 Pregnancy
 Active peptic ulcer
 Current use of anticoagulants: the higher the INR, the higher the risk
of bleeding
Treatment of STEMI
Percutaneous Coronary Intervention
•Primary PCI : Pasien langsung di lakukan tindakan
reperfusi dengan membuka sumbatan di
arteri koroner tanpa dilakukan fibrinilotik
terlebih dahulu
•Rescue PCI : Dilakukan PCI setelah gagal dengan terapi
fibrinolitik
•Facilitated PCI : Pasien dilakukan fibrinolitik terlebih
dahulu meskipun sudah ada rencana PCI
•Urgent PCI: As soon as possible
•Early PCI : Dalam waktu 24 jam pertama

Early/urgent PCI: Resiko tinggi, hemodinamik tidak stabil,


aritmia maligna, angina (+) dgn terapi, EF <40%,Gagal
jantung, Riwayat PCI, CABG dl 6 bl
Tim PCI
Target

1. Time to balloon : 90 m
2. Yang dibuka hanya Culprit lesion (pembuluh
darah tersumbat yang menyebabkan IMA kali ini)
saja
3. Aliran darah yang diintervensi kembali lancar
Primary PCI Case
 A 53 yo man reffered from a private
hospital for primary PCI
 A typical chest after exercise 2 hr prior to
admission
 ECG send by fax
 PCI appointment via phone
 Patient directly transfer red to cath lab
Komplikasi MI

 Mechanical
 Electrical
 Ischemia
 Embolic
 Inflammation
Komplikasi Mekanik

 Ventricular Septal Rupture


 Mitral Regurgitation
 Cardiac free wall rupture
 Large ventricular aneurysms
 LV pump failure and cardiogenic shock
 Dynamic LVOT obstruction
 RV failure
Gagal Jantung (Kriteria Framingham)

Major Minor
 Acute pulmonary edema  Night cough
 PND or orthopnea  Tachycardia >120
 Crackles  Pleural effusion
 S3 gallop  Hepatomegaly
 HJR/Increased JVP  Ankle edema
 Cardiomegaly  Vital capacity decrease
 Wt loss >4.5 kg 5d into >1/3 from max
Rx

*Two major or one major and two minor*


Komplikasi Elektrik

 SA Dysfunction
 Atrial Fibrillation
 First-Second degree AV block
 Total AV Block
 Left Bundle Branch Block
 Right Bundle Branch Block
 Ventricular Tachycardia
 Ventricular Fibrillation
Komplikasi Ischemik

 Perluasan Infark
 Angina Post-infark
Komplikasi Emboli

 Systemic embolism ;
stroke, limb ischemia, renal infarction,
intestinal ischemia
Komplikasi Inflamasi

 Early Pericarditis
 Late Pericarditis (Dresslers syndrome)
Primary PCI Case
CASE 2
CABG

 Failed PCI with persistent pain or hemodynamic


instability in patients with coronary anatomy suitable for
surgery.
 Persistent or recurrent ischemia refractory to medical
therapy in patients who have coronary anatomy suitable
for surgery, have a significant area of myocardium at
risk, and are not candidates for PCI or fibrinolytic
therapy.
 At the time of surgical repair of postinfarction ventricular
septal rupture (VSR) or mitral valve insufficiency.
CABG

 Cardiogenic shock in patients less than 75 years old with


ST elevation, LBBB, or posterior MI who develop shock
within 36 hours of STEMI, have severe multivessel or left
main disease, and are suitable for revascularization that
can be performed within 18 hours of shock

 Life-threatening ventricular arrhythmias in the presence


of greater than or equal to 50% left mainstenosis and/or
triple-vessel disease.
Tips
 Obat anti ischemik atau anti nyeri segera di berikan
 Anti platelet dan heparin dimasukkan secepatnya
setelah diagnosis ACS-NSTEMI ditegakkan, jangan
di tunda
 Turunkan kebutuhan/kerja jantung dengan berikan
rasa nyaman dan aman pasien dan bed rest total
 Setengah duduk pada pasien dengan gagal
jantung
 Pikirkan immediate/urgent PCI pada pasien resiko
tinggi/hemodinamik tidak stabil/nyeri
berkepanjangn/aritmia maligna dll
Yang sering di lupakan…..
Edukasi pasien mengenai :
 Mengapa bisa sampai sakit….. Pola hidup
 Kepatuhan untuk merubah pola hidup
 Faktor resiko di kendalikan, rokok, HT, dll
 Kepatuhan minum obat
 Mencegah serangan jantung berikutnya
dengan…..merubah pola hidup, atur pola
makan, olah raga teratur dan terukur
 Reperfusi adalah awal dimulainya hidup baru
…agar koroner tetap terbuka
Simpulan

 Tegakkan diagnosa dengan cepat dan


tepat
 Terapi dengan cepat dan tepat : Reperfusi
 Monitor ketat
 Cegah komplikasi
 Edukasi untuk prevensi dan rehabilitasi

…..…….Kerja keras di awal……


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