Acute Coronary Syndrome

(Focus on early recognition

and initial management)

TENGKU WINDA ARDINI

Cardiology and Vascular Department,

RSUP HAJI ADAM MALIK MEDAN
 What Is Acute
Coronary Syndrome?
 ACS Definition
Acute coronary syndrome (ACS) = Heart Attack
“refers to spectrum of presentations that is consistent to be
caused by myocardial ischemia”

By ECG differentiation

NSTE-ACS STE-ACS

Unstable
Angina
NSTEMI STEMI
 What cause ACS ?

Stable
Angina Acute Coronary Syndrome
What happened in ACS ?
Why should
we care?
 ACS is a cardiac emergency

High mortality and morbidity

Global Major Causes of Death

ACS were
responsible to
half of CVD
deaths

Global Atlas on Cardiovascular Disease Prevention And Control. WHO 2011

ACS Morbidity and Mortality
1/3 of STEMI patients die within 24 hours of onset of ischemia

15% of UA patients die or experience a reinfarction within

30 days of diagnosis
up to 30% of discharged patients are rehospitalized within
6 months

9% - 19% ACS patients die in the first 6 months after diagnosed,

with about one-half of deaths occurring within 30 days.

18% of men and 23% of women over age

40 may die within 1 year following MI (STEMI & NSTEMI)
STE-ACS vs NSTE-SCS
Incidence : NSTEMI > STEMI
Hospital mortality:
STEMI > NSTEMI (7 % vs 5 % )
6th month mortality :
STEMI = NSTEMI (12 % vs 13 % )
Long Term Follow Up Mortality
NSTEMI > STEMI
 ACS DISTRIBUTION
Consecutive ACS
N=2797

STEMI NSTEMI UAP

N= 869 (31,1%) N= 789 (28,2%) N= 1139 (40,7%)

No reperfusion Fibrinolytic Primary PCI

N= 510 (59%) N= 96 (11%) N= 263 (30%)

Source: JAC registry data base 2010, NCCHK

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)
Are all bad
news??
 Evidence-Based Medical Therapy

Significantly lowered morbidity & mortality

Started with an adequate diagnosis (not an

underdiagnosed one) and an appropriate
treatment
 How to
diagnose ACS?
 Diagnosing ACS

1. ACS is A CLINICAL DIAGNOSIS

not an ECG diagnosis

Recognize the symptom

correctly
Symptoms compatible with ischaemic
heart disease
Symtomps compatible with
ischaemic heart disease
Typical chest pain/
Specific Angina pectoris

Angina equivalent
Less Complications of
specific coronary heart
disease
 Typical chest pain
Quality Squeezing, heaviness, pressure, weight, very
strong pain, burning, tightness
Location Centre of the chest, left chest with radiation to
shoulder, neck, jaw, inner arm, epigastrium (can
occur without chest pain)
Duration Unstable angina 10-20 min.
Myocardial infarction last longer
Setting Triggered by exercise, sexual activity, exposure to
cold weather, emotional stress (anger, fright,
frustration), or a large meal.
Reliever or No effect of position or respiration to quantity or
exaggerator quality of chest pain. Lessened by nitrat

Accompanying shortness of breath, lightheadedness, nausea, or

symptom sweating
Typical chest pain
Typical chest pain
Angina Equivalent
Late Presentation
Atypical Chest Pain
Typical chest pain
(local terms)
=
ANGIN DUDUK
 Diagnosing ACS

2. Look For Risk Factors

Diagnosing Heart Disease
Atypical symptom Typical symptom
and sign and sign

Risk Risk
Factors Factors

Evidence of
heart disease

Less More Most

Definite
likely likely likely
Diagnosing ACS

3. Evidence of ACS

Role of ECG in ACS

Diagnosing Heart Disease
Atypical symptom Typical symptom
and sign and sign
With or without With or without
Risk Factors Risk Factors

Evidence of heart disease (diagnostic ECG

abnormality)

Definite heart disease

 Roles of ECG in ACS
Typical/ Specific Atypical/ Less
Symptom Specific Symptom
But with a diagnostic
ECG

Acute Coronary Syndrome

 ECG Changes
Unstable Angina
STEMI NSTEMI

Normal ECG
ACS Management
 The philosophy of treating
ACS is to lower the patient
mortality (not only in-
hospital but also long term
mortality)
The mortality benefit of ACS treatment
started from the earliest treatment
given
 Clinical diagnosis of ACS is likely
Atypical presentation but with diagnostic ECG

Give initial pharmacological treatment (MONACO)

1. O2 nasal 4 lpm
2. Aspirin 300 mg chew (*)
3. Clopidogrel 300 mg if available (*)
4. ISDN 5 mg sublingual (interval 5 min, max 3 dose)
5. Morphin 2-4 mg iv (if pain isn’t responding to
nitrate)

Refer to Hospital with cardiologist

ECG Analysis
 ECG Analysis

STEMI STEMI
< 12 hours of > 12 hours of NSTE - ACS
onset onset

Manage conservatively:
Reperfusion: • ICU/ICCU (*)
• Continuos nitrat infusion
• Fibrinolytic • Dual antiplatelet regimen (aspirin and
clopidogrel) (*)
• Primary PCI • Anticoagulant
(heparin/fondaparinux/enoxaparin) (*)
• High intensity statin (*)
• ACE inhibitor (*)
• Beta blocker (*)
(*) gives mortality and
morbidity benefit PCI in selected high-risk feature patient (*)
Initial Pharmacological Treatment for
Acute Coronary Syndrome
MONACO
Morphin-Oxygen-Nitrate-Aspirin-Clopidogrel
1. Oxygen
a. Indication : Patients with SpO2 < 90 %
(revised recommendaation)
b. Contraindication : COPD (high dose O2)
c. Dosage :
• 1 – 6 L/min via nasal cannula
• 4 L/min for AMI
• 6 – 10 L/min via non-breathing face mask
d. Target therapy : Maintain O2 sat > 94%
Initial Pharmacological Treatment for
Acute Coronary Syndrome
2. Nitrate [Isosorbid dinitrate (ISDN)]
a. Indication :
• Ischemic chest pain
b. Contraindication :
• Hipotension (SBP < 90 mmHg)
• < 48 hours use of PDE-I (Viagra)
c. Caution :
• Beware of hypotension, give bolus of saline if it
happen
• Right ventricular infatction
d. Dosage :
• 5 mg sublingually (interval 5 min, max 3 doses)
e. Target therapy :
• Relieve of ischaemic symptomps
Initial Pharmacological Treatment for
Acute Coronary Syndrome
3. Aspirin
a. Indication :
• All ACS patient for antiplatelet agregation
b. Contraindication :
• Active bleeding or bleeding tendency
c. Dosage :
• Loading dose of 162-325 mg (usually 300mg)
chew
• Continue 85-100 mg once daily
e. Therapy benefit:
• Improve survival and outcome
Initial Pharmacological Treatment for
Acute Coronary Syndrome
4. Clopidogrel
a. Indication :
• All ACS patient for antiplatelet agregation
b. Contraindication :
• Active bleeding or bleeding tendency
c. Dosage :
• Loading dose of 300 mg on time
• Patient > 70 yo: use maintenance dose of 75
mg
e. Therapy benefit:
• Improve survival and outcome
Initial Pharmacological Treatment for
Acute Coronary Syndrome
5. Morphine
a. Indication :
• Chest pain not responding to nitrate
• Pulmonary oedema
b. Contraindication :
• Hipotension
• Right ventricular infarction
c. Dosage :
• 2-4mg IV Q5-30min, titrate to effect
e. Close monitor to:
• Blood pressure
• CNS/respiratory depression
STEMI Management
(INSIGHT)
 CONCEPT OF MANAGEMENT

STEMI N- STEMI
1. Revascularization 1. Anti - Ischemia

2. Anti - Trombotic 2. Anti - Trombotic

3. Anti - Ischemia 3. Revascularization

Spektrum SKA

Presentasi Nyeri dada

klinis

Diagnosis
Sindrom koroner akut
kerja

ECG-N
ECG Elevasi ST-T Tidak
Segment ST Abnormalitas jelas

Bio
Kimia

Diagnosis
STEMI

Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054 45

 Revaskularisasi

VS. Intervensi koroner

Observasi dan pemantauan kontinu

Fibrinolitik
Perkutan

Mulai terapi adjuvant

ADP antagonis
- Ticagrelor
- Clopidogrel
Anti-iskemik
- Nitrat
- Penyekat beta reseptor
47
FIBRINOLITYCS vs. PRIMARY PCI

Primary PCI
Fibrinolitik
(Intervensi koroner perkutan primer )
• Onset simtom < 12 jam • Dilakukan dalam 120 menit
• Primary PCI > 90 menit. • Kontraindikasi fibrinolitik
• Kontraindikasi (-) • “Door –to-wire” 90 menit
• 10 min (door-to-needle time) • Pasien STEMI dan syok kardiogenik dan
gagal jantung berat
• Diagnosis STEMI meragukan

1.Steg PG, et al. European Heart Journal. 2012;33:2569-2619 ; 2. Anderson JL, et al. Circulation. 2007;116:e148-e304.
Tatalaksana STEMI
 Revaskularisasi

Fibrinolitik VS. Intervensi koroner

Perkutan

Aspirin Aspirin
Anti-Platelets

ADP antagonist ADP antagonist

(Loading) (Loading)
Clopidogrel • Ticagrelor 180 mg
< 75 thn  300 mg rumatan 90 mg bid
> 75 thn  (-) • Clopidogrel 600 mg
rumatan 75 mg bid
 Dosis obat fibrinolitik

Dosis Kontraindikasi
Streptokinase 1.5 juta unit dalam 30-60 SK sebelumnya
(SK) menit
Alteplase 15 mg i.v. bolus
(tPA) 0.75 mg/kg B dalam 30
menit (maks 50 mg),
dilanjutkan
0.5 mg/kgBB dalam 60
menit

Steg
51 PG, et al. European Heart Journal. 2012;33:2569-2619
 Kontraindikasi fibrinolitik

Absolut Relatif
Perdarahan intrakranial atau stroke yang tidak diketahui Serangan iskemia transien dalm 6 bulan
penyebabnya setiap saat.
Terapi antikoagulan oral
Stroke iskemik dalam 6 bulan terakhir
Kehamilan dan post partum dalam 1 minggu
Kerusakan, neoplasma dan malformasi atrioventricular
Hipertensi refrakter (SBP > 180 mmhg and DBP
Susunan Saraf Pusat
110 mmhg
Trauma mayor baru/ bedah/ jejas kepala (dalam 3 minggu )
Kelainan hepar lanjut
Perdarahan traktus GI dalam 1 bulan terakhir
Infektif endokarditis
Diketahui dengan kelainan perdarahan (kecuali menses)
Ulkus peptikum aktif
Diseksi aorta
Resusitasi berkepanjangan atau trauma
riwayat puncture dalam 24 jam terakhir, yang tidak bisa di
kompresi

Steg
52 PG, et al. European Heart Journal. 2012;33:2569-2619
 Intervensi paska fibrinolitik
Recommendasi Kelas/Level
Indikasi “Rescue PCI” segera bila fibrinolisis gagal (<50% ST- 1A
segment resolution at 60 min).
Indikasi PCI Emergensi pada kasus iskemia berulang or bukti 1B
adanya re oklusi setelah fibrinolisis awal berhasil.
Indikasi Angiografi Emergensi dengan rencana revaskularisasi 1A
indikasi pada pasien dengan gagal jantung/ syok
Indikasi Angiografi dengan rencana revaskularisasi (arteri yang 1A
berhubungan dengan area infark) setelah fibrinolisis berhasil.
Waktu yang optimal untuk angiografi, pada pasien yang IIA
fibrinolisis berhasil dan stabil : 3–24 h.

Steg
53 PG, et al. European Heart Journal. 2012;33:2569-2619
Ko terapi untuk
Intervensi koroner perkutan primer
Antiplatelet
Dosis Loading 150–300 mg po,
Aspirin
dikuti dosis rumatan 75–100 mg/hari.
Dosis Loading 180 mg po,
Ticagrelor
diikuti dosis rumatan 90 mg b.i.d.
Dosis Loading 600 mg po,
Clopidogrel
diikuti dengan dosis rumatan 75 mg/hari.
 Ko-terapi untuk Fibrinolisis
Antiplatelet
Aspirin
Antithrombin Dosis Loading 150–300 mg po, dikuti dosis rumatan 75–100 mg/hari.
Unfractionated 60 U/kg i.v. bolus, maximum of 4000 U
Clopidogrel
heparin Dosis
Diikuti Loading 30012mg
koninua i.v. po,maximum
U/kg diikuti dengan
of 1000 dosis
U/jamrumatan
for 24–4875 mg/hari.
h. Target
>aPTT:
75 tahun
50–70 stanpa
or 1.5dosis
to 2.0loading
kali kontrol di monitor 3, 6, 12 dan 24 h.
Enoxaparine Usia pasien <75 tahun:
30 mg i.v. bolus diikuti 15 min later by 1 mg/kg s.c. every 12 h
hingga dipulangkan atau maximum 8 hari Dosis pertama dan kedua tidak
melebihi 100 mg.
Usia pasien>75 tahun:
Tanpa i.v. bolus; mulai dengan dosis s.c. dose of 0.75 mg/kg, maximum 75
mg
Fondaparinux 2.5 mg i.v. bolus diikuti dengan followed by a s.c. dose of 2.5 mg sc hingga 8
hari atau dipulangkan.
Pemberian Streptokinase
PERLATATAN:
• Mesin EKG
• IV line
• Monitoring Tekanan darah
• Monitoring EKG
• Defibrilator
Cara Pemberian
• 1.5 juta unit di encerkan dalam 100cc NS atau
dalam dextrose 5% selama 45 menit – 1 jam
• Monitoring nadi dan irama jantung selama
pemberian streptokinase.
•  keberhasilan fibrinolitik ditandai dengan aritmia
repesfusi . Bisa ringan bisa berat. Oleh karena itu
harus ada trolley emergensi dengan defibrilator.
• Tanda vital di obeservasi setiap 5 menit
PERHATIAN
• ARITMIA REPERFUSI
• Hanya ditindak bila sustained (lebih dari 30 detik) dan ada simpstoms
• HIPOTENSI
• posisikan pasien telentang (supine)
• Infus streptokinase dilambatkan
• Atau stop infus dan dimulai kembali bila TD naik
• Loading cairan 1 cc/kgs
• PERDARAHAN
• Hematuria
• Abdominal pain
• Melena
• Defisit neurologis
• ALERGI
• Rash, diberi dexamethason dan difenhidramin
SETELAH FIBRINOLITIK
• Rekam EKG 30 menit setelah fibrinolitik
Tanda keberhasilan fibrinolitik:
• Nyeri dada hilang
• ST segment kembali normal
• Artimia reperfusi (idioventricular rhythm)
Terapi jangka panjang untuk STEMI

• Beta Blocker
• Lipid-lowering therapy
• Nitrates
• Calcium antagonists
• ACE inhibitor dan ARB (angiotensin receptor blockers)
• Aldosterone antagonists
• Magnesium, glucose–insulin–potassium, lidocaine

60
 Kriteria keberhasilan Fibrinolysis
- Resolusi nyeri dada :
- pengurangan mendadak  prediktor reperfusi dengan
sensitifitas 66-84 %
 hanya terjadi pada 30-50 %
 spesifisitas < 30 %
 dipengaruhi oleh terapi analgetik
- Resolusi segmen ST
- Penurunan segmen ST 25-50 %.
- Diukur 90 menit setelah permulaan trombolitik: akurasi
diagnosis 80-85 % pada kegagalan untuk mencapai aliran
TIMI 3.
 EARLIER IS BETTER

TIME IS MUSCLE

MUSCLE MEANS SURVIVOR

 Resume
ACS is a fatal cardiac emergency with a rising
incidence and high mortality and morbidity
ACS diagnosis is a clinical diagnosis;
ECG role is not important in diagnosing ACS
Recent advances in treatment of ACS has
proven to have a huge mortality benefit
In STEMI cases, every minutes delay of
revascularization increase mortality
 “Saving peoples from
heart attack starts from you”

Thank You