Acute Coronary Syndrome

EIRENE E.M.GAGHAUNA
Introduction

 Cause of Cardiac Arrest

 Life Threatening Condition
 Mortality rate 12.000.000 / year
 30% Mortality during first 2 hours from onset
 Six-month mortality rates in the Global Registry of
Acute Coronary Events (GRACE) were 13% for
patients with NSTEMI ACS and 8% for those with
unstable angina.
Con’t

 Peringkat 9 penyebab kematian di Indonesia

(2007)
 Peringkat 1 penyebab kematian di rumah sakit di
Indonesia
 30 % kematian terjadi dalam 2 jam perawatan
 Bisa menyebabkan Silent Infarct dan Cardiac
arrest
Definition

 Acute coronary syndrome (ACS) is conditions compatible with

acute myocardial ischemia and/or infarction that are usually due to
an abrupt reduction in coronary blood flow
Terminology ACS:
1. STEMI
2. NSTEMI
3. Unstable angina
Acute Coronary Syndrome

http://www.nejm.org/doi/full/10.1056/NEJMra1216063
Sign & Symtoms

Nyeridada yang khas (Cardiac Chest Pain)

Perubahan ECG : ST Deviasi
Kenaikan enzim jantung
Cardiac Chest Pain
 Site : Retrosternal area – often qiute diffuse
 Onset : Usually rapid (over 5-10 menit)
 Character : Heavy, tight, band-like
 Radiation :To neck, jaw, left shoulder and arm
 Associated Symtom : Sweating, anxiety, pallor
 Time Course : MI usually result in pain lasting >30 minutes, angina
may resilt in briefer episodes
 Exacerbating / Relieving factors : Angina ussually exacerbated by
exertion, relieves by rest or GTN, MI pain usually only relieved by
opiate analgesia
 Severity : MI pain usually very severe
ECG

Normal ECG Acute Coronary Syndrome

Cardiac Enzim

 CKMB
 Troponin
Lokasi Infark

Septal: V1 V2
Anterior : V3 V4
Lateral: I, AvL, V5, V6
Inferior: II, III, AvF
Posterior: V7 V8 V9
Right Lead ECG
Bagaimana memasang sadapan posterior ??

 Lakukan pemasangan
sadapan posterior (V7,
V8, V9) jika ditemukan
ST Depresi pada V1 -
V3
 elevasi ST 0,5 mm pada
V7 - V9
Location
 LeftCoronary
Artery:
 LCX: Lateral
 LAD: Anteroseptal

 Right Coronary
Artery:
 Main: RVI, Post, Inf
 LDP: inferior
 Acute Coronary Syndrome
Chest Pain

ECG Changes

Yes No

ST Elevasi ST Depression / T Inversion Normal ECG

Cardiac Marker Cardiac Enzim

Cardiac Enzim Rise
Normal

STEMI NSTEMI UNSTABLE ANGINA

Primary Goal Theraphy

 Reduce the amount of myocardial necrosis

 PreventMACE : Death, MI  revascularization
immediatly
 Preserving Left Ventricular Function
 Threat life threatening conditions (such as VT, VF,
Ect)

Robert E. O'Connor et al. Circulation. 2010;122:S787-S817

Treatment

Prehospital
Rumah sakit
IGD
Perawatan lanjut
Prehospital Management of Acute
coronary Syndrome
EMS Triage &
Early
Assessment & Hospital
Recognition
Care Destination

Patient & First

Monitoring
Responder

Health care provider Treatment

Prehospital ECG

Fibrinolitic Cheklist
Improving System Care of Acute Coronary
Syndrome

Sanford Health
Early Recognition of ACS
Focused History and Physical Exam

 Chest discomfort

 Spread to Arms, Soulders, neck, jaw, Don’t Forget

back, or upper abdomen

 Shortness of breath

 Cool, clammy skin

 Nausea

 Lightheadedness
Call for Help
911

Advanced Cardiovascular Life Support American Heart Association (2010)

 EMS Assessment, Care, and Hospital
Preparation
Instruction & Treatment  Vital sign and cardiac
rhythm
Monitor and support ABC
 Prepare to Provide
CPR (30:2)
 Using a defibrillator
Administer Aspirin, O2, Nitroglicerin if needed
and Morfine (MONA)

Obtain a 12-lead ECG

Complete a fibrinolytic checklist

Notify Hospital
Prehospital Triage & Hospital Destination

 Direct triage from the scene to a PCI capable hospital may reduce
the time to definitive therapy and improve outcome
 Mortality rate ACS Patient was significantly reduced (8.9% versus
1.9%) when transport time was less than 30 minutes.
 Fibrinolytic therapy is recommended if patient arrived in 2 hours
since sign and symptoms are appear

Robert E. O'Connor et al. Circulation. 2010;122:S787-S817

Kapan PCI lebih diutamakan daripada
fibrinolitik ?
 The ability to perform PCI within 90 minute from
presentation to hospital
 The presence of Q wave on initial ECG
 Time to presentation >3 hours
 Cardiogenic shock
 Severe heart failure
 Contraindication to thrombolisis
 Doubt about diagnosis of STEMI
PCI
Robert E. O'Connor et al. Circulation. 2010;122:S787-S817
Kontraindikasi Trombolitik

 Stroke
 Ada riwayat trauma mayor/bedah/luka kepala dalam 3
minggu
 Perdarahan Gastro Intestinal dalam 1 bulan terakhir
 Kelainan darah
 Dissecting aneurisma
Kontraindikasi relatif

 Serangan iskemia transient dalam 6 bulan terakhir

 Terapi coumadin/walfarin
 Kehamilan
 Puncture atau kebocoran yang tidak bisa ditekan saja
 Resusitasi trauma
 Hipertensi refrakter (sistolik>180mmHg)
 Riwayat terapi laser retina.
Fase perawatan lanjut

 12 - 24 jam setelah serangan, pasien harus diobservasi di

ruang perawatan intensif:
 cardiac monitor
 Tanpa komplikasi, pasien boleh duduk pada hari pertama.
Hari kedua, pasien bisa berjalan 200 m
Komplikasi

Syok kardiogenik
Cardiac arrest
Gagal jantung
Ruptur muskulus papilaris
Aritmia
Edukasi pada saat pemulangan

 Cemas
 Merubah kebiasaan buruk
 Terapi antiplatelet: aspirin 165 mg PO / hari
Case presentation
Case Presentation

laki - laki 54 thn, nyeri dada, palpitasi, diaphoresis

Case Presentation
Case Presentation
Case Presentation

Laki - laki usia 48 thn, sesak nafas, berkeringat dingin

Time Is Muscle