ACUTE CORONARY

SYNDROME
dr. Benny Antama Syant
OUTLINES
 Introduction

Setiap 40 detik
• Sindroma Koroner Akut (SKA) Kasus baru IMA

• Masalah utama penyakit kardiovaskular

• Angka morbiditas dan mortalitas tinggi RISKESDAS 2018 :
PJK 1.5% dari total
penduduk

20%
Tidak jauh berbeda di
benua lainnya

Ibanez B, et al. European Heart Journal. 2017;39:119-177. 3

Introduction

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Diagnosis

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Diagnosis

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Stable Vs. Unstable Angina

(i) At rest angina and for prolonged periods

(>20 min);
(ii)new-onset angina, i.e. recent (2 months)
onset of moderate-to-severe angina CCS II-
III;
(iii) Crescendo angina, i.e. previous angina,
which progressively increases in severity and
intensity, and at a lower threshold, over a
short period of time
(iv)Post-myocardial infarction (MI) angina.

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 Typical Angina

STABLE UNSTABLE
Angina by CCS Classification
I Angina with strenouos or prolonged
exertion (i) Angina prolonged periods (>20 min);
II Angina with moderate exertion (ii) new-onset angina (angina CCS II-III);
III Angina with mild exertion (iii)Crescendo angina
IV Angina at rest

Chronic Coronary Syndrome Acute Coronary Syndrome

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• Nyeri dada :
• Myocarditis 🡪 nyeri dada tipikal
• Pleuritis 🡪 nyeri dada dipengaruhi saat bernafas inpirasi/ekspirasi
• Pericarditis 🡪 dipengaruhi posisi, lebih nyeri saat berbaring, berkurang
dengan membungkuk
• Diseksi aorta 🡪 nyeri terasa seperti di robek di punggung/dada
• GERD 🡪 nyeri dada seperti terbakar
• Pneumothorax 🡪 nyeri dada dengna Riwayat trauma sebelumnya
• Herpes zoster 🡪 nyeri sesuai dermatome dengan kelainan kulit

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• Sesak nafas:
• Onset, quality saat?, Framingham
• Airway sama breathing
• Airway : obstruktif (partial/total),
• Breathing : structural anamotical
• Cardiac : CHF, AHF, RHF, VHD 🡪 congestif? Posisi 🡪 sesak meningkat saat
berbaring,
• Non cardiac : Paru (broncus, alveoli, pleura) 🡪 posisi sama saja
• Demam ? Batuk? Berdahak?

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ACUTE CORONARY
SYNDROME

ACUTE CORONARY
SYNDROME

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 ACUTE CORONARY SYNDROME

Clinical Presentation

Typical chest discomfort with

- sweating, nausea, epigastric pain, dyspnoea, and syncope
Atypical complaints are more often observed in the older patient, in women, and in patients with diabetes,
chronic renal disease, or dementia

Likelihood of NSTE-ACS (Risk Factor)

Diabetes, hyperlipidaemia, smoking, hypertension, family history of coronary artery disease
(CAD), Older age, male sex, renal dysfunction, previous manifestation of CAD, and peripheral or
carotid artery disease
Exacerbate or precipitate NSTE-ACS include anaemia, infection, inflammation, fever, hypertensive peak, anger,
emotional stress, and metabolic or endocrine (particularly thyroid) disorders.

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Clinical Presentation

• Airway, Breathing, Circulation (ABC)

• Vital Sign, General Observation
• Jugular Venous Distension
• CVS : Pulse, heart murmur/gallop
• Lungs : rales
• CNS: consciousness, weakness
• Sytemic hypoperfusion

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 ECG
ST-ELEVATION
New ST-
elevation at
J-Poin in two
contiguous
lead
<40 yo ≥40 yo All Ages
V2-V3 ≥ 2.5 mm ≥ 2 mm ≥ 1.5 mm
Others Lead ≥ 1 mm ≥ 1mm ≥ 1mm

ST-DEPRESION and T Wave Changes

New horizontal or down-sloping ST-depression

≥0.5 mm in two contiguous leads and/or
T inversion > 1mm in two contiguous leads with
prominent R wave or R/S ratio >1

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NST-ACS ECG

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STEMI ECG

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Lead Placement

Standard Lead Rightside Lead Posterior Lead

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Cont…..

Site ECG Artery

Anterior V2-V4 LAD
Anteroseptal V1-V4 LAD
Lateral I,aVL LCx
Anterior extensive V1-V6, I, aVL LAD
Inferior II,III,aVF RCA, LCx
Right Ventricle V4R RCA
Posterior V8-V9 RCA, LCx
Inferior Wall MI :
• ST elevation in lead II,III,aVF
• AV Block
• RV infarction (V4R)
• Posterior 19
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Yang dipakai RSUP dr. M. Djamil Padang

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- An initial hs-TnT <5 ng/L may rule-
out acute myocardial injury for at
least 3 h onset
- An initial hs-TnT <12 ng/L at 0 h and
an increase of <3 ng/L after 1–3 h
may rule-out acute myocardial
injury.
- a single measurement rule-out
strategy should not be used in
patients who present <3 h after
symptom onset (i.e., early
presenters), and a second
measurement should be taken at 3 h
or later after the onset of symptoms
because of the time dependency of
troponin release

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 THERAPY
2018

M Morphine sulfate
iv 1-5 mg
• Can be repeated per 10 – 30 min, for patient who not
responsive

O O2 • when SaO2 < 90% or PaO < 60

N NTG / ISDN • If ongoing chest pain by the time admitted at ER

A
ASPIRIN Ticagrelor • 180 mg loading dose + 90 mg BID
• 300 mg loading dose + 75 mg OD if ticagrelor is not
Loading or available or contraindicated
160 – 320mg clopidogrel*

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 SPECIAL CONDITION
Killip I : No evidence HF
Killip Class Killip II : Rales, Increase JVP, S3 🡪 Furosemide
Killip III : Pulmonary edema 🡪 Furosemide, morphine, NTG
Killip IV : Cardiogenic Shock 🡪 Furosemide, Inotropic and Vasopressor

- Atrophine IV 0.5mg bolus (repeat every 3-5 min max 3 mg)

- Transcutaneous pacing or Dopamine IV 2-20 mcg/min or Epinephrine IV 2-10
Bradycardia
mcg/min

Tachycardia

- Normal saline (40 ml/min, up to total of 2 l, intravenously) 🡪 stop if volume overload

RV infarct - Vasopressor and inotropic

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 EMERGENCY DRUGS
Waktu
Obat Indikasi Klinis Paruh Dosis
Dobutamin Penurunan Curah Jantung (Gagal Jantung Dekompensasi, 2-3 mnt 2.0 to 20 µg /kg/mnt
syok kardiogenik, sepsis menyebabkan disfungsi miokard) (maks 40 µg /kg/mnt)
bradikardi dengan gejala yang tidak respon terhadap
atrophine
Dopamin Syok Kardiogenik/vasodilator, gagal jantung, bradikardi 2 mnt 2-10 µg /kg/mnt
dengan gejala yang tidak respon terhadap atropine 5-10 µg /kg/mnt (inotropik)
> 10 µg /kg/mnt (vasopresor)
Epinephrine Syok kardiogenik/vasodilator, henti jantung, 2 mnt Infusion: 0.01-0.1 µg /kg/mnt
bronkospasm/anafilaktik, bradikardi dengan gejala atau blok Bolus: 1 mg IV setiap 3-5 menit (maks 0.2
jantung yang tidak respon terhadap atropin mg/kg)
IM: (1:1000): 0.1 to 0.5 mg (maks 1 mg)
Norepinephrine Syok kardiogenik/vasodilator 2-2.5 mnt 0.01 to 3 µg /kg/mnt

Nitroglycerine HT emergency 1-5 mnt 5–200 mg/min, 5 mg/min increase every

5 min
Nicardipine 30–40 min 5–15 mg/h as continuous i.v. infusion,
starting dose 5 mg/h, increase every
15–30 min with 2.5 mg until goal BP,
thereafter decrease to 3 mg/h

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GENERAL APPROACH

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Cont..

2015
Guidelines

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NSTE-ACS
2020
Guidelines

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STEMI

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STEMI

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STEMI

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STEMI PPCI

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FIBRYNOLYTIC

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FIBRYNOLYTIC CONTRAINDICATION

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COMPLICATION

Complication Manifestation Timeline

Heart blocks, atrial and ventricular

Arrhythmic 1 to 3 days
arrhythmias

Reinfarction, peri-infarct ischemia,

Ischemic Most common in the initial few days
infarct extension

Mitral valve and chordae

rupture/tear, ventricular septal defect
Mechanical Usually first week to first month
(VSD), ventricular free wall rupture,
tamponade, aneurysm

First week to months (Dressler

Pericarditis, post-myocardial
Inflammatory syndrome typically manifests days to
infarciton (MI) Dressler syndrome
weeks later)

Cardiogenic shock, heart failure,

embolic cerebrovascular accident,
Systemic Within 24 hours.
MI, and systemic and lower
extremity embolism

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1. QUIZ
53 yo man fell chest discomfort since 4 h, VS 120/80 mmHg, HR 90x/min, dx? Tx?

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2. QUIZ
49 yo woman fell chest discomfort since 7 h, VS 80/60 mmHg, HR 110x/min, JVP 5+1 cmH2O, no rales, dx? Tx?

V4R

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3. QUIZ
31 yo man fell chest discomfort and dyspneu since 15 h, at ER VT 130/80, HR 120x/m, RR 30x/min, rales ½ lung fields, dx? Tx?

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4. QUIZ
51 yo man fell chest discomfort since 13 h, at ER VT 72/60, HR 110x/m, trop i 1200, dx? Tx?

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