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Acute Coronary Syndrome Sindroma Koroner Akut

Acute Coronary Syndrome Sindroma Koroner Akut. Toni Mustahsani Aprami, dr., SpPD, SpJP Department of Cardiology and Vascular Medicine Division of Cardiovascular, Department of Internal Medicine Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung. DEFINISI.

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Acute Coronary Syndrome Sindroma Koroner Akut

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  1. Acute Coronary Syndrome Sindroma Koroner Akut Toni Mustahsani Aprami, dr., SpPD, SpJP Department of Cardiology and Vascular Medicine Division of Cardiovascular, Department of Internal Medicine Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung

  2. DEFINISI Suatu sindroma klinik yang menandakan adanya iskemia miokard akut, terdiri dari : • Infark miokard akut Q wave (STEMI) • Infark miokard akut non-Q (NSTEMI) • Angina pektoris tidak stabil (UAP) Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis.

  3. PATOGENESIS • Umumnya disebabkan oleh aterosklerosis koroner • Plak aterosklerosis ruptur  terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koroner • Apabila sumbatan terjadi secara total  hampir seluruh dinding ventrikel akan nekrosis

  4. Risk Factors Uncontrollable Controllable • High blood pressure • High blood cholesterol • Smoking • Physical activity • Obesity • Diabetes • Stress and anger • Sex • Hereditary • Race • Age

  5. The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance MyocardialIschemia CAD plaque Atherosclerosis Risk Factors ( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc) DYSLIPIDEMIA Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

  6. The cardiovascular continuum of events Coronary Thrombosis Myocardial Ischemia CAD Atherosclerosis Risk Factors ( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc) DYSLIPIDEMIA Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

  7. The cardiovascular continuum of events ACS Coronary Thrombosis Myocardial Ischemia CAD Atherosclerosis Risk Factors ( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc) DYSLIPIDEMIA Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

  8. Stable angina Plaque rupture Coronary thrombosis UA/NSTEMI STEMI

  9. Penyempitan Pembuluh darah

  10. Clinical Spectrum of Acute Coronary Syndrome Acute Coronary Syndrome ST Segment Elevation Non-ST Segment Elevation STEMI NSTEMI Unstable Angina Pectoris Non-Q-wave Q-wave Acute Myocardial Infarction

  11. Unstable Angina STEMI NSTEMI • Non occlusive • thrombus • Non specific • ECG • Normal cardiac • enzymes • Occluding thrombus • sufficient to cause • tissue damage & mild • myocardial necrosis • ST depression +/- • T wave inversion on • ECG • Elevated cardiac • enzymes • Complete thrombus • occlusion • ST elevations on • ECG or new LBBB • Elevated cardiac • enzymes • More severe • symptoms

  12. Diagnosis Anamnesis Pemeriksaan Fisik Pemeriksaan Penunjang : 1. Laboratorium 2. Elektrokardiografi 3. Thoraks Foto

  13. HISTORY • PRODROMAL SYMPTOMS • History very valuable to establish D/. Prodoma : chest discomfort – unstable angina • 1/3 symptoms for 1 – 4 wks • 20% symptoms for < 24 hrs • Malaise, exhaustion • NATURE OF PAIN • Most patients • severe prolonged,  30 minutes - hours • Constricting, crushing, oppressing, compressing • heavy weight or squeezing in chest • Choking, vise-like, heavy pain or stabbing, knife-like, boring or burning discomfort • Location : retrosternal, spreading frequently to both sides of the chest with predilection to the left side • Often pain radiates down ulnar aspect of left arm, producing tingling sensation in left wrist, hand and fingers

  14. NATURE OF PAIN • SOME INSTANCES : pain begins in epigastrium, and simulates abdominal disorder • Sometimes pain radiates to shoulders, upper extremities, neck, jaw and interscapular region favoring the left side • Elderly : no chest pain but acute left ventricular failure and chest tightness or marked weakness or syncope • Pain arises from nerve endings in ischemic or injured, but not necrotic, myocardium • OTHER SYMPTOMS • 50% nausea or vomiting in transmural infarcts • Occasionally diarrhea, profound weakness, dizziness, palpitation, cold perspiration, sense of impending doom • Occasionally : cerebral embolism or systemic arterial embolism

  15. Pain Patterns with Myocardial Ischemia

  16. Anamnesis untuk UAP • 3 kategori presentasi klinik UAP: • Angina saat istirahat (resting angina) • Angina awitan baru (new onset angina) • Angina yang bertambah berat (increasing angina) • Riwayat penyakit dahulu : • Riwayat angina on effort, infark atau operasi pintas • Riwayat penggunaan nitrogliserin • Identifikasi faktor-faktor risiko

  17. PHYSICAL EXAMINATION GENERAL APPEARANCE Anxious, considerable distress, restless, fist on chest (Levine sign) LV failure & symp. stimulation : cold perspiration, pallor, dyspnea, cough with frothy pink or blood-streaked sputum. Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientation HEART RATE Variable depending on underlying rhythm and degree or ventr. failure Most commonly, HR 100 – 110/min; > 95% patients : VPB’s within first 4 hours

  18. BLOOD PRESSURE Majority normotensive, but syst. BP may decline and diast. BP may rise  Half of pts with inferior MI  parasympathetic stimulation : hypotension, bradycardia or both (Bezold – Jarisch reflex)  half of pts with anterior MI,  sympathetic excess : hypertension, tachycardia or both TEMPERATURE AND RESPIRATION Most pts with extensive MI  fever within 24-48 hrs, fever resolves by 4th or 5th day Respiration  due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure

  19. JUGULAR VENOUS PULSE JVP usually normal RV infarction : marked jug. venous distension CAROTID PULSE Small pulse  reduced stroke volume Pulse alternans : severe LV dysfunction

  20. CHEST LV failure and/or LV compliance ↓ : moist rales Severe failure : diffuse wheezing, cough + hemopthysis 1967 : Killip & Kimball : prognostic classification Class I : patients free of rales or S3 II : rales < 50% lung fields +/- S3 III : rales > 50% lung fields, frequently pulm. edema IV : cardiogenic shock

  21. Pemeriksaan Penunjang • Pemeriksaan EKG • Gambaran EKG infark miokard akut Q-wave (STEMI) : • Elevasi segmen ST  1 mm pada  2 sadapan extremitas • Atau  2 mm pada  2 sadapan prekordial yang berurutan • Atau gambaran LBBB baru atau diduga baru

  22. ST-segment elevation

  23. Gambaran EKG infark miokard akut non-Q-wave (NSTEMI) atau angina pektoris tidak stabil (UAP) : • Depresi segment ST atau gelombang T terbalik pada  2 sadapan berurutan • Inversi gelombang T minimal 1 mm pada 2 sadapan atau lebih yang berurutan. • Perubahan segment ST saat keluhan dan kembali normal saat keluhan hilang  sangat menyokong UAP

  24. ST-segment depression

  25. T-wave inversion

  26. ELEKTROKARDIOGRAM Current-of-injury patterns with acute ischemia

  27. Pemeriksaan Penanda Jantung/Enzim jantung • (Cardiac Markers): • Yang lazim adalah CKMB, dapat pula troponin T (TnT) atau troponin I (TnI) • Peningkatan marka jantung akan terlihat pada infark miokard akut Q-wave (STEMI) dan non-Q-wave (NSTEMI)

  28. Plot of the appearance of cardiac markers in blood versus time after onset of symptoms A myoglobin C CK-MB B troponin D troponin in UA

  29. Diagnosis Banding Diseksi aorta Perikarditis Nyeri angina atipikal pada kardiomiopati hipertrofi Penyakit esofageal, GI atas atau traktus biliaris Penyakit paru-paru : pneumotoraks, emboli, pleuritis Sindroma hiperventilasi Gangguan dinding dada : muskuloskeletal, neurogen Psikogen

  30. Manajemen

  31. The cardiovascular continuum of events ACS Coronary Thrombosis Arrhythmia and Loss of Muscle Myocardial Ischemia Remodeling Ventricular Dilatation CAD Atherosclerosis Congestive Heart Failure Risk Factors ( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc) End-stage Heart Disease DYSLIPIDEMIA Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

  32. DELAY TO THERAPY 1. From onset of symptoms to patient recognition 2. Out-hospital transport 3. In-hospital evaluation

  33. ISCHEMIC CHEST PAIN ALGORYTHM Chest pain suggestive of ischemia

  34. ISCHEMIC CHEST PAIN TYPICAL ANGINA EQUIVALENT ANGINA • NO CHEST DISCOMFORT • LOCATION • INDIGESTION • UNEXPLAINED WEAKNESS • DIAPORESIS • SHORTNESS OF BREATH • CHEST DISCOMFORT • LOCATION • RADIATION • UNLIKELINESS

  35. Immediate ED assessment and immediate ED general treatment Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  36. Immediate ED assessment ( 10 min) • Vital sign • Oxygen saturation • Obtain IV access • Obtain ECG 12 lead • Brief history and physical exam • Check contraindication for fibrinolytic • Initial serum cardiac markers • Initial electrolyte and coagulation • study • Portable chest x-ray ( 30 minutes) • Immediate ED general treatment • O2 at 4 L/min (maintain O2 sat 90%) • Aspirin 160-325 mg • Nitroglycerin SL, spray, or IV • Morphine IV 2-4 mg repeated every • 5-10 minutes (if pain not relieved • with nitroglycerine) • Memory: “MONA” greets all patients Chest discomfort suggestive of ischemia 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  37. Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Acute coronary syndrome algorithm 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  38. Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Acute coronary syndrome algorithm ST elevation or new or presumably new LBBB strongly suspicious for injury 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  39. Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury ST-depression or dynamic T-wave inversion strongly suspicious for injury 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  40. Normal or non-diagnostic changes in ST-segment or T-waves (intermediate/ low-risk UA) Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI) ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI) 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  41. ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI) ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI) Normal or non-diagnostic changes in ST-segment or T-waves (intermediate/ low-risk UA) Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Start adjunctive treatment 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  42. ADJUNCTIVE TREATMENT (Do not delay reperfusion) • Beta-adrenergic receptor blocker • Clopidogrel • Heparin (UFH or LMWH) 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  43. ST elevation or new or presumably new LBBB strongly suspicious for injury ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or non-diagnostic changes in ST-segment or T-waves Time from onset of symptoms  12 hours • Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) • ACE-I/ARB • Statin Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Start adjunctive treatment 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  44. ST elevation or new or presumably new LBBB strongly suspicious for injury ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or non-diagnostic changes in ST-segment or T-waves Acute coronary syndrome algorithm Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Start adjunctive treatment Start adjunctive treatment Time from onset of symptoms  12 hours • Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) • ACE-I/ARB within 24 hours of onset • Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  45. Adjunctive treatment • Heparin (UFH/LMWH) • Glycoprotein IIb/IIIa receptor inhibitors • -Adrenoreceptor blockers • Clopidogrel 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  46. ST elevation or new or presumably new LBBB strongly suspicious for injury ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or non-diagnostic changes in ST-segment or T-waves  12 hrs Admit to monitored bed Assess risk status • High risk: early invasive strategy • Continue ASA, heparin, ACE-I, statin Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Start adjunctive treatment Start adjunctive treatment Time from onset of symptoms  12 hours • Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) • ACE-I/ARB within 24 h of symptom onset) • Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  47. VERY HIGH-RISK PATIENT • Refractory chest pain • Recurrent/persistent ST deviation • Ventricular tachycardia • Hemodynamic instability • Sign of pump failure • Shock within 48 hours 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

  48. ST elevation or new or presumably new LBBB strongly suspicious for injury ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or non-diagnostic changes in ST-segment or T-waves Develops high or intermediate risk criteria or troponin-positive Monitored bed in ED Develops high or intermediate risk criteria or troponin-positive No evidence of ischemia and MI: discharge with follow-up Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG Start adjunctive treatment Start adjunctive treatment Time from onset of symptoms  12 hrs Admit to monitored bed Assess risk status  12 hours • High risk: early invasive strategy • Continue ASA, heparin, ACE-I, statin • Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) • ACE-I/ARB within 24 h of symptom onset) • Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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