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Acute Coronary Syndrome Sindroma Koroner Akut Toni Mustahsani Aprami, dr., SpPD, SpJP Department of Cardiology and Vascular Medicine Division of Cardiovascular,

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Presentasi berjudul: "Acute Coronary Syndrome Sindroma Koroner Akut Toni Mustahsani Aprami, dr., SpPD, SpJP Department of Cardiology and Vascular Medicine Division of Cardiovascular,"— Transcript presentasi:

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

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

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

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

8 Stable anginaPlaque ruptureCoronary thrombosisUA/NSTEMISTEMI

9 Penyempitan Pembuluh darah

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

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 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 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 15 Pain Patterns with Myocardial Ischemia

16 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 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 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 hrs, fever resolves by 4 th or 5 th day Respiration  due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure

19 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 20 CHEST LV failure and/or LV compliance ↓ : moist rales Severe failure : diffuse wheezing, cough + hemopthysis 1967 : Killip & Kimball : prognostic classification ClassI: patients free of rales or S3 II: rales < 50% lung fields +/- S3 III: rales > 50% lung fields, frequently pulm. edema IV: cardiogenic shock

21 21 Pemeriksaan Penunjan g 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

24

25 25 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

26 ST-segment depression

27 T-wave inversion

28 28 Current-of-injury patterns with acute ischemia ELEKTROKARDIOGRAM

29 29 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)

30 30 Plot of the appearance of cardiac markers in blood versus time after onset of symptoms Amyoglobin CCK-MB BtroponinDtroponin in UA

31 31 1.Diseksi aorta 2.Perikarditis 3.Nyeri angina atipikal pada kardiomiopati hipertrofi 4.Penyakit esofageal, GI atas atau traktus biliaris 5.Penyakit paru-paru : pneumotoraks, emboli, pleuritis 6.Sindroma hiperventilasi 7.Gangguan dinding dada : muskuloskeletal, neurogen 8.Psikogen Diagnosis Banding

32 Manajemen

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

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

35 ISCHEMIC CHEST PAIN ALGORYTHM Chest pain suggestive of ischemia

36 ISCHEMIC CHEST PAIN TYPICAL ANGINAEQUIVALENT ANGINA 1.CHEST DISCOMFORT 2.LOCATION 3.RADIATION 4.UNLIKELINESS 1.NO CHEST DISCOMFORT 2.LOCATION 3.INDIGESTION 4.UNEXPLAINED WEAKNESS 5.DIAPORESIS 6.SHORTNESS OF BREATH

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

38 Chest discomfort suggestive of ischemia 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 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 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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

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

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

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

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

44 1.Beta-adrenergic receptor blocker 2.Clopidogrel 3.Heparin (UFH or LMWH) ADJUNCTIVE TREATMENT (Do not delay reperfusion) 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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

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

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

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

49 VERY HIGH-RISK PATIENT 1.Refractory chest pain 2.Recurrent/persistent ST deviation 3.Ventricular tachycardia 4.Hemodynamic instability 5.Sign of pump failure 6.Shock within 48 hours 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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

51

52

53 53  Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan  Aspirin  Beta-blocker  ACE inhibitor Pengobatan Pasca Perawatan  Berhenti merokok  Pertahankan BB optimal  Aktivitas fisik sesuai dengan hasil treadmill  Diet  Rendah lemak jenuh dengan kolesterol, bila perlu dengan target LDL < 100 mg/dL  Pengendalian hipertensi  Pengendalian ketat gula darah pada penderita DM Modifikasi Faktor Risiko

54 Get regular medical checkups. Control your blood pressure. Check your cholesterol. Don’t smoke. Exercise regularly. Maintain a healthy weight. Eat a heart-healthy diet. Manage stress.

55 Thank you for your attention

56 56 Anamnesis Nyeri dada atau nyeri epigastrium hebat yang mengarah pada iskemia miokard : Seperti dihimpit benda berat Terasa tercekik Rasa ditekan, ditinju, ditikam Rasa terbakar Biasanya dirasakan dibelakang stenum  seluruh dada terutama kiri, dapat ke tengkuk, rahang, bahu, punggung, lengan kiri atau kedua lengan Terutama laki-laki > 35 tahun dan Wanita > 40 tahun Seringkali disertai mual atau muntah, dapat pula rasa tidak enak disertai sesak nafas, lemah, penurunan kesadaran, dan keringat banyak

57 57 Pemeriksaan Fisik Biasanya penderita tampak cemas, gelisah, pucat, dan keringat dingin Periksa tanda-tanda vital : Denyut nadi cepat, reguler tetapi dapat pula bradi atau tachycardia, irama ireguler Tekanan darah biasanya normal bila belum terjadi komplikasi, dapat pula terjadi hipo atau hipertensi Bunyi jantung dapat terdengar redup S3 dapat terdengar bila kerusakan miokard luas Paru-paru dapat terdengar ronkhi basah dan atau wheezing yang menandakan terjadinya bendungan paru  tergantung ada tidaknya gangguan fungsi ventrikel kiri


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