Sasmojo Widito

Malang
2014
Work experience

1994-1997 Community Health Center of Sumbawa,
West Nusa Tenggara

1998-2005 Cardiovascular Resident,
University of Airlangga, Surabaya

2005-now Cardiovascular Specialist,
Dr. Saiful Anwar Teaching Hospital, Malang

2005-now Cardiovascular Lecturer, School of Medicine,
University of Brawijaya, Malang

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Training & studying
1986-1993 University of Sebelas Maret, Surakarta,
Medical Doctor
1998-2004 University of Airlangga, Surabaya,
Cardiologist
2007 National Cardiovascular Center Harapan Kita,
Jakarta,
Basic Invasive Training
2011-2012 Binawaluya Cardiac Center, Jakarta
Advanced interventional cardiovascular

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Sequence of Ischemic Heart Disease
Risk Factor
Endothelial dysfunction
CAD
Ischemia
Angina
Silent
MI
Arrythmias
Lost of muscle
Remodeling
Progresif dilatation
Heart Failure
Death
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Management
Before STEMI
4
1 2
3 4 5 6
Onset of STEMI
- Prehospital issues
- Initial recognition and management
in the Emergency Department (ED)
- Reperfusion
Hospital Management
- Medications
- Arrhythmias
- Complications
- Preparation for discharge
Secondary Prevention/
Long-Term Management
Modified from Libby. Circulation 2001;104:365,
Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.
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Naghavi et al. Circulation 2003;108:166484
Normal coronary artery
no atherosclerosis, wide
lumen
Atherosclerotic plaque
has caused 60 - 70 %
stenosis
A thrombus is well-
established, only 3 small
lumens remain
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capsul
core
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Symptom
Recognition
Call to
Medical System
ED
Cath Lab
PreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment Denied
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healthcare providers should assist patients,

making anticipatory plans for timely recognition and response to
an acute event

taking chew nonenteric-coated aspirin (162 to 325 mg) and 1
nitroglycerin in response to chest pain promptly

If symptoms are unimproved or worsening 5 minutes after 1 dose,
the patient should be instructed to call EMS immediately

Family members, close friends should be enlisted as reinforcement
for rapid action when the patient experiences symptoms of
possible STEMI

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preexisting bias that a heart attack should present dramatically
with severe, crushing chest pain

one third of patients with MI experience symptoms other than
chest pain

reasoning that symptoms will be self-limited or are not serious
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attribution of symptoms to other preexisting conditions

fear of embarrassment should symptoms turn out to be a false
alarm

reluctance to trouble others unless really sick

preconceived stereotypes of who is at risk for a heart attack
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lack of knowledge of the importance of rapid action,

unavailability of EMS

unavailability of reperfusion therapies

attempted self-treatment with prescription and/or
nonprescription medications
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STEMI
Clinical syndrome
Symptoms: myocardial ischemia
ECG: ST elevation
Lab: release of biomarkers of myocardial necrosis.
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Heart attack warning signs

Chest discomfort
pressure, squeezing, fullness, or pain in the center of chest

Discomfort in one or both arms, back, neck, jaw, or
stomach

Shortness of breath
often comes with or before chest discomfort

Breaking out in a cold sweat, nausea, or light-
headedness

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Heart attack warning signs


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Diagnostic ST elevation
New ST elevation at the J point in at least 2 contiguous leads of 2
mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2
V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or
the limb leads.

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RBBB
QRS complex duration prolonged
V
1
Monophasic R, rsr, Rsr, RSr, RSR, rSr,rSR, rsR, qR.
ST depression (discordant)
V
6
Wide S, RS complex
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Diagnostic ST elevation
RBBB, STEMI anterior
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LBBB
V
1
, V
2
, V
3
QS, rS, with ST elevation (discordant)
I,aVL,V
5
,V
6
monophasic R, with ST depression (discordant)
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Diagnostic ST elevation
LBBB with STEMI

Sgarbossa criteria
I,aVL,V
5
,V
6
ST elevation 1 mm, concordant QRS complex (score 5)
V
1
,V
2
, or V
3
ST depression 1 mm (score 3)
V
2
-V
4
ST elevation 5 mm, discordant QRS complex (score 2)

Score of 3 had a specificity of 98% for STEMI, but a score of 0 did
not rule out STEMI

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Diagnostic ST elevation
LBBB with STEMI: Sgarbossa criteria
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Diagnostic ST elevation
ST depression in 2 precordial leads (V1V4) may indicate
transmural posterior injury
STEMI Inferoposterior



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Clinical findings:
Shock with clear lungs, elevated JVP
Kussmaul sign
Hemodynamics:
Increased RA pressure (y descent)
Square root sign in RV tracing
ECG:
ST elevation in R sided leads
Echo:
Depressed RV function
Rx:
Maintain RV preload
Lower RV afterload (PA---PCW)
Inotropic support
Reperfusion
V
4
R
Modified from Wellens. N Engl J Med 1999;340:381.
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Diagnostic ST elevation

Multilead ST depression with coexistent ST elevation in lead aVR:
left main or proximal left anterior descending artery occlusion

Hyperacute T-wave changes: early phase of STEMI, before the
development of ST elevation

Baseline ECG abnormalities other than LBBB (e.g., paced rhythm,
LV hypertrophy, Brugada syndrome) may obscure interpretation.

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Echocardiography: provide focal wall motion abnormalities,
facilitate triage in case with ECG findings that are difficult to
interpret.

If doubt persists, immediate referral for invasive angiography may
be necessary to guide therapy in the appropriate clinical context.

Cardiac troponin: preferred biomarker of MI.
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Some of the independent predictors of early death
from STEMI include

Age, Killip class,
Time to reperfusion, Cardiac arrest,
Tachycardia, Hypotension,
Anterior infarct location, Prior infarction,
Diabetes Mellitus, Smoking status,
Renal function, Biomarker findings
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Thrombolysis In Myocardial Infarction (TIMI) risk
score
http://www.mdcalc.com/timi-riskscore-for-stemi

GRACE
http://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.html


Risk assessment is a continuous process, should be repeated
throughout hospitalization and at time of discharge.


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Regional systems of stemi care and goals for reperfusion therapy

Strategies for shortening door-to-device times

Prehospital Fibrinolytic Therapy
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CABG, coronary artery bypass graft; DIDO, door-in door-out; FMC, first medical contact; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.
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Performance of PCI is dictated by an anatomically appropriate
culprit stenosis

Cardiogenic shock or severe heart failure initially seen at a non
PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible,
irrespective of time delay from MI onset.

Angiography and revascularization should not be performed
within the first 2 to 3 hours after administration of fibrinolytic
therapy

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Back ground studies:
CAPTIM (Comparaison de lAngioplastie Primaire et de la
Thrombolyse) trial,
WEST (Which Early ST-Elevation Myocardial Infarction Therapy)
trials
USIC (Unit de Soins Intensifs Coronaires) Registry
Swedish Registry of Cardiac Intensive Care

Advantages:
lower STEMI mortality rates


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Effort:
Training for EMS officer in rural areas
Funding for necessary equipment.

Prehospital fibrinolysis is more widespread in some regions of Europe
and the United Kingdom.

further research into the implementation of prehospital fibrinolytic
strategies to reduce total ischemic time.
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Timing of Fibrinolytic
Therapy
Benefits are well established,
with a time-dependent reduction
in both mortality and morbidity
rates during the initial 12 hours
after symptom onset
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Timing of Fibrinolytic
Therapy
When interhospital transport times
are short, there may be advantages
to the immediate delivery of
fibrinolytic therapy versus any
delay to primary PCI for patients
with STEMI and low
bleeding risk who present within
the first 1 to 2 hours of symptom
onset
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Timing of Fibrinolytic
Therapy
Benefit from fibrinolytic therapy in
patients who present 12 hours after
symptom onset has not been
established

8/31/2014 42 PKB. Malang. 2014
Timing of Fibrinolytic
Therapy
Consensus:
consideration should be given to
administering a fibrinolytic agent in
symptomatic patients presenting 12 hours
after symptom onset with STEMI and a
large area of myocardium at risk or
hemodynamic instability if PCI is
unavailable
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Choice of Fibrinolytic Agent
Fibrin-specific agents are preferred when available. Adjunctive antiplatelet and/or
anticoagulant therapies are indicated, regardless of the choice of fibrinolytic agent.
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Contraindications and
Complications With
Fibrinolytic Therapy
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Contraindications and
Complications With
Fibrinolytic Therapy
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Fibrinolytic Therapy When There Is an
Anticipated Delay to Performing
Primary PCI Within 120 Minutes of
FMC
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Fibrinolytic Therapy When There Is an
Anticipated Delay to Performing
Primary PCI Within 120 Minutes of
FMC
Indications for fibrinolytic therapy when there is a >120 min
delay from FMC to primary PCI
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Adjunctive Antiplatelet
Therapy With Fibrinolysis
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Adjunctive Anticoagulant
Therapy With Fibrinolysis
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Assessment of Reperfusion
After Fibrinolysis
The relatively sudden and complete relief
of chest pain coupled with 70% ST
resolution is highly suggestive of
restoration of normal myocardial blood
flow.

Complete (or near complete) ST-segment
resolution at 60 or 90 minutes after
fibrinolytic therapy is a useful marker of a
patent infarct artery

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Assessment of Reperfusion
After Fibrinolysis
The combination of 50% ST resolution and
the absence of reperfusion arrhythmias at 2
hours after treatment predicts TIMI flow 3
in the infarct artery.

Lack of resolution of ST elevation by at
least 50% in the worst lead at 60 to 90
minutes should prompt strong
consideration of a decision to proceed with
immediate coronary angiography and
rescue PCI.

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Indications for Transfer for
Angiography After
Fibrinolysis
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Indications for Transfer for
Angiography After
Fibrinolysis
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Indications for Transfer for
Angiography After
Fibrinolysis
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
PKB. Malang. 2014
Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
PKB. Malang. 2014
Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
PKB. Malang. 2014
Primary PCI in STEMI
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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;
MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
PKB. Malang. 2014
Use of Stents in Primary PCI
Balloon angioplasty without stent placement may be used in
selected patients.
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Antiplatelet Therapy to Support
Primary PCI for STEMI
The recommended maintenance dose of aspirin to be
used with ticagrelor is 81 mg daily.
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Antiplatelet Therapy to Support
Primary PCI for STEMI
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Anticoagulant Therapy to Support
Primary PCI
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Anticoagulant Therapy to Support
Primary PCI
Posthospital management
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Medications
Antithrombotic therapies
Beta blockers
ACE inhibitors/ARBs/aldosterone antagonists
Statins

Physical activity & cardiac rehabilitation
Physical Activity
Cardiorespiratory fitness (MET capacity)




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Risk factor modification & lifestyle interventions
Smoking cessation
Diet/nutrition

Management of comorbidities
Overweight/obesity
Lipids
Hypertension
Diabetes
HF
Arrhythmia/arrhythmia risk

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Psychosocial factors
Sexual activity
Gender-specific issues
Depression, stress, and anxiety
Alcohol use
Culturally sensitive issues
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Provider follow-up
Cardiologist
Primary care provider
Advanced practice nurse/physician assistant
Other relevant medical specialists
Electronic personal health records
Influenza vaccination
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Patient/family education

Plan of care for acute MI
Recognizing symptoms of MI
Activating EMS, signs and symptoms for urgent vs emergency
evaluations
CPR training for family members
Risk assessment & prognosis
Advanced directives
Social networks/social isolation

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Socioeconomic factors

Access to health insurance coverage
Access to healthcare providers
Disability
Social services
Community services

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Electro-
cardiogram
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Stress
Test
Electro-
cardiogram
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Stress
Test
Coronary
Angiography
Electro-
cardiogram
Public
Health
perspective
of CHD
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6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
8/31/2014 PKB. Malang. 2014 76
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
8/31/2014 PKB. Malang. 2014 77
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Media:
Educate patients
Monitor results & compliance
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
8/31/2014 PKB. Malang. 2014 78
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Cardiologist:
Initiate early treatments: anticoagulants,
antiplatelets, -blockers, narcotics
Master triage, and transfer
Media:
Educate patients
Monitor results & compliance
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
8/31/2014 PKB. Malang. 2014 79
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Cardiologist:
Initiate early treatments: anticoagulants,
antiplatelets, -blockers, narcotics
Master triage, and transfer
Media:
Educate patients
Monitor results & compliance
Interventional cardiologist:
Expert in short D2B interventions
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
8/31/2014 PKB. Malang. 2014 80
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Cardiologist:
Initiate early treatments: anticoagulants,
antiplatelets, -blockers, narcotics
Master triage, and transfer
Media:
Educate patients
Monitor results & compliance
Interventional cardiologist:
Expert in short D2B interventions
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
Hospital:
Provide exceptional ED, CVL, and
CCU services
8/31/2014 PKB. Malang. 2014 81
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
Public
Health
perspective
of CHD
Family physician:
Learn of options that exist for CAD patients
Risk factors modifications
Cardiologist:
Initiate early treatments: anticoagulants,
antiplatelets, -blockers, narcotics
Master triage, and transfer
Media:
Educate patients
Monitor results & compliance
Interventional cardiologist:
Expert in short D2B interventions
Patients, communities:
Take care of yourself
Know of treatment options
Seek treatment early
Hospital:
Provide exceptional ED, CVL, and
CCU services
Politicians and Leaders:
Allocate appropriate resources
the next patient maybe you or your
loved one
8/31/2014 PKB. Malang. 2014 82
6
th
Asian Interventional Cardiovascular Therapeutics, 2010
The End