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SIDROMA KORONER AKUT

UMAR F SHIBLY
SPESIALIS JANTUNG DAN PEMBULUH DARAH

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Atherosclerotic Plaque Stability

SUPPLY

DEMAND

Adapted from Weissberg. Atherosclerosis. 1999;147:S3S10

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Characteristics of the stable atherosclerotic plaque

Lipid core

Adventitia

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SAKIT DADA

JANTUNG

NON JANTUNG

ANGINA STABIL TAK STABIL KEDARURATAN

ATIPIKAL

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FEATURES NOT CHARACTERISTIC OF MYOCARDIAL ISCHEMIA (CONTD)

Pain reproduced with movement or palpation of the chest wall or arms Very brief episodes of pain that last a few seconds or less Pain that radiates into the lower extremities

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FEATURES NOT CHARACTERISTIC OF MYOCARDIAL ISCHEMIA

Pleuritic pain (i.e., sharp or knife-like pain brought on by respiratory movements or cough) Primary or sole location of discomfort in the middle or lower abdominal region Pain that may be localized at the tip of 1 finger, particularly over the LV apex

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UA/NSTEMI EMERGENCY ROOM TRIAGE

Chest pain or severe epigastric pain, typical of

myocardial ischemia or MI:

Substernal compression or crushing chest pain Pressure, tightness, heaviness, cramping,

aching sensation Unexplained indigestion, belching, epigastric pain Radiating pain to neck, jaw, shoulders, back or to one or both arms

Associated dyspnea, nausea and/or vomiting,

diaphoresis
IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG

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UA/NSTEMI THREE PRINCIPAL PRESENTATIONS

Angina occurring at rest and prolonged, usually > 20 minutes New-onset angina of at least CCS Class III severity Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by > 1 CCS) class to at least CCS Class III severity.

Rest Angina* New-onset Angina Increasing Angina

* Pts with NSTEMI usually present with angina at rest.

Braunwald Circulation 80:410; 1989

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RISK STRATIFICATION IN EMERGENCY DEPARTMENT

HIGH RISK-FEATURES (RISK RISES WITH NUMBER)

History Clinical findings Prolonged ischemic discomfort (>20 min), ongoing rest pain, accelerating tempo of ischemia Pulmonary edema; S3 or new rales New MR murmur Hypotension, bradycardia, tachycardia Age >75 years Rest pain with transient ST-segment changes > 0.05 mV; new bundle-branch block, new sustained VT Elevated (e.g. TnT or TnI>0.1 ng/mL)

ECG

Cardiac markers

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ACUTE CORONARY SYNDROME

No ST Elevation

ST Elevation

NSTEMI

Unstable Angina

NQMI QwMI Myocardial Infarction

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PURSUIT TRIAL: DEATH OR MI

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0.98
0.96 0.94 0.92 0.9 0.88 0.86 0.84 0.82 0.8 0 30 60 90 120 150 180

Days

N Engl J Med. 339:436-43, 1998

RECOMMENDATION
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Class I
1. Patients with suspected ACS with chest discomfort at rest for >20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED or a specialized chest pain unit.
Other patients with a suspected ACS may be seen initially in an ED, a chest pain unit, or an outpatient facility.

ANTI - ISCHEMIC Rx
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Class I
1. Bed rest with continuous ECG monitoring in pts with ongoing rest pain. 2. NTG, sublingual tablet or spray, followed by IV administration for ongoing chest pain. 3. Supplemental O2 for pts with hypoxemia, cyanosis or respiratory distress; finger pulse oximetry or arterial blood gas determination to confirm SaO2>90%. 4. Morphine sulfate IV when symptoms are not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.

ANTI - ISCHEMIC Rx (contd)

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Class I
5. A -blocker with the first dose administered IV if there is ongoing chest pain, followed by oral administration. 6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or diltiazem) as initial therapy in pts with continuing or frequently recurring ischemia when -blocker is contraindicated. 7. An ACEI when hypertension persists despite treatment with NTG and a -blocker in pts with LV systolic dysfunction or congestive heart failure and in ACS patients with diabetes.

ANTIPLATELET Rx
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Class I
1. Administer ASA as soon as possible after presentation and continue indefinitely. 2. A thienopyridine (clopidogrel or ticlopidine) in pts unable to take ASA.

3. Add IV UFH or subcutaneous LMWH to antiplatelet therapy with ASA, clopidogrel, or ticlopidine.
4. Add platelet GP IIb/IIIa receptor antagonist in pts with continuing ischemia or with other high-risk features and in pts in whom early PCI is planned.

ANTIPLATELET Rx
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Class I
Possible ACS Aspirin Likely/Definite ACS Definite ACS with continuing Ischemia or Other High-Risk Features or planned PCI

Aspirin Aspirin + + Subcutaneous LMWH IV heparin/LMWH + or IV platelet GP IIb/IIIa antagonist IV heparin

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BIOCHEMICAL CARDIAC MARKERS IN PTS WITH SUSPECTED ACS WITHOUT STE

Advantages

CK-MB
1. Rapid, costefficient, accurate assays 2. Ability to detect early reinfarction

Myoglobin
1. High sensitivity 2. Useful in early detection of MI 3. Detection of reperfusion 4. Most useful in ruling out MI

Troponins
1. Powerful for stratification 2. Greater sensitivity and specificity than CK-MB 3. Detection of recent MI up to 2 weeks after onset 4. Useful for selection of therapy 5. Detection of reperfusion

COCAINE
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CLINICAL CHARACTERISTICS

Ischemic chest pain Usually male < 40 years Cigarette smokers, but no other risk factors for atherosclerosis Associated with all routes of administration Not dose dependent Often associated with use of cigarettes and/or alcohol
Adapted from Pitts et al. Prog. Cardiovasc. Dis. 40:65, 1997

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SPECIAL GROUPS COCAINE

Class I
1. NTG and oral Ca2+ blocker for pts with ST deviation that accompanies ischemic chest discomfort. 2. Immediate coronary arteriography in pts with ST elevation after NTG and Ca2+ blocker; thrombolysis if a thrombus is detected.

ED MANAGEMENT OF UA/NSTEMI
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ST ? NO Nondiagnostic ECG Normal serum cardiac markers ST and/or T wave changes Ongoing pain + cardiac markers Hemodynamic abnormalities Evaluate for Reperfusion YES

Observe Follow-up at 4-8 hours: ECG, cardiac markers

No recurrent pain; Neg follow-up studies Stress study to provoke ischemia prior to discharge or as outpatient Neg: nonischemic discomfort;low-risk UA/NSTEMI

Recurrent ischemic pain or + UA/NSTEMI follow-up studies Diagnosis of UA/NSTEMI confirmed

+ UA/NSTEMI confirmed

ADMIT

Outpatient follow-up

POST-HOSPITAL DISCHARGE CARE

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A B C D E

Aspirin and Anticoagulants Beta blockers and Blood Pressure Cholesterol and Cigarettes Diet and Diabetes Education and Exercise

MEDICATIONS AT HOSPITAL DISCHARGE

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Class I
1. Aspirin 75 to 325 mg/d 2. Clopidogrel 75 mg/qd for patients with contraindication to ASA 3. -Blocker 4. Lipid-lowering agent and diet in patients with LDL cholesterol >130 mg/dL 5. Lipid-lowering agent if LDL cholesterol level after diet is > 100 mg/dL 6. ACEI for patients with CHF, LV dysfunction (EF<0.40) hypertension, or diabetes

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INSTRUCTIONS AT HOSPITAL DISCHARGE RISK FACTOR MODIFICATION

Class I
1. Smoking cessation and achievement or maintenance of optimal weight, daily exercise, and diet. 2. HMG-CoA reductase inhibitor for LDL cholesterol > 130 mg/dL. 3. Lipid-lowering agent if LDL cholesterol after diet is > 100 mg/dL. 4. Hypertension control to a BP < 130/85 mm Hg. 5. Tight control of hyperglycemia in diabetics. 6. Consider referral of smokers to a smoking cessation program.

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