SINDROMA KORONER

AKUT
Indry Putri Festari

SMF JANTUNG DAN PEMBULUH DARAH

RSI SITI RAHMAH PADANG

JANTUNG SEBAGAI POMPA

Kanan

Kiri

Penyakit Kardiovaskuler :
Masalah Yang Berakibat Fatal
Lain-lain

Kondisi Ibu Hamil dan

Persalinan
&
defisiensi
nutrisi

Peny.Infeksi &
parasit

Kecelakaan
Peny.Respirasi
Non infeksi

Kanker

30%

Infeksi Respirasi

CV
Survey Kesehatan Indonesia 2001
WHO World Health Report, 2001

Penyebab kematian
nomor I di dunia dan
Indonesia

Proses penyempitan pembuluh darah

(Aterosklerosis)
Normal

Garis lemak

Tumpukan
lemak

Penyempitan

Plak pecah
Dan tersumbat

UAP

MCI
MATI

STROKE

Gejala tersembunyi

Sakit dada

Meningkat sesuai umur

Critical Leg
Ischemia

AWAS
SERANGAN JANTUNG !!!

SAKIT DADA

Faktor Risiko
3. Diabetes/ Insulin Resistance

1. Lifestyle
Diet

4. Emerging Risk Factors :

Smoking
Obesity

- Plasma Homocysteine (tHcy)

Physical

inactivity
2. Blood Pressure
3. Plasma lipids
LDL-C
TG
HDL-C
Other Lipid Factors :
Apoliproprotein B
Lipoprotein (a)

-- Thrombogenic Factors
-- plasma fibrinogen
-- Plasminogen Activator Inhibitor

-- Markers of Inflammation
5. Genetics
Family history

(PAI-1)

Gangguan metabolisme
Faktor risiko
Kegemukan
( Lingkaran Perut )
Laki
Wanita
Trigliserida
HDL-C
Laki
Wanita
Tekanan Darah
Gula Puasa

Batas Nilai

>102 cm (>40 in)

>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg
110
mg/dL
JAMA. 2001;285:2486-2497.

MATI

PREVENTIVE

PREVENTIVE

CRP

FAKTOR RISIKO

SINDROMA KORONER AKUT

Acute Coronary Syndrome

The spectrum of clinical conditions ranging from:

unstable angina pectoris
Non ST elevasi (Non-STEMI)
ST elevasi myocard infarct (STEMI)

Characterized by the common pathophysiology of a

disrupted atheroslerotic plaque

Acute Coronary Syndrome

Ischemic Discomfort
Unstable Symptoms

No ST-segment
elevation

Unstable
angina

ST-segment
elevation

Non-Q
AMI

Q-Wave
AMI

History
Physical Exam

ECG

Acute
Reperfusion

Unstable Angina - Definition

Angina at rest (> 20 minutes)

new-onset (< 2 months) exertional angina (at least CCSC

III in severity)

recent (< 2 months) acceleration of angina (increase in

severity of at least one CCSC class to at least CCSC class
III)

Angina Post MI

Unstable Angina Likelihood of CAD

Previous history of CAD

Presence of risk factors

Older age

ST-T wave ischemic ECG changes

Unstable Angina precipitating factors

Inappropriate tachycardia
anemia, fever, hypoxia, tachyarrhythmias,
thyrotoxicosis

High afterload
aortic valve stenosis, LVH

High preload
high cardiac output, chamber dilatation

Inotropic state
sympathomimetic drugs, cocaine intoxication

Unstable Angina prognostic

indicators

Presence of ST-T-wave changes with pain

Hemodynamic deterioration
pulmonary edema, new mitral regurgitation,
3rd heart sound, hypotension

Other predictors
left ventricular dysfunction, extensive CAD, age,
comorbid conditions (diabetes mellitus, obstructive
pulmonary disease, renal failure, malignancy)

Unstable Angina pathogenesis

Plaque
Acute

disruption

thrombosis

Vasoconstriction

Atherosclerosis: A Progressive Process

Normal

Fatty
Streak

Plaque
Rupture/
Occlusive
Fibrous Atherosclerotic Fissure &
Thrombosis
Plaque
Plaque

Unstable
Angina

MI
Coronary
Death
Stroke
Clinically Silent

Effort Angina
Claudication

Increasing Age
Courtesy of P Ganz.

Critical Leg
Ischemia

Non-Q-Wave MI clues to diagnosis

Prolonged chest pain

Associated symptoms from the autonomic nervous system

nausea, vomiting, diaphoresis

Persistent ST-segment depression after resolution of chest

pain

Unstable Angina Risk Stratification

Low Risk
new-onset
minor
pain

exertional angina

chest pain during exercise

relieved promptly by nitroglycerine

Management
can

be managed safely as an outpatient (assuming

close follow-up and rapid investigation)

Unstable Angina Risk Stratification

Intermediate Risk

prolonged chest pain

diagnosis of rule-out MI

Management

observe in the ER or Chest Pain Unit

monitor clinical status and ECG

obtain cardiac enzymes (troponin T or I) every 8 to 12

hours

Unstable Angina Risk Stratification

High Risk

recurrent chest pain

ST-segment change

hemodynamic compromise

elevation in cardiac enzymes

Management

monitor in the Coronary Care Unit

Risk Stratification by ECG

The risk of death or MI at 30 days is strongly related to the
ECG at the time of chest pain.

ST depression

10%

T-wave inversion

No ECG changes 1-2%

5%

Unstable Angina Therapeutic Goals

Therapeutic Goals

Reduce myocardial ischemia

Control of symptoms

Prevention of MI and death

Medical Management

Anti-ischemic therapy

Anti-thrombotic therapy

Unstable Angina Medical Therapy

Anti-ischemic

therapy

nitrates, beta blockers, calcium antagonists

Anti-thrombotic
Anti-platelet therapy

therapy

aspirin, ticlopidine, clopidogrel,

GP IIb/IIIa inhibitors

Anti-coagulant therapy

heparin, low molecular weight heparin (LMWH),

warfarin, hirudin, hirulog

Unstable Angina Anti-ischemic

Therapy

restrict activities

morphine

oxygen

nitroglycerine
pain relief, prevent silent ischemia, control hypertension,
improve ventricular dysfunction
nitrate free period recommended after the first 24-48 hours

Unstable Angina Anti-ischemic

Therapy

beta-blockers
lowering angina threshold
prevent ischemia and death after MI
particularly useful during high sympathetic tone

calcium antagonists
particularly the rate-limiting agents
nifedipine is not recommended without concomitant blockade

Unstable Angina Anti-thrombotic

Therapy

Thrombolytics are not indicated

lytic agents may stimulate the thrombogenic process and

result in paradoxical aggravation of ischemia and myocardial
infarction
Circulation 1994; 89:1545-1556

Platelets in Acute Coronary

Syndromes
Platelets
Sources

play a key role in ACS

of platelet activation (triggers)

thromboxane A2 (TXA2)
ADP
epinephrine
collagen
thrombin

Unstable Angina Anti-platelet

Therapy

aspirin is the gold standard

irreversible inhibition of the cyclooxygenase pathway in
platelets, blocking formation of thromboxane A2, and
platelet aggregation
in AMI, ASA reduced the risk of death by 20-25%
in UA, ASA reduced the risk of fatal or nonfatal MI by 71%
during the acute phase, 60% at 3 months, and 52% at 2
years
bolus dose of 160-325 mg, followed by maintenance dose of
80-160 mg/d

Unstable Angina Anti-platelet

Therapy
Thienopyridines

ticlopidine (Ticlid; Hoffmann-La Roche)

clopidogrel (Plavix; Bristol-Myers Squibb)

block platelet aggregation induced by ADP and

the transformation of GP IIb/IIIa into its high
affinity state

GP IIb/IIIa Receptor
Final Pathway to Platelet
Aggregation

Platelet

activation and aggregation are early events

in the development of coronary thrombosis

GP

IIb/IIIa receptors on activated platelets undergo

a conformational change allowing recognition and
binding of fibrinogen

Fibrinogen

acts like glue, bridging GP IIb/IIIa

receptors on adjacent platelets, leading to platelet
aggregation

Unstable Angina Anti-platelet Therapy

GP IIb/IIIa inhibitors
abciximab (monoclonal antibody)
eptifibatide (peptidic inhibitor)
lamifiban and tirofiban (non-peptides)
direct occupancy of the GP IIb/IIIa receptor by a
monoclonal antibody or by synthetic compounds
mimicking the RGD sequence for fibrinogen binding
prevents platelet aggregation

Unstable Angina
Anti-coagulant Therapy

Heparin
recommendation is based on documented efficacy in
many trials of moderate size
meta-analyses (1,2) of six trials showed a 33% risk
reduction in MI and death, but with a two fold
increase in major bleeding
titrate PTT to 2x the upper limits of normal
1. Circulation 1994;89:81-88
2. JAMA 1996;276:811-815

Unstable Angina
Anti-coagulant Therapy

Low-molecular-weight heparin
advantages over heparin:
better bio-availability
higher ratio (3:1) of anti-Xa to anti-IIa activity
longer anti-Xa activity, avoid rebound
induces less platelet activation
ease of use (subcutaneous - qd or bid)
no need for monitoring

NEW ACLS - ACS ALGORITHM

ACC / AHA
Update 2007

a
n
o

o
C
_

ACC/AHA ACLS ACS

Algorithm 2006
1
Nyeri dada (kecurigaan ischemia)

2
Diagnosa, penatalaksanaan dan persiapan/pre hospital oleh EMS :
- Monitor, support ABC. Persiapan untuk CPR dan defibrilasi
- Berikan oksigen, aspirin, nitroglycerin dan morphine bila dibutuhkan
- Jika tersedia, periksa ECG 12 lead, jika terdapat ST-Elevasi :
Hubungi rumah sakit yang dituju dengan DX pasien
Mulai membuat fibrinolytic checklist
- RS yang dituju harus menyaiapkan Mobilize Hospital Resources untuk
merespon pasien STEMI

3
Diagnosa cepat oleh Emergency Departemen
E.D
(<10min)
-

Check vital signs, evaluasi saturasi O2

Pasang IV line
ECG 12 lead
Anamnese singkat, terarah, pemeriksaan fisik

- Periksa awal level cardiac marker, elektrolit

tidak
Dan faal hemostatis
- Periksa Rontgen dada (<30 m)

Penatalaksanaan umum cepat oleh

Morphin IV jika nyeri tidak berkurang dengan

nitroglycerin
O2 4 L/mnt, pertahankan saturasi O2 > 90%
- Nitroglycerin SL atau spray atau IV
-

Aspirin 160 samapai 325 mg (jika

diberikan oleh EMS)

Ulang pemeriksaan ECG 12 lead

13

ST Elevasi atau LBBB baru atau

diasumsikan baru; dicurigai kuat
ST-Elevasi MI (STEMI)

ST depresi atau T inverted;

dicurigai kuat suatu ischemia
Resiko tinggi unstable angina / Non
ST Elevation MI (AU/NSTEMI)

Normal atau tidak ada perubahan

segmen ST atau gelombang T
Resiko rendah atau sedang untuk
unstable angina

6
14

10

Mulai terapi tambahan sesuai

indikasi. Jangan menunda
reperfusi

-Clopidogrel
-Nitroglycerin
--adrenergic reseptor blockers
-Heparin (UFH or LMWH)
-Glycoprotein IIb/IIIa inhibitor

-Clopidogrel
--adrenergic reseptor blockers
-Heparin (UFH or LMWH)

11
7

Opname di ruangan dgn

monitoring bed
Tentukan status resiko

Onset gejala < 12 jam

Berlanjut memenuhi kriteria

sedang atau tinggi (tabel
3,4)atau troponin positive?

Mulai terapi tambahan sesuai

indikasi

15

Pertimbangkan opname di ED
chest paint unit atau monitored
bed di ED
Lanjutkan dengan :
Serial cardiac marker (termasuk
troponin)
Ulang ECG, monitor segmen ST
Pertimbangan stress test

12

Strategi reperfusi:
Terapi ditetapkan berdasarkan
keadaan pasien dan center
criteria
Menyadari tujuan terapi reperfusi:
Door-to-balloon inflation (PCI) =
90 mnt
Door-to-needle (fibrinolysis) = 30
mnt
Lanjutkan dengan terapi:
ACE inhibitor/angiotensi receptor
blocker (ARB) 24 jam dari onset
HMG CoA reductase inhibitor
(statin therapy)

Pasien High-risk:
Refractory ischemic chest pain
Recurrent/persistent ST deviation
Ventricular tachycardia
Hemodynamic tachycardia
Signs of pump failure
Strategi invasive awal termasuk
kateterisasi & revaskularisasi
penderita IMA dgn syok dlm 48 jam
Lanjutkan pemberian ASA, heparin &
terapi lain sesuai indikasi:
ACE inhibitor / ARB
HMG CoA reductase inhibitor (statin
therapy)
Tidak pada resiko tinggi: penentuan
penggolongan resiko dari cardiology

16

Berlanjut memenuhi kriteria

resiko tinggi atau sedang
(tabel 3,4)
atau
troponin-positive

17

Jika tidak ada ischemia atau

infare, maka dapat pulang
dengan rencana kontrol

Low Risk ACS

Intermediate Risk ACS

High Risk ACS

Early Conservative Management

Aspirin* (Class IA)

Early Invasive Management

Aspirin* (Class IA)

Clopidogrel# (Class IA)

Clopidogrel (Class IA)

LMWH (enoxaparin)/UFH (Class

IA)

* Or Clopidogrel if contraindicated (IA)

#
For at least 1 month (IA) and for up to 9 months (IB)
Gibler, WG, et al. Circul. 2005; 111: 2699-2710

LMWH (enoxaparin)/UFH (Class

IA)

04/23/16

ACC/AHA 2007 Guidelines Update

untuk UA / NSTEMI
Rekomendasi untuk Antiplatelet dan Anticoagulant

ESC Guidelines 2007

ASA

( Klas 1 A )

Direkomendasikan pada semua pasien NSTE-ACS bila tidak ada

kontra indikasi, dengan initial LD 160-325 (non enteric) dan dosis
pemeliharaan 75 100 mg untuk jangka panjang

CLOPIDOGREL

( Klas 1A )

Untuk semua pasien ACS, SEGERA berikan Clopidogrel 300mg LD,

dilanjutkan dengan 75mg/ hari, Clopidogrel harus dilanjutkan
hingga 12 bulan, kecuali ada resiko tinggi perdarahan.
Untuk pasien yang kontra indikasi terhadap ASA, Clopidogrel
harus digunakan sebagai penggantinya ( 1B )

GUIDELINE 2007

AUSSIE ( Australia & New Zealand )

Non STEMI
In Hospital ( Early Initiation )

Pengobtan awal segera harus dimulai dengan ASA dan Clopidogrel ( 300 mg LD
and 75 mg/hari) dengan mempertrimbangkan:

Clopidogrel harus dihindari pada pasien yang akan menjalani emergency coronary
bypass surgery
Jika memungkinkan, clopidogrel, harus dihentikan 5 hari sebelum coronary bypass
surgery.

Long-term management (Discharge Medication)

Semua pasien harus diberikan ASA 75 150 mg/hari kecuali kontra indikasi
Clopidogrel harus diberikan selama 12 months setelah diagnosa ACS, khususnya
setelah pemasangan stent, dengan lamanya therapy tergantung tipe stent dan
keadaan lokasi pemasangan
Clopidogrel juga dapat diberikan sebagai alternative kontraindikasi thd ASA,
atau sebagai tambahan ASA, pada pasien UA atau kejadian Kardiovaskular
berulang

GUIDELINE 2007

AUSSIE ( Australia & New Zealand )

STEMI

Semua pasien yang mendapatkan reperfusion therapy pada STEMI ( PCI atau Fibrinolysis ) harus
diberikan ASA dan CLOPIDOGREL kecuali ada kontra indikasi.

- Fibrinolytic Therapy

Pada pasien dengan fibrinolytic therapy, Clopidogrel (300 mg LD ) harus ditambahkan pada ASA, kecuali
kontraindikasi, Clopidogrel (75 mg/hari ) harus dilanjutkan paling tidak 1 bulan setelah fibronolytic
therapy

CRUSADE

Kepatuhan pada Guidelines

Menurunkan angka Mortality di Rumah Sakit

In-hospital Mortality (%)

Increased Adherence to Guidelines Decreases

Mortality

CRUSADE is a national quality improvement initiative of the Duke Clinical Research Institute. Partial funding
for CRUSADE is provided by the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.
CRUSADE Data Q3 2006. Cumulative CRUSADE data through September 2003.
Duke Clinical Research Institute. Available at: http://www.crusadeqi.com. Accessed February 13, 2007.

LEARNING FROM GUIDELINES

1. Clopidogrel di indikasikan pada pasien dengan UA, NSTEMI, dan
STEMI dan diberikan bersama ASA. Clopidogrel diberikan tunggal
jika ASA kontraindikasi.
2. Efek yang cepat dan

Co
_
a
on
M
memberikan perlindungan

yang lebih besar

jika pemberian clopidogrel therapy dimulai dengan loading dose

300-mg. dosis
3. Clopidogrel direkomendasikan sebagai antiplatelet Class 1 untuk
penanganan ACS baik STEMI maupun NON STEMI. ( ACC-AHA /
ESC / AUSSIE )

BALON ANGIOPLASTI

STENTING ( CINCIN )