Acute Coronary

Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI STEMI

1.24 million .33 million

Admissions per year Admissions per year

Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. About
0.57 million NSTEMI and 0.67 million UA.
ESC Guidelines for the management of Acute Coronary Syndrome in patients without
persistent ST Elevation.2011
 No ST elevation ST elevation
Stable Unstable NSTEMI STEMI
angina angina

ACUTE CORONARY SYNDROMES

 Atherosclerosis Timeline

Foam Fatty Intermediate Fibrous Complicated

Cells Streak Lesion Atheroma Plaque Lesion/Rupture

Endothelial Dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen hematoma

Stary HC et al. Circulation 1995;92:1355-1374.

Category Anatomy of Occlusion
Proximal LAD Proximal to septal
perforator
Mid LAD Proximal to large diagonal
but distal to first septal
perforator
Distal LAD or diagonal Distal to large diagonal or
diagonal itself
Moderate to large inferior Proximal RCA or left
(posterior, lateral, right circumflex
ventricular)
Small inferior Distal RCA or left
circumflex branch
ECG Findings
ST elevation V1-6, I, avL,
and fascicular or bundle
branch block
ST elevation V1-6, I, avL
ST elevation V1-4, or I,
avL, V5-6
ST elevation II, III, avF,
and any of the following:
a. V1, V3R, V4R
b. V5-6
c. R>S in V1-2
ST elevation II, III, avF
only
Occluded artery
Anterior STEMI

ECG demonstrates large anterior infarction

 Inferior STEMI
Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
Inferior STEMI
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Diagnosis Marka Jantung
 Ischemic Heart Disease

Nonischemic Cardiovascular Disease

Gastrointestinal

Pulmonary
 ECG Classification - GUSTO I Outcome
Category Occlusion Site ECG 1-Year
Mortality
1. Prox LAD before septal ST V1-6, I, aVL 25.6%
fasicular or BBB
2. Mid LAD before diagonal ST V1-6, I, aVL 12.4%
3. Distal LAD beyond diagonal ST V1-4 or 10.2%
Diagonal in diagonal ST I, aVL, V5-6
4. Moderate-to- proximal RCA ST II, III, aVF and 8.4%
large inferior or LCX V1, V3R, V4R or
(post, lat, RV) V5-6 or
R > S V1-2
5. Small inferior distal RCA or ST II, III, aVF only 6.7%
LCX branch
 Hemodynamic Subgroups - Killip Class

GISSI-1 (%)
Killip Definition Incidence Control Lytic
Class Mortality Mortality
I No CHF 71 7.3 5.9
II S3 gallop or 23 19.9 16.1
basilar rales
III Pulmonary edema 4 39.0 33.0
(rales >1/2 up)
IV Cardiogenic shock 2 70.1 69.9
 The Original Paradigm

Re-establish
Limit Infarct
Infarct Vessel Mortality
Size
Patency
ESC guideline for STEMI 2012
 TATALAKSANA INFARK MYOCARDIAL AKUT

Thrombololytic PRIMARY PTCA

 Aspirin indefinitely (ticlopidine or clopidogrel for aspirin
allergy or intolerance)
Beta blockers for at least 2-3 years
ACE inhibitors for CHF, LVEF<40%, or large infarction
(even with preserved LVEF)
Lipid lowering agents
Coumadin for mural thrombus, extensive anterior
infarct, DVT, atrial fibrillation
Extension / Ischemia Arrhythmia
Pericarditis

Expansion / Aneurysm Acute MI RV Infarct

Mechanical Heart Failure Mural Thrombus

Prevensi Sekunder
A Aspirin and Anticoagulants

B Beta blockers and Blood Pressure

C Cholesterol and Cigarettes

D Diet and Diabetes

E Education and Exercise