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Acute Coronary

Syndromes

Bag / SMF Ilmu Penyakit Dalam


FK Universitas Islam Sultan Agung
Semarang
MI 1 2010 ®
What is Acute Coronary Syndrome
(ACS) ?
Acute Coronary Syndrome is when occlusion of
one or more of the coronary arteries occurs,
usually following plaque rupture, resulting in
decreased oxygen supply to the heart muscle.
ACS is the largest cause of death in U.S. Over 1
million people will have Myocardial Infarctions
this year; almost half will be fatal.
Majority of mortality associated with ST
Elevation Myocardial Infarction (STEMI).
Acute Coronary Syndrome
Dimana Rasa Nyeri Dirasakan??
CAD Causes
Type Comments
Atherosclerosis Most common cause. Risk factors: hypertension,
hypercholesterolemia, diabetes mellitus, smoking, family history of
atherosclerosis.
Spasm Coronary artery vasospasm can occur in any population but is most
prevalent in Japanese. Vasoconstriction appears to be mediated by
histamine, serotonin, catecholamines, and endothelium-derived
factors. Because spasm can occur at any time, the chest pain is
often not exertion-related.
Emboli Rare cause of coronary artery disease. Can occur from vegetations
in patients with endocarditis.
Congenital Congenital coronary artery abnormalities are present in 1 to 2% of
the population. However, only a small fraction of these
abnormalities cause symptomatic ischemia.

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Ed6ition:
http://www.accesspharmacy.com
Pembuluh darah yang mengalami aterosklerosis & trombosis
Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment


Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
Expanding Risk Factors
Smoking Age-- > 45 for male/55
Hypertension for female
Diabetes Mellitus Chronic Kidney Disease
Dyslipidemia Lack of regular physical
activity
 Low HDL < 40
Obesity
 Elevated LDL / TG
Lack of diet rich in fruit,
Family History—event veggies, fiber
in first degree relative
>55 male/65 female
Diagnosis Acute Coroner
Syndrome
At least 2 of the
following
 Ischemic symptoms
 Diagnostic ECG
changes
 Serum cardiac
marker elevations
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)
Canadian Cardiovascular Society Classification
Agency for Health Care Policy Research - 1994
Unstable Angina and
Non-Q-Wave Myocardial
Infarction
Evaluation and
management similar
Preliminary diagnosis
 Clinical symptoms
 Risk factors
 Electrocardiogram
 Cardiac enzymes
Assess short-term
risks
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
TIMI Risk Score for Non–ST-Segment Elevation Acute Coronary Syndromes

Past Medical History Clinical Presentation


Age >65 years ST-segment depression (>0.5 mm)
>3 Risk factors for CAD >2 episodes of chest discomfort in the past 24 hrs
Hypercholesterolemia Positive biochemical marker for infarctiona
HTN
TM
Smoking
Family history of premature CHD
50% stenosis of coronary artery)
Use of aspirin within the past 7 days
Using the TIMI Risk Score
One point is assigned for each of the seven medical history and clinical presentation findings. The score (point)
total is calculated, and the patient is assigned a risk for experiencing the composite end point of death, myocardial
infarction or urgent need for revascularization as follows:
High Risk Medium Risk Low Risk
TIMI risk score 5–7 points TIMI risk score 3–4 points TIMI risk score 0–2 points
a Troponin I, troponin T, or creatinine kinase MB greater than the MI detection limit.
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th E1d6ition:
http://www.accesspharmacy.com
GRACE RISK SCORE
Age ( Years ) Point Heart Rate Creatinin (mg/dl)
< 40 0 < 70 0 0,0 – 0,39 2
40 – 49 8 70 – 89 7 0,4 – 0,79 5
50 – 59 36 90 – 109 13 0,8 – 1,19 8
60 – 69 55 110 – 149 23 1,2 – 1,59 11
70 – 79 73 150 – 199 36 1,6 – 1,99 14
> 80 91 > 200 46 0,2 – 3,99 23
Systolic BP (mmHg ) Killip class >4 31
< 80 63 Class I 0

80 – 99 58 Class II 20
Total possible score is 258
100 – 119 47 Class III 39

120 – 139 37 Class IV 59

140 – 159 26 Cardiac arrest at admission 43


160 – 199 11 Elevated cardiac marker 15
> 200 0 ST segmen deviation 30
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 therapy
 Anti-platelet therapy
 aspirin, ticlopidine, clopidogrel,
GP IIb/IIIa inhibitors
 Anti-coagulant therapy
 heparin, low molecular weight heparin (LMWH),
warfarin, hirudin, hirulog
Myocardial Infarction

Occlusion of coronary artery by


thrombus
Progression of necrosis with time
Diagnosis
 Clinicalsymptoms
 Electrocardiogram

 Cardiac enzymes
Differential Diagnosis

Ischemic Heart Disease


• angina, aortic stenosis
Nonischemic Cardiovascular Disease
• pericarditis, aortic dissection
Gastrointestinal
• esophageal spasm, gastritis,
pancreatitis, cholecystitis
Pulmonary
• pulmonary embolism, pneumothorax,
pleurisy
Acute Inferior Wall MI

http://homepages.enterprise.net/djenkins/ecghome.html
ST-Segment Elevation MI
GUIDELINE PENANGANAN PASIEN
ACS NON STENT

BAGAIMANA GUIDELINES MENURUT ESC & ACC-AHA


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

Diagnosa cepat oleh Emergency Departemen Penatalaksanaan umum cepat oleh E.D
(<10min)

- Check vital signs, evaluasi saturasi O2 - Morphin IV jika nyeri tidak berkurang dengan
- Pasang IV line nitroglycerin
- ECG 12 lead - O2 4 L/mnt, pertahankan saturasi O2 > 90%
- Anamnese singkat, terarah, pemeriksaan fisik - Nitroglycerin SL atau spray atau IV
- Periksa awal level cardiac marker, elektrolit - Aspirin 160 samapai 325 mg (jika tidak
Dan faal hemostatis diberikan oleh EMS)
- Periksa Rontgen dada (<30 m)
Ulang pemeriksaan ECG 12
lead

ST Elevasi atau LBBB baru ST depresi atau T inverted; Normal atau tidak ada perubahan
segmen ST atau gelombang T
atau diasumsikan baru; dicurigai kuat suatu ischemia
Resiko rendah atau sedang untuk
dicurigai kuat ST-Elevasi MI Resiko tinggi unstable angina unstable angina
(STEMI) / Non ST Elevation MI
(AU/NSTEMI)
Mulai terapi tambahan
Mulai terapi tambahan sesuai Berlanjut memenuhi kriteria
sesuai indikasi. Jangan sedang atau tinggi (tabel
indikasi
menunda reperfusi 3,4)atau troponin positive?
-Clopidogrel -Clopidogrel
-Nitroglycerin
--adrenergic reseptor
--adrenergic reseptor blockers
blockers -Heparin (UFH or LMWH)
-Heparin (UFH or LMWH) -Glycoprotein IIb/IIIa inhibitor
Pertimbangkan opname di ED
chest paint unit atau
“monitored bed” di ED
Lanjutkan dengan :
Serial cardiac marker
Opname di ruangan dgn (termasuk troponin)
Onset gejala < 12 jam “monitoring bed” Ulang ECG, monitor segmen
Tentukan status resiko ST
Pertimbangan stress test

Strategi reperfusi:
Terapi ditetapkan Pasien High-risk:
berdasarkan keadaan pasien Refractory ischemic chest pain Berlanjut memenuhi
dan center criteria Recurrent/persistent ST kriteria resiko tinggi atau
Menyadari tujuan terapi deviation sedang (tabel 3,4)
reperfusi: Ventricular tachycardia atau
Door-to-balloon inflation Hemodynamic tachycardia troponin-positive
(PCI) = 90 mnt Signs of pump failure
Door-to-needle (fibrinolysis) Strategi invasive awal termasuk
= 30 mnt kateterisasi & revaskularisasi
Lanjutkan dengan terapi: penderita IMA dgn syok dlm 48
ACE inhibitor/angiotensi jam Jika tidak ada ischemia
receptor blocker (ARB) 24 Lanjutkan pemberian ASA, atau infare, maka dapat
jam dari onset heparin & terapi lain sesuai pulang dengan rencana
HMG CoA reductase inhibitor indikasi: kontrol
(statin therapy) ACE inhibitor / ARB
HMG CoA reductase inhibitor
(statin therapy)
Tidak pada resiko tinggi:
penentuan penggolongan resiko
dari cardiology
Kepatuhan pada Guidelines
CRUSADE

Menurunkan angka Mortality di


Rumah Sakit
Increased Adherence to Guidelines Decreases Mortality
In-hospital 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.
Definite Indications for
Thrombolytic Therapy
Consistent Clinical Syndrome
Chest pain, new arrhythmia,
unexplained hypotension or pulmonary
edema
Diagnostic ECG
ST elevation  1 mm in  2 contiguous
leads or new left bundle-branch block
Less than 12 hours since onset of pain
Continuing Therapy
Heparin infusion after thrombolysis
(except after streptokinase)
Aspirin daily
Nitroglycerin for 24- 48 hours
-blocker unless contraindicated
Angiotensin-converting enzyme (ACE)
inhibitor within first 24 hours
Summary
UA NSTEMI AMI

Simptom Angineus 20 mnt/>  Berat > 30 mnt

Sign + + + & > berat

EKG ST elevasi/depresi ST depresi Hiperakut T


T: pos tinggi & menetap > dlm & ST elevasi
simetris /neg dalam lama
Q patologis
T : neg dalam

Marker CKMB ( - ) CKMB positif CKMB ( + )


Tropinin + / - Troponin - / + Troponin + / -
Pengobatan Cepat pada SKA

Oksigenisasi 2-3 l/mnt dg kanul


Aspirin 160 – 300 mg dikunyah 
diberikan pada semua pasien SKA
Clopidogrel 300 mg
Nitrogliserin (SL) 5 mg, jika sakit
dada tetap berlanjut dapat diulang
setiap 5 menit sampai 3 kali
pemberian ” tidak boleh
diberikan pada pasien dengan
hipotensi”.

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