3 Acute Coronary Syndrome

Acute Coronary Syndrome

Sindroma Koroner Akut

Toni Mustahsani Aprami, dr., SpPD, SpJP

Department of Cardiology and Vascular Medicine

Division of Cardiovascular, Department of Internal Medicine

Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung

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DEFINISISuatu sindroma klinik yang menandakan

adanya iskemia miokard akut, terdiri dari : Infark miokard akut Q wave (STEMI) Infark miokard akut non-Q (NSTEMI) Angina pektoris tidak stabil (UAP)

Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis.

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PATOGENESIS• Umumnya disebabkan oleh

aterosklerosis koroner

• Plak aterosklerosis ruptur terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koroner

• Apabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan nekrosis

Uncontrollable

•Sex

•Hereditary

•Race

•Age

Controllable

•High blood pressure

•High blood cholesterol

•Smoking

•Physical activity

•Obesity

•Diabetes

•Stress and anger

Risk Factors

CAD

Atherosclerosis

Risk Factors( , BP, DM, Insulin Resistance, Platelets,

Fibrinogen, etc)

The cardiovascular continuum of events

DYSLIPIDEMIA

Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263

Myocardial Ischemia

plaque

Ischemia = oxygen supply

and demand imbalance

CAD

Atherosclerosis


Fibrinogen, etc)


DYSLIPIDEMIA


Myocardial Ischemia

Coronary Thrombosis

CAD

Atherosclerosis


Fibrinogen, etc)


DYSLIPIDEMIA


Myocardial Ischemia

Coronary Thrombosis

ACS

Stable anginaPlaque ruptureCoronary thrombosisUA/NSTEMISTEMI

PenyempitanPembuluh darah

Clinical Spectrum of Acute Coronary Syndrome

Acute Coronary SyndromeAcute Coronary Syndrome

Non-ST SegmentNon-ST SegmentElevationElevation

ST SegmentST SegmentElevationElevation

UnstableUnstableAngina PectorisAngina Pectoris

Non-Q-waveNon-Q-wave Q-waveQ-wave

Acute Myocardial InfarctionAcute Myocardial Infarction

STEMISTEMI

NSTEMINSTEMI

Unstable

Angina STEMI

NSTEMINSTEMI

Non Non occlusive occlusive thrombusthrombus

Non specific Non specific ECGECG

Normal Normal cardiac cardiac enzymesenzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus Complete thrombus occlusionocclusion

ST elevations on ST elevations on ECG or new LBBBECG or new LBBB

Elevated cardiac Elevated cardiac enzymesenzymes

More severe More severe symptomssymptoms

Diagnosis

Anamnesis

Pemeriksaan Fisik

Pemeriksaan Penunjang :

1. Laboratorium

2. Elektrokardiografi

3. Thoraks Foto

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HISTORYPRODROMAL SYMPTOMS

History very valuable to establish D/. Prodoma : chest discomfort – unstable angina

1/3 symptoms for 1 – 4 wks

20% symptoms for < 24 hrs

Malaise, exhaustion

NATURE OF PAIN• Most patients

severe prolonged, 30 minutes - hours• Constricting, crushing, oppressing, compressing

heavy weight or squeezing in chest• Choking, vise-like, heavy pain or stabbing, knife-like, boring or

burning discomfort• Location : retrosternal, spreading frequently to both sides of the

chest with predilection to the left side• Often pain radiates down ulnar aspect of left arm, producing

tingling sensation in left wrist, hand and fingers

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NATURE OF PAIN

• SOME INSTANCES : pain begins in epigastrium, and simulates

abdominal disorder

• Sometimes pain radiates to shoulders, upper extremities, neck, jaw and

interscapular region favoring the left side

• Elderly : no chest pain but acute left ventricular failure and chest

tightness or marked weakness or syncope

• Pain arises from nerve endings in ischemic or injured, but not necrotic,

myocardium

OTHER SYMPTOMS

50% nausea or vomiting in transmural infarcts

Occasionally diarrhea, profound weakness, dizziness, palpitation, cold

perspiration, sense of impending doom

Occasionally : cerebral embolism or systemic arterial embolism

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Pain Patterns with Myocardial Ischemia

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Anamnesis untuk UAP

• 3 kategori presentasi klinik UAP: Angina saat istirahat (resting angina) Angina awitan baru (new onset angina) Angina yang bertambah berat

(increasing angina)

• Riwayat penyakit dahulu : Riwayat angina on effort, infark atau

operasi pintas Riwayat penggunaan nitrogliserin Identifikasi faktor-faktor risiko

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PHYSICAL EXAMINATIONGENERAL APPEARANCEAnxious, considerable distress, restless, fist on chest

(Levine sign)LV failure & symp. stimulation : cold perspiration, pallor,

dyspnea, cough with frothy pink or blood-streaked sputum.

Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientation

HEART RATEVariable depending on underlying rhythm and degree or

ventr. failureMost commonly, HR 100 – 110/min; > 95% patients :

VPB’s within first 4 hours

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BLOOD PRESSUREMajority normotensive, but syst. BP may decline and diast.

BP may rise Half of pts with inferior MI parasympathetic stimulation

: hypotension, bradycardia or both (Bezold – Jarisch reflex)

half of pts with anterior MI, sympathetic excess : hypertension, tachycardia or both

TEMPERATURE AND RESPIRATIONMost pts with extensive MI fever within 24-48 hrs, fever

resolves by 4th or 5th dayRespiration due to anxiety and pain, in LV failure : resp.

rate correlates with degree of heart failure

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JUGULAR VENOUS PULSE

JVP usually normal

RV infarction : marked jug. venous distension

CAROTID PULSE

Small pulse reduced stroke volume

Pulse alternans : severe LV dysfunction

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CHEST

LV failure and/or LV compliance ↓ : moist rales

Severe failure : diffuse wheezing, cough + hemopthysis

1967 : Killip & Kimball : prognostic classification

Class I : patients free of rales or S3

II : rales < 50% lung fields +/- S3

III : rales > 50% lung fields, frequently pulm. edema

IV : cardiogenic shock

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Pemeriksaan Penunjang

• Pemeriksaan EKG

Gambaran EKG infark miokard akut Q-wave (STEMI) :

Elevasi segmen ST 1 mm pada 2 sadapan extremitas

Atau 2 mm pada 2 sadapan prekordial yang berurutan

Atau gambaran LBBB baru atau diduga baru

ST-segment elevation

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Gambaran EKG infark miokard akut non-Q-wave (NSTEMI) atau angina pektoris tidak stabil (UAP) :

– Depresi segment ST atau gelombang T terbalik pada 2 sadapan berurutan

– Inversi gelombang T minimal 1 mm pada 2 sadapan atau lebih yang berurutan.

– Perubahan segment ST saat keluhan dan kembali normal saat keluhan hilang sangat menyokong UAP

ST-segment depression

T-wave inversion

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Current-of-injury patterns with acute ischemia

ELEKTROKARDIOGRAM

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• Pemeriksaan Penanda Jantung/Enzim jantung

(Cardiac Markers):

Yang lazim adalah CKMB, dapat pula troponin T (TnT) atau troponin I (TnI)

Peningkatan marka jantung akan terlihat pada infark miokard akut Q-wave (STEMI) dan non-Q-wave (NSTEMI)

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Plot of the appearance of cardiac markers in blood versus time after onset of symptoms

A myoglobin C CK-MBB troponin D troponin in UA

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1. Diseksi aorta

2. Perikarditis

3. Nyeri angina atipikal pada kardiomiopati hipertrofi

4. Penyakit esofageal, GI atas atau traktus biliaris

5. Penyakit paru-paru : pneumotoraks, emboli, pleuritis

6. Sindroma hiperventilasi

7. Gangguan dinding dada : muskuloskeletal, neurogen

8. Psikogen

Diagnosis Banding

Manajemen

ACS

Coronary Thrombosis

Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors( , BP, DM,

Insulin Resistance, Platelets, Fibrinogen, etc)



DYSLIPIDEMIA

Arrhythmia andLoss of Muscle

Remodeling

Ventricular Dilatation

Congestive Heart Failure

End-stage Heart Disease

DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of ischemia

ISCHEMIC CHEST PAIN

TYPICAL ANGINA EQUIVALENT ANGINA

1. CHEST DISCOMFORT

2. LOCATION

3. RADIATION

4. UNLIKELINESS

1. NO CHEST DISCOMFORT

2. LOCATION

3. INDIGESTION

4. UNEXPLAINED WEAKNESS

5. DIAPORESIS

6. SHORTNESS OF BREATH

Chest discomfort suggestive of ischemia

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Immediate ED assessment and immediate ED general treatment

Acute coronary syndrome algorithm


Immediate ED assessment ( 10 min)

• Vital sign

• Oxygen saturation

• Obtain IV access

• Obtain ECG 12 lead

• Brief history and physical exam

• Check contraindication for fibrinolytic

• Initial serum cardiac markers

• Initial electrolyte and coagulation

study

• Portable chest x-ray ( 30 minutes)

Immediate ED general treatment

• O2 at 4 L/min (maintain O2 sat 90%)

• Aspirin 160-325 mg

• Nitroglycerin SL, spray, or IV

• Morphine IV 2-4 mg repeated every

5-10 minutes (if pain not relieved

with nitroglycerine)

Memory: “MONA” greets all patients


Review initial 12 lead ECG





ST elevation or new or presumably new LBBB strongly suspicious for

injury






ST-depression or dynamic T-wave

inversion strongly suspicious for injury


injury








(UA/NSTEMI)


injury (STEMI)





Normal or non-diagnostic changes in ST-segment or T-waves (intermediate/

low-risk UA)


Start adjunctive treatment

Normal or non-diagnostic changes in ST-segment or T-waves (intermediate/

low-risk UA)



(UA/NSTEMI)


injury (STEMI)






1. Beta-adrenergic receptor

blocker

2. Clopidogrel

3. Heparin (UFH or LMWH)

ADJUNCTIVE TREATMENT

(Do not delay reperfusion)



Normal or non-diagnostic changes in

ST-segment or T-waves

ST-depression or dynamic T-wave inversion strongly

suspicious for injury


injury





Time from onset of symptoms

- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)

- ACE-I/ARB- Statin

12 hours




- ACE-I/ARB within 24 hours of onset- Statin

12 hours







injury







• Heparin (UFH/LMWH)

• Glycoprotein IIb/IIIa receptor inhibitors

• -Adrenoreceptor blockers

• Clopidogrel

Adjunctive treatment




- ACE-I/ARB within 24 h of symptom onset)

- Statin

12 hours







injury






12 hrs Admit to monitored bedAssess risk status

- High risk: early invasive strategy- Continue ASA, heparin, ACE-I, statin

VERY HIGH-RISK PATIENT

1.Refractory chest pain

2.Recurrent/persistent ST

deviation

3.Ventricular tachycardia

4.Hemodynamic instability

5.Sign of pump failure

6.Shock within 48 hours





- ACE-I/ARB within 24 h of symptom onset)

- Statin

12 hours

12 hrs







injury





Admit to monitored bedAssess risk status

- High risk: early invasive strategy- Continue ASA, heparin, ACE-I, statin

Develops high or intermediate risk criteria

or troponin-positive

Monitored bed in ED

Develops high or intermediate risk criteria

or troponin-positive

No evidence of ischemia and MI: discharge with follow-up

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Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan

Aspirin Beta-blocker ACE inhibitor

Pengobatan Pasca Perawatan

Berhenti merokok Pertahankan BB optimal Aktivitas fisik sesuai dengan hasil treadmill Diet Rendah lemak jenuh dengan kolesterol, bila

perlu dengan target LDL < 100 mg/dL Pengendalian hipertensi Pengendalian ketat gula darah pada

penderita DM

Modifikasi Faktor Risiko

•Get regular medical checkups.

•Control your blood pressure.

•Check your cholesterol.

•Don’t smoke.

•Exercise regularly.

•Maintain a healthy weight.

•Eat a heart-healthy diet.

•Manage stress.

Thank you for your attentionThank you for your attention

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Anamnesis• Nyeri dada atau nyeri epigastrium hebat yang

mengarah pada iskemia miokard : Seperti dihimpit benda berat Terasa tercekik Rasa ditekan, ditinju, ditikam Rasa terbakarBiasanya dirasakan dibelakang stenum seluruh

dada terutama kiri, dapat ke tengkuk, rahang, bahu,

punggung, lengan kiri atau kedua lengan

• Terutama laki-laki > 35 tahun dan Wanita > 40 tahun

• Seringkali disertai mual atau muntah, dapat pula rasa tidak enak disertai sesak nafas, lemah, penurunan kesadaran, dan keringat banyak

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Pemeriksaan Fisik

• Biasanya penderita tampak cemas, gelisah, pucat, dan keringat dingin

• Periksa tanda-tanda vital : Denyut nadi cepat, reguler tetapi dapat pula

bradi atau tachycardia, irama ireguler Tekanan darah biasanya normal bila belum

terjadi komplikasi, dapat pula terjadi hipo atau hipertensi

Bunyi jantung dapat terdengar redup S3 dapat terdengar bila kerusakan miokard

luas Paru-paru dapat terdengar ronkhi basah dan

atau wheezing yang menandakan terjadinya bendungan paru tergantung ada tidaknya gangguan fungsi ventrikel kiri

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3 Acute Coronary Syndrome

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