kuliah ska
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MI 1
Acute Coronary
Syndromes
®
Bag / SMF Ilmu Penyakit Dalam
FK Universitas Islam Sultan Agung
Semarang
2010
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What is Acute Coronary Syndrome(ACS) ?
Acute Coronary Syndrome is when occlusion ofone 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).
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Acute Coronary Syndrome
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Dimana Rasa Nyeri Dirasakan??
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Acute Coronary Syndrome
Ischemic Discomfort
Unstable Symptoms
No ST-segment
elevation
ST-segment
elevation
Unstable Non-Q Q-Wave
angina AMI AMI
ECG
Cardiac
marker
History
Physical Exam
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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 vegetationsin 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.
6DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:
http://www.accesspharmacy.com
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Pembuluh darah yang mengalami aterosklerosis & trombosis
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Thrombus Formation and ACS
UA NQMI STE-MI
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Non-ST-Segment Elevation AcuteCoronary Syndrome (ACS)
ST-SegmentElevation
Acute
Coronary
Syndrome
(ACS)
Old
Terminology:
NewTerminology:
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Expanding Risk Factors
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Low HDL < 40
Elevated LDL / TG
Family History—
eventin first degree relative
>55 male/65 female
Age-- > 45 for male/55
for female
Chronic Kidney Disease
Lack of regular physicalactivity
Obesity
Lack of Etoh intake
Lack of diet rich infruit, veggies, fiber
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Diagnosis Acute Coroner
Syndrome At least 2 of the
following
Ischemic symptoms Diagnostic ECG
changes
Serum cardiacmarker elevations
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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)
Agency for Health Care Policy Research - 1994
Canadian Cardiovascular Society Classification
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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
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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
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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, myocardialinfarction 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
15
aTroponin 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 Edition:
http://www.accesspharmacy.com
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Adverse Ischemic Events in Patients
with NSTE-ACS
Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk
score for unstable angina/non-ST elevation MI: a method for prognostication and
therapeutic decision making. JAMA.. 2000;284:835-842. Copyright © 2000, American
Medical Association. All rights reserved.
4.7 8.3
13.2
19.9 26.2
40.9
0
10
20
30
40
50
0/1 2 3 4 5 6/7
Number of Risk Factors
D e
a t h ,
M I , o r U r g e n t
R e
v a s c u l a r i z a t i o n
( % )
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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
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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
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Myocardial Infarction
Occlusion of coronary artery by thrombus
Progression of necrosis with time
Diagnosis
Clinical symptoms
Electrocardiogram
Cardiac enzymes
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Ischemic Heart Disease
• angina, aortic stenosis
Nonischemic Cardiovascular Disease
• pericarditis, aortic dissection
Gastrointestinal
•
esophageal spasm, gastritis, pancreatitis,cholecystitis
Pulmonary
• pulmonary embolism, pneumothorax,
pleurisy
Differential Diagnosis
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Acute Inferior Wall MI
http://homepages.enterprise.net/djenkins/ecghome.html
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ST-Segment Elevation MI
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BAGAIMANA GUIDELINES MENURUT ESC & ACC-AHA
GUIDELINE PENANGANAN PASIEN
ACS NON STENT
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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)
Nyeri dada (kecurigaan ischemia)
ACC/AHA ACLS ACS Algorithm 2006
1
2
3
4
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Ulang pemeriksaan ECG 12lead
ST Elevasi atau LBBB baruatau 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 perubahansegmen ST atau gelombang T
Resiko rendah atau sedang untuk unstable angina
Mulai terapi tambahansesuai indikasi. Janganmenunda reperfusi -Clopidogrel --adrenergic reseptorblockers
-Heparin (UFH or LMWH)
Mulai terapi tambahan sesuaiindikasi
-Clopidogrel
-Nitroglycerin
--adrenergic reseptor blockers
-Heparin (UFH or LMWH)
-Glycoprotein IIb/IIIa inhibitor
Berlanjut memenuhi kriteriasedang atau tinggi (tabel
3,4)atau troponin positive?
Onset gejala < 12 jam Opname di ruangan dgn
“monitoring bed” Tentukan status resiko
Pertimbangkan opname di EDchest paint unit atau
“monitored bed” di ED
Lanjutkan dengan :
Serial cardiac marker(termasuk troponin)
Ulang ECG, monitor segmenST
Pertimbangan stress test
Strategi reperfusi:
Terapi ditetapkanberdasarkan keadaan pasiendan center criteria
Menyadari tujuan terapireperfusi: Door-to-balloon inflation(PCI) = 90 mnt
Door-to-needle (fibrinolysis)= 30 mnt
Lanjutkan dengan terapi:
ACE inhibitor/angiotensireceptor blocker (ARB) 24
jam dari onset HMG CoA reductase inhibitor(statin therapy)
Pasien High-risk: Refractory ischemic chest pain
Recurrent/persistent STdeviation
Ventricular tachycardia
Hemodynamic tachycardia Signs of pump failure
Strategi invasive awal termasuk kateterisasi & revaskularisasipenderita IMA dgn syok dlm 48
jam
Lanjutkan pemberian ASA,heparin & terapi lain sesuaiindikasi:
ACE inhibitor / ARB
HMG CoA reductase inhibitor(statin therapy)
Tidak pada resiko tinggi:penentuan penggolongan resikodari cardiology
Berlanjut memenuhikriteria resiko tinggi atau
sedang (tabel 3,4)atau
troponin-positive
Jika tidak ada ischemiaatau infare, maka dapatpulang dengan rencanakontrol
4
5 9
10
11
12
6
7
8
13
14
15
16
17
CRUSADE
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5,95%
5,16% 4,97%
4,16%
6,33%
5,07%4,63%
4,17%
0
1
2
3
4
5
6
7
≤25% 25%–50% 50%–75% ≥75%
Hospital Composite Quality Quartiles
Adjusted
Unadjusted
Kepatuhan pada Guidelines
Menurunkan angka Mortality di Rumah Sakit
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.
I n - h o s p i t a l M o r t a l i t y ( % )
Increased Adherence to Guidelines Decreases Mortality
CRUSADE
Definite Indications for
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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
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Absolute Contraindications for
Thrombolytic Therapy History of hemorrhagic stroke
Stroke or CVA within 1 year
Allergy to the agent
Surgery or trauma in past 2wks
Known intracranial neoplasm Suspected aortic dissection
Active internal bleeding(except menstruation)
e a ve on ra n ca ons or
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e a ve on ra n ca ons or Thrombolytic Therapy
Active peptic ulcer disease Significant hepatic dysfunction
Severe uncontrolled hypertension (> 180/110
mmHg ) History of chronic severe hypertensoin
Current anticoagulant use
Recent trauma ( within 2-4 weeks) Pregnancy
Allergy or prior exposure to streptokinase
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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
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Summary
UA NSTEMI AMI
Simptom Angineus 20 mnt/> Berat > 30 mnt
Sign + + + & > berat
EKG ST elevasi/depresi
T: pos tinggi &simetris /neg dalam
ST depresi
menetap > dlm &lama
T : neg dalam
Hiperakut T
ST elevasiQ patologis
Marker CKMB ( - )
Tropinin + / -
CKMB positif
Troponin - / +
CKMB ( + )
Troponin + / -
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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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