WORKSHOP

ACUTE CORONARY SYNDROME

Sanggam Sinambela, MD
ACUTE CORONARY SYNDROME

Definition :

 A spectrum of conditions compatible with acute myocardial

ischemia and/or infarction due to an abrupt reduction in
coronary blood flow

 Spectrum of ACS :
 STEMI (ST elevation Myocardial Infarction)
 NSTEMI (Non ST Elevation Myocardial Infarction)
 UAP (Unstable Angina Pectoris)
ACC/AHA 2014 Guidelines NSTEACS.
 Chest pain

ST elevation ST depression
ECG ST segment

Bio-chemistry Troponin rise / Troponin

fall normal

Diagnosis

STEMI NSTEMI UA
3 Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
PATHOPHYSIOLOGY

Atherosclerosis is a chronic, inflammatory,

fibroproliferative disease of the intima of
large and medium-sized arteries characterized
by early retention and modification of
atherogenic lipoproteins, recruitment of
monocytes and T lymphocytes, and subsequent
accumulation of abundant fibrous tissue

ESC Textbook of Cardiovascular Medicine, p.335-337

PATHOPHYSIOLOGY

Risk factors :
 Non-modifiable
 Gender
 Age (for women : menopause, men : 10 years younger)
 Family history

 Modifiable
 Smoking
 Hypertension
 Diabetes and metabolic syndrome
 Abnormal serum lipid
 Lack of physical exercise ESC Textbook of Cardiovascular Medicine, p.335-337
PATHOPHYSIOLOGY

Braunwald Heart Disease 9th Edition p.901

PATHOPHYSIOLOGY

Acute Coronary Syndrome :

A Companion to Braunwald Heart Disease 2nd Edition; p.43
ESC 2018 Universal Definition of Myocardial Infarction
STEMI
CLINICAL FEATURES

Less typical symptoms

(angina equivalent):

• Older patients,
• Women,
• Diabetic
• Prior heart failure

ACC/AHA 2004 STEMI Guidelines

PHYSICAL EXAMINATION

General appearance Anxious, distress, restless, cold perspiration,

skin pallor
Levine sign
Blood Pressure Normotensive or
Hypertensive or
Hypotensive (shock)
Heart rate Marked bradycardia, regular tachycardia,
irregular tachycardia
Respiration Slightly elevated / tachypnoea
Jugular Venous Pressure (JVP) Normal or increased
Chest Normal or rales (+)
Cardiac Softened S1; S4 (+)
Murmur  secondary MR
Extremities Normal or cyanosis in shock
Braunwald Heart Disease 9th Edition p.1101
 Diagnosis – ECG in 10 minutes

In the absence of LVH and LBBB In the presence LBBB or ST depression

New ST elevation at the J point in 2
contiguous leads with ≥0.2 mV in men
(>40 years old) or ≥ 0.15 mV in women
in leads V2-V3 and/or ≥0.1 mV in other
leads
• New LBBB, and symptoms suggestive of
ACS
• ST depression in leads V1–V3 indicate
inferobasal myocardial ischemia
(especially when the terminal T-wave is
positive)

In suspected posterior (circumflex artery-

related) or right ventricle-related infarction

• ST elevation in V7,V8 and V9 using a cut-point

>0.05 mV.
• ST elevation in V3R and V4R, using a cut-off
point >0.05 mV, and >0.1 mV in men <30
years.
ST Segment LBBB
Elevation

Steg G et al. Eur Heart J. 2012;33:2569-619

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 STEMI OF RIGHT VENTRICLE

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 ECG CHANGES OF INJURY ACUTE MYOCARDIAL INFARCTION

In early stage of AMI , ECG may be

normal or near normal

5- 30 min after onset of

infarction

Changes
< 1 mm - > 10 mm

1-2 hours of onset

symptoms

• ST resolves - anterior up to 2 weeks;

posterior > 2 weeks
• T wave : many months

Morris F, Brady WJ. BMJ 2002 Apr 6;;324(7341) :831-4

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Laboratorium : Troponin
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 NSTE-ACS

(NSTEMI or U.A.P)
CLINICAL FEATURES
 CLINICAL
FEATURES

Causes
of chest pain

Braunwald Heart Disease

9th Edition
p.1077
 CLINICAL FEATURES
Likelihood

Braunwald Heart Disease 9th Edition; p.1201

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http://www.inaheart.org/upload/file/Buku-ACS-2018.pdf
HATUR NUHUN
Dokter bekerja di RS swasta di Kota
Bandung
 Laki-laki, 49 tahun, nyeri dada seperti tertindih benda berat,
menjalar ke lengan kiri, keringat banjir

 Perokok aktif (+)

 Tindakan selanjutnya ?
Dokter bekerja di salah satu RS di
Sukabumi, yang ada SpJP
 Perempuan 79 tahun, sesak napas berat, disertai keringat dingin

Tindakan selanjutnya ?
Tindakan selanjutnya ?
Dokter bekerja di RS di Depok

 Laki-laki 40 tahun, keluhan dada tengah seperti tertekan benda

berat. DM (+). Perokok aktif

 Tindakan selanjutnya ?
 Onset of STEMI Hospital Management Modified from Libby. Circulation 2001;104:365,
- Prehospital issues - Medications Hamm et al. The Lancet 2001;358:1533 and
- Initial recognition and management - Arrhythmias Davies. Heart 2000;83:361.
in the Emergency Department (ED) - Complications
- Reperfusion - Preparation for discharge
Secondary Prevention/
Management Long-Term Management
Before STEMI

Chronology of the
interface between the
1 2 3 4 5 6 patient and the
4 clinician through the
progression of plaque
Presentation
Ischemic Discomfort
formation and the
Acute Coronary Syndrome
Working Dx
onset of complications
ECG No ST Elevation ST Elevation
of STEMI.
UA NSTEMI
Cardiac
Biomarker

Final Dx Unstable NQMI QwMI

Angina
Myocardial Infarction 94
ESC 2018
Universal
Definition
of
Myocardial
Infarction
ESC 2018 Universal Definition of Myocardial Infarction
ESC 2018 Universal Definition of Myocardial Infarction