Dr.

Afdhalun Hakim
,SpJP,FIHA,FAsCC
Definisi
Pengertian SKA merujuk pada sekumpulan
keluhan dan tanda klinis yang sesuai
dengan iskemia miokardium akut.
Sindrom koroner akut merupakan suatu spektrum
 dalam perjalanan penderita penyakit jantung
koroner (aterosklerosis koroner). SKA
 dapat berupa angina pektoris tidak stabil, infark
miokard dengan non-ST elevasi, infark miokard
dengan ST elevasi dan atau kematian jantung
mendadak.
 AMI (ACS STEMI)
 UAP
 ACS NSTEMI
 SUDDENT CARDIAC DEATH
 ACS STEMI (AMI)

 ACS NSTEMI (UAP/ACUTE NON Q MI)

 ACS NSTEMI > STEMI
 HOSPITAL MORTALITY STEMI > NSTEMI
(7 % VS 5 % )
 6 BULAN MORTALITY EQUAL (12 VS 13 %)
 LONG TERM FOLLOW UP MORTALITY
NSTEMI > STEMI
 PENYEBAB UTAMA KEMATIAN KV
 SYMPTOM (TYPICAL CHEST PAIN)

 ECG CHANGES (ST ELEVATION/NEW LBBB

OR ST DEPRESSION/T INVERTED/FLAT)

 CARDIAC MARKER (ENZYME)

 Character
 Time of onset, duration, frequency
 Changes in tempo
 Exacerbating and alleviating factors
 Pain during situation associated with increased
myocardial O2 demand ( e.g. exertion, stress )
Levine Sign
 ST ELEVATION

 NEW LBBB
 CK-MB
 TROP-T/I
 MYOGLOBIN
 HISTORICAL POINTS RISK OF CARDIAC EVENTS (%)
Age  65 1 BY 14 DAYS IN TIMI 11B*

 3 CAD risk factors RISK DEATH DEATH, MI OR

(FHx, HTN,  chol, DM, active smoker) 1 SCORE OR MI URGENT REVASC

Known CAD (stenosis  50%) 1 0/1 3 5

ASA use in past 7 days 1 2 3 8
PRESENTATION 3 5 13
Recent ( 24H) severe angina 1 4 7 20
 cardiac markers 1 5 12 26
ST deviation  0.5 mm 1
6/7 19 41
RISK SCORE = Total Points (0 - 7)
*Entry criteria:UA or NSTEMI defined as ischemic pain
Low = 0-2 points, Medium = 3-4 points
at rest within past 24H, with evidence of CAD (ST segment
High = 5-7 points deviation or +marker)
Antman et al JAMA 2000; 284: 835 - 842
RISIKO TINGGI

Sekurang-kurangnya 1 dari berikut hasus ada:

1. Anamnesis
• Simtom nyeri dada iskemik meningkat cepat
dalam 46 jam terakhir
• Prolonged rest pain (berlangsung >20 min)
2. Temuan klinis
• Tanda edema paru
• S3 atau rhpnki baru / bertambah
• Hypotensi,bradikardia,takicardia
• Usia > 75 yrs
3. ECG
• Angina waktu istirahat dgn perubahan transien segm ST
>0.05 mV,BBB (baru a’ diperkirakan baru ),Sustained VT
4. Cardiac markers : kenaikanTnT or TnI >0.1ng/ml
 SYMPTOMS COMPATIBLE
WITH STEMI

PREHOSP
D/,TRIAGE GP/CARDIO
EMS SELF DECISION
AND CARE LOGIST

PRIVATE PRIVATE
AMBULANCE TRANSPORT TRANSPORT

PCI CAPABLE NONPCI CAPABLE

HOSPITAL HOSPITAL
 O 2 ( 4 L/M, NASAL KANUL)
 ASPIRIN 160-325 MG CHEWING
 NITRAT SL/IV
 ISDN 5 MG SL (3X)
 NITRAT IV (INITIAL DOSE : 10 MCG/M
>>200 MCG/M)
 MORPHINE SULPHATE (2,5-5 MG IV)
 CLOPIDOGREL (LOADING DOSES 300 MG)
FOR STEMI ( ST ELEVATION/NEW LBBB)
ONSET <12 JAM :
 PCI

 PHARMACOLOGIST
REPERFUSION(TROMBOLYSIS)

 PCI ≤ 2 JAM FMC (FIRST MEDICAL

CONTAC) FOR PTS LARGE AMOUNT
MYOCARDIAL RISK DELAY < 90 MIN
 INDIKASI :
 ACS STEMI
 ONSET < 12 JAM

 KONTRA INDIKASI ABSOLUT

:
 STROKE HEMORAGIK KAPAN PUN
 STROKE NH <3 BLN>3 JAM
 DISEKSI AORTA
 ACTIVE INTEERNAL BLEEDING
 TRAUMA KEPALA TERTUTUP/WAJAH < 3 BLN
 TUMOR CEREBRI/AV MALFORMATION
 Streptokinase
 Dosis : 1,5 Juta IU (+ Dx 5%/NaCl 100 cc/30-60
min)
 Kabikinase
 Ateleptase
 rTPA
 Dosis : bolus 15 mg IV, 0,75 mg/Kg
BB/30’,kmd 0,5 mg/KgBB/60 min (dosis total
tidak lebih 100 mg)
 DOOR TO BALLON < 90 MENIT
 RS DENGAN FASSILITAS PCI DAN TENAGA
SKILL
 CARDIAC ARREST ( EC VT/VF)
 SHOCK CARDIOGENIC
 HF
 AV BLOCK
 MECHANICAL RUPTUR
(VSD/MR/TAMPONADE)
 FROM  TO
 SAFETY  SAFETY
 RESPONSE  RESPONSE/GASPIN
 A G
 B  C
 C  A
 B
 D
 D
RSOB OK !!!!

RSOB OK !
 Tn Z/Lk/45 Th
Datang Ke IGD RSDS dengan
KU : Nyeri dada kiri seprti ditekan benda berat
rasa ditengah dada dan disetai keringan dingin
dan muntah 2 kali dirumah, ortopne/palpitasi
(-)
Riw DM (+), Perokok berat (2 bks/hari),kolesterol
tinggi
BB 70 Kg TB 160 cm
 Sadar CM
 TD 140/90 mmhg HR 90x/m RR 18 x/m
 Sat O2 93%
 Cor : S1 S2 N,reguler,m(-),Gallop (-)
 Pulmo : Rh-/-, Whz -/-
 Abd/Extr : Normal
 LaB :
Hb 13 gr%, HT 36 ,L 10,000
Ure/Cr : 20/0,9 / SGOT/GPT :
20/18
Trop T 2,0 ( N : (-) )
CKMB 300
Na 140 K 3,7 Cl 80
GDS 300 mg/dl
 D/ ACS STEMI (Anterior Wall ) , Killip 1
 Hiperglikemia ec DM II
 Hipertensi Gr 1

 Th/ MONACO
 O 2 4 L/m ( bila Sat O2 < 94%)
 Aspirin 160 mg (Dikunyah )
 ISDN 5 mg Sl (dpt diulang sp 3x ) CI ( VIAGRA
dan TD <90 mmHG)
 Clopidogrel 300 mg (oral)
 Mo (bila masih nyeri)
 Reperfusion therapi
 Primary PCI (bila tersedia)
 Trombolisis terapi
 Streptokinase ( 1,5 juta IU + 100 cc Nacl/Dx5%
dalam 30-60 min (Pastikan tidak ada CI Absolut)
 LMWH (Low Moleculer Weight Heparin) SC Abd

 Insuline therapy (Target GDS < 180 mg/dl)

 Statin (Simvastatin/ Atorvastatin 1x40 mg)
 Beta Bloker (BB) : Bisiprolol (1x 2,5 mg) antr
wall
 ACE-I (Captopril/ Enalapril )
 Rawat ICU/HCU)