Acute Coronary Syndrome

T. Rahadiyan Sofyan
Dept. of Cardiology & Vascular Medicine Dr.Soetomo
Teaching Hospital, Faculty of Medicine, Airlangga
University- Surabaya.
Clinical Manifestation of CAD
• Silent Ischemia/asymptomatic
• Stable Angina
• Acute Coronary Syndrome (Non-
STEMI/UA and STEMI)
• Arrhythmias
• Heart Failure
• Sudden Death (kematian mendadak)
 Pain patterns with myocardial ischemia
Less common sites of pain with
Usual distribution of pain with
myocardial ischemia
myocardial ischemia
situs yang kurang umum dari sakit dengan
distribusi biasa sakit dengan iskemia
iskemia miokard
miokard

Right side Jaw

Epigastrium Back
 Clinical presentation of ACS
• Prolonged (>20 min) anginal pain at rest
• New onset (de novo) severe angina (CCS class III)
• Recent destabilization of previously stable angina with at least
CCS III (crescendo angina) or
• Post MI angina

Translate
• Berkepanjangan ( > 20 menit ) nyeri angina saat istirahat
• onset baru ( de novo ) angina berat ( CCS kelas III )
• destabilisasi terbaru dari angina sebelumnya stabil dengan
setidaknya CCS III ( crescendo angina ) atau
• Pasca MI angina
Admission CHEST PAIN

Working
Suspicion of Acute Coronary Syndrome ( ACS )
Diagnosis

Persistent Normal /
ECG ST-Elevation
ST/T-abnormalities
Undetermined ECG

Biochemistry Troponin (+) Troponin 2x (-)

Risk High Risk Low Risk

Stratification

Diagnosis STEMI NSTEMI UA

Treatment Reperfusion Invasive Non-Invasive

Guideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14th, 2007
 Acute Coronary
Syndrome
( ACS )

ST-segment ST-segment
Depression Elevation

Biomarkers of Biomarkers of Biomarkers of

Cardiac Injury ( - ) Cardiac Injury ( + ) Cardiac Injury ( + )

NSTEMI STEMI
UA ( Non ST-Elevation ( ST-Elevation
( Unstable Angina ) Myocardial Myocardial
European Heart Journal (2007) 28,882 Infarction ) Infarction )
PATHOPHYSIOLOGY
Hyperacute phase of extensive
anterior-lateral myocardial
infarction
Management of ACS
HEART ATTACT !!!!
 ESC : Management Strategy in ACS Patients
Clinical suspicion of ACS

Physical examination
ECG monitoring, blood samples

Persistent No persistent Undetermined

ST-segment elevation ST-segment elevation diagnosis

Thrombolysis ASA, Fonda/Enox/UHF ASA

PCI clopidogrel*, beta-blockers, nitrates

*Omit clopidogrel if
the patient is likely to High risk Low risk
go to CABG within 5 Second troponin measurement
days GPIIb/IIIa,
coronary angiography
Positive Twice negative

PCI, CABG or medical management Stress test,

depending upon clinical and angiographic features coronary angiography

1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.

Management of STEMI
 Goals of Treatment
Avoid
Prevention of complication
Reduce Unfavorable
Reduce Mortality Clinical Events
Infarct size
Recurrent
Myocardial
infarction Safety
Congestive heart failure

Sudden death

Arrhythmias

Repeat Intervention
Satler L. SCAI-ACC I2 Summit 2008
 Symptom Call to Prehospital ED CCU Cath Lab
Recognition Medical System

Delay in initiation of Pharmacologic

Reperfusion
 PELAYANAN KEGAWATAN JANTUNG KORONER
Hospital fibrinolysis :
Door-to-Needle within 30 min

Not PCI
capable

Onset of 9-1-1 EMS on-scene EMS

symptoms EMS • Encourage 12-lead ECGs Triage
of STEMI Dispatch • Consider prehospital fibrinolytic if Plan
capable and EMS-to-needle within 30 min

Goals† PCI
capable
EMS on EMS transport
Patient Dispatch scene EMS transport:EMS-to-Balloon within 90 min
5 min after 1 min Within Prehospital fibrinolysis : Patient self-transport:Hospital Door-to-Balloon within 90 min
symptom onset 8 min EMS-to-Handle within 30 min

Total ischemic time: Within 120 min*

*Golden Hour = First 60 minutes
ESC Guidelines 2008
 REPERFUSION
CLASS I
1. STEMI patients presenting to a hospital with PCI capability should be
treated with primary PCI within 90 minutes of first medical contact as a
system goal
(Level of Evidence : A)
2. STEMI patients presenting to a hospital without PCI capability and who
cannot be transferred to a PCI center and undergo PCI within 90 minutes
of first medical contact, should be treated with fibrinolytic therapy
within 30 minutes of hospital presentation as a system goal unless
fibrinolytic therapy is contraindicated
(Level of Evidence : B)

Translate
1. pasien STEMI yang datang ke rumah sakit dengan kemampuan PCI harus
diperlakukan dengan PCI primer dalam waktu 90 menit dari kontak medis
pertama sebagai tujuan sistem (Level of Evidence : A )
2. pasien STEMI yang datang ke rumah sakit tanpa kemampuan PCI dan yang
tidak dapat ditransfer ke pusat PCI dan menjalani PCI dalam waktu 90 menit
dari kontak medis pertama , harus ditangani dengan terapi fibrinolitik dalam
waktu 30 menit dari presentasi rumah sakit sebagai tujuan sistem kecuali
terapi fibrinolitik merupakan kontraindikasi (Level of Evidence : B )
European Heart Journal (2007) 28,882
 Time to presentation…
• Survival benefit greatest when lytics administered within first 3 hours after
onset of symptoms, particularly within the first 70 minutes
• Mortality benefit less likely at 13-18 hours
• There MAY be benefit in patients presenting >12hours if patient has on-
going chest pain

“AHA recommendations (2004): administer lytics if no contraindications

w/in 12 hr of symptom onset; reasonable to administer at 12-24 hr if
continuing symptoms or persistent ST elevation on EKG”

Translate
• Kelangsungan hidup manfaat terbesar ketika lytics diberikan dalam waktu
3 jam pertama setelah timbulnya gejala , terutama dalam pertama 70 menit
• Manfaat Kematian cenderung pada 13-18 jam
• Ada MUNGKIN menjadi manfaat pada pasien > 12hours jika pasien
memiliki on- akan nyeri dada
" Rekomendasi AHA ( 2004) : mengelola lytics jika tidak ada kontraindikasi
w / di 12 jam dari onset gejala ; wajar untuk mengelola di 12-24 hr jika
gejala terus atau persisten elevasi ST pada EKG "
Time & Myocardial Salvage
 Long-term survival…
• Long-term benefit primarily seen in patients who achieved TIMI 3 flow w/
lytic administration
• Vessel opening (TIMI 2 or 3) reported in 60-87% of patients receiving
lytics, but normalization (TIMI 3) in only 50-60% of arteries. Only TIMI 3
flow associated w/ improved LV function and survival
• Note: TIMI 3 flow is achieved in ~90% of patients treated with primary PCI
!!!

Translate
• Manfaat jangka panjang terutama terlihat pada pasien yang mencapai TIMI 3
aliran w / administrasi litik
• Pembukaan kapal ( TIMI 2 atau 3 ) dilaporkan pada 60-87 % dari pasien yang
menerima lytics , tapi normalisasi ( TIMI 3 ) hanya 50-60 % dari arteri . Hanya
TIMI 3 aliran terkait w / perbaikan fungsi LV dan kelangsungan hidup
• Catatan : TIMI 3 aliran dicapai di ~ 90 % pasien yang diobati dengan PCI primer
!!!
 CONTRAINDICATIONS
It is estimated that 20-30% of patients ineligible for
thrombolytic therapy…

This is what we missed on the in-service!!

Translate
Diperkirakan 20-30 % pasien tidak memenuhi syarat
untuk terapi trombolitik...
Ini adalah apa yang kita tidak terjawab di dalam - layanan !!
 What agents...
• Some agents : Streptokinase, alteplase, reteplase, and tenecteplase
• Identical in effectiveness, safety, yield the same success rate
• Performed dual iv-line
• Streptokinase dose : 1.5 million iu, given over 40-60 mnt
• Pretreatment :
• Ranitidine & Ondansetron - IV
• Diphenhydramine (Benadryl), 25 mg – IV

Translate
• Beberapa agen : Streptokinase , alteplase , reteplase , dan tenecteplase
• Identik dalam efektivitas , keamanan , menghasilkan tingkat keberhasilan yang
sama
• Dilakukan ganda iv –line
• Dosis Streptokinase : 1,5 juta iu , mengingat lebih dari 40-60 mnt
• pretreatment : Ranitidin & Ondansetron - IV , Diphenhydramine ( Benadryl ) , 25
mg - IV
 Therapeutic Standard
• Oxygen, should be guided by pulse oximetry
• Nitroglycerin (SL tab or spray, paste, or IV), unless there is hypotension or allergy or susp RV
infarction
• Morphine sulphate if nitroglycerin does not relieve chest pain, unless C.I. by hypotension or allergy.
• Aspirin given immediately : 162 – 325 mg orally, non-enteric coated !!
• Clopidogrel : 300 mg orally, followed by 75 mg daily
• Lidocaine or other anti-dysrrhythmic agent if the px manifests significant new arrhythmia ( >> 6
PVCs/min, multifocal PVCs, 3-beat V-tach, etc).
• Start Fibrinolytic therapy in the emergency room, If not the reason should be stated in the chart !

Translate
• Oksigen , harus dipandu oleh pulse oximetry
• Nitrogliserin ( tab SL atau semprot , pasta , atau IV ) , kecuali ada hipotensi atau alergi atau susp RV
infark
• Morfin sulfat jika nitrogliserin tidak menghilangkan rasa sakit dada, kecuali C.I. oleh hipotensi atau
alergi .
• Aspirin diberikan segera : 162-325 mg per oral , dilapisi non - enterik !!
• Clopidogrel : 300 mg secara oral , diikuti oleh 75 mg sehari
• Lidocaine atau lainnya agen anti - dysrrhythmic jika px memanifestasikan aritmia baru yang signifikan
( >> 6 PVC / min , PVC multifokal , 3- beat V- tach , dll ) .
• Memulai terapi fibrinolitik di ruang gawat darurat , Jika tidak alasannya harus dinyatakan dalam
grafik!
Management of
NSTEMI / UA