Post on 27-Jan-2016
description
Acute Coronary Syndrome
Sindroma Koroner Akut
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DEFINISI Suatu 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 from Dzau et al. Am Heart J. 1991;121:1244-1263
Myocardial Ischemia
plaque
Ischemia = oxygen supply
and demand imbalance
CAD
Atherosclerosis
Risk Factors ( , BP, DM, Insulin Resistance, Platelets,
Fibrinogen, etc)
The cardiovascular continuum of events
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263
Myocardial Ischemia
Coronary Thrombosis
CAD
Atherosclerosis
Risk Factors ( , BP, DM, Insulin Resistance, Platelets,
Fibrinogen, etc)
The cardiovascular continuum of events
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263
Myocardial Ischemia
Coronary Thrombosis
ACS
Stable angina Plaque rupture Coronary thrombosis UA/NSTEMI STEMI
Penyempitan Pembuluh darah
Clinical Spectrum of Acute Coronary Syndrome
Acute Coronary Syndrome
Non-ST Segment
Elevation
ST Segment
Elevation
Unstable
Angina Pectoris Non-Q-wave Q-wave
Acute Myocardial Infarction
STEMI
NSTEMI
Unstable Angina STEMI
NSTEMI
Non occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes
Occluding thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
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HISTORY PRODROMAL 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 EXAMINATION GENERAL APPEARANCE Anxious, 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 RATE Variable depending on underlying rhythm and degree or
ventr. failure Most commonly, HR 100 – 110/min; > 95% patients : VPB’s within first 4 hours
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BLOOD PRESSURE Majority 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 RESPIRATION Most pts with extensive MI fever within 24-48 hrs, fever
resolves by 4th or 5th day Respiration 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-MB B 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)
Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263
The cardiovascular continuum of events
DYSLIPIDEMIA
Arrhythmia and Loss 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
Chest discomfort suggestive of ischemia
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
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Review initial 12 lead ECG
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Acute coronary syndrome algorithm
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
ST-depression or dynamic T-wave
inversion strongly suspicious for injury
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
ST-depression or dynamic T-wave
inversion strongly suspicious for injury
(UA/NSTEMI)
ST elevation or new or presumably new LBBB strongly suspicious for
injury (STEMI)
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Normal or non-diagnostic changes in ST-segment or T-
waves (intermediate/ low-risk UA)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
Normal or non-diagnostic changes in ST-segment or T-
waves (intermediate/ low-risk UA)
ST-depression or dynamic T-wave
inversion strongly suspicious for injury
(UA/NSTEMI)
ST elevation or new or presumably new LBBB strongly suspicious for
injury (STEMI)
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
1. Beta-adrenergic receptor blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)
ADJUNCTIVE TREATMENT
(Do not delay reperfusion)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
Normal or non-diagnostic changes in
ST-segment or T-waves
ST-depression or dynamic T-wave inversion strongly
suspicious for injury
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Time from onset of symptoms
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)
- ACE-I/ARB - Statin
12 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Time from onset of symptoms
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset - Statin
12 hours
Start adjunctive treatment
Normal or non-diagnostic changes in
ST-segment or T-waves
ST-depression or dynamic T-wave inversion strongly
suspicious for injury
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
• Heparin (UFH/LMWH)
• Glycoprotein IIb/IIIa receptor inhibitors
• -Adrenoreceptor blockers
• Clopidogrel
Adjunctive treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Time from onset of symptoms
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of symptom onset)
- Statin
12 hours
Start adjunctive treatment
Normal or non-diagnostic changes in
ST-segment or T-waves
ST-depression or dynamic T-wave inversion strongly
suspicious for injury
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Start adjunctive treatment
12 hrs Admit to monitored bed Assess 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
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Time from onset of symptoms
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of symptom onset)
- Statin
12 hours
12 hrs
Start adjunctive treatment
Normal or non-diagnostic changes in
ST-segment or T-waves
ST-depression or dynamic T-wave inversion strongly
suspicious for injury
ST elevation or new or presumably new LBBB strongly suspicious for
injury
Chest discomfort suggestive of ischemia
Review initial 12 lead ECG
Immediate ED assessment and immediate ED general treatment
Start adjunctive treatment
Admit to monitored bed Assess 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 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 terbakar
Biasanya 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