Download Acute Coronary Syndrome

Mengenali ACS: Cegah dan
tangani dg cepat dan benar
Mohammad Saifur Rohman, dr.SpJP, PhD.FICA
Mengapa Penting?
Jantung adalah organ yang sangat vital
 Menjamin pasokan kebutuhan seluruh
organ tubuh
 Jantung memompa lebih dari 1 juta gallon
pertahun
 Berhenti ----- Death
 Pertanda awal  Kenali !
 Terlambat Irreversible (?)
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Kegawatdarutan kardiak
Cardiac arrest
 Acute coronary syndrome
 Cardiac dysrhythmias
 Acute pulmonary oedema
 Trauma – both blunt & penetrating
 Cardiogenic shock
 Aortic dissection
 Valve insufficiency
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Bgm Keluhan & Tanda ?
Slide No.
3
Mengapa Harus Cepat?
Serangan Jantung
 Proses adaptasi terhadap perubahan
yang sangat cepat
 Kompensasi
 Dekompensasi
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Dapat di kenali dan diantisipasi serta dicegah
Diperbaiki? Tidak!, Dicegah? Ya !
Prevalensi SKA
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Di Amerika : kejadian Infark miokard Akut
(IMA) lebih 1 Juta/tahun
200,000 – 300,000 pasien IMA meninggal
sebelum sampai RS
Total : Warga negara Amerika mengalami IMA
setiap 29 detik dan meninggal setiap menit.
Indonesia ?
Tahun 2008: PJN Harapan Kita 7 pasien SKA ,
50-60% IMA
!0% IMA < 40 thn
Topol EJ. CV med 2009
Data PJN HK 2008
SKA DI RSSA MALANG
AMI prevalence in Saiful Anwar General
ApaHospital
penyebab
KEMATIAN?
keterlambatan
pasien
59 patients
death cases among
356 patients
datang ke RS
Penanganan
di
RS
The second deadliest diseases
The mortality rate was 16,6% in 2010
Seeking care behaviour pattern
Patient
Saiful
Anwar
Hospital
General
Practitioner
role
Self
Medication
PHC
Aterosklerosis  SKA
Atherogenesis
Progression of Plaque toward rupture
Progression of Plaque toward rupture
Plaque Rupture
Platelet aggregation in ruptured plaque
Platelets aggregate at the
site of rupture / erosion
Lipid core
Adventitia
Weissberg, 1999
Thrombus formation
Thrombus forms and
extends into the lumen
Thrombus
Lipid core
Adventitia
Weissberg, 1999
Plaque Rupture Toward Occlusion
Spektrum SKA
Unstable Angina Pectoris :
(EKG normal, Trop T/I (-))
 Acute Non ST-Elevation Myocardial Infarction
(NSTEMI) :
(EKG normal/ST depresi/T inversi dan Trop
T/I (+))
 Acute ST-Elevation Myocardial Infarction
(STEMI) :
EKG ST elevasi dan Trop T/I(+)
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Bagaimana Diagnosa SKA ?
Membedakan Nyeri dada: SKA?
1. Cardiac or non cardiac
 2. Cardiac : Ischemic non Ischemic
 3. Ischemic : Coronary non Coronary
 4. Angina pektoris stabil atau SKA
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Nyeri (tidak enak) dada ….. ?
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Sifat :Berat/ tertindih (pressure, tightness, or heaviness,
strangling, constricting, or compression), Panas
(burning) ; Masuk angin, Sesak,”maag”
Lokasi: Di dada kiri/tengah tidak bisa ditunjuk
Penjalaran : ke bahu/lengan, leher, dagu,
belakang,epigastrium
Lama : 5-30’
Pencetus :aktifitas/stres/dingin
Berkurang: Nitrat/Istirahat
Tidak khas: Pingsan/kejang/tidak sadar/berdebar
ESC guidelines for SAP 2006
ESC AMI ST elevation guidelines 2008
Angina Pectoris
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A syndrome resulting from myocardial
ischemia
Demand and supply imbalance
Careful history taking; mode of onset,
location, quality of pain, duration, precipitating
factors, pattern of disappearance, risk factor,
etc
Angina Pectoris
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A syndrome resulting from myocardial
ischemia
Demand and supply imbalance
Careful history taking; mode of onset,
location, quality of pain, duration, precipitating
factors, pattern of disappearance, risk factor,
etc
Hati-hati : Angina Equivalent
Indigestion, belching, dyspnea
 DM, wanita, manula (post operative)
 Didapatkan 5% dari ACS
 2% dipulangkan ternyata ACS
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Braunwalds Heart Disease 8th Ed 2008
DD Chest pain
Ischemic
 Stenosis Aorta
 Regurgitasi Aorta
 Hypertrophic Cardiomyopathy
 Angina pada Hypertensi
 Hipertensi pulmonal berat
11th ed Hurst’s the heart 2005
DD Chest Pain
Non Ischemic
 Diseksi Aorta
 Pericarditis
 Mitral valve prolaps
11th ed Hurst’s the heart 2005
DD Chest Pain
Gastro intestinal
 Esophageal spasm/reflux/rupture
 Peptic Ulcer
Neuromusculoskeletal
 Costochondritis
 Herpes zoster
 Chest wall pain dan tenderness etc
11th ed Hurst’s the heart 2005
DD chest pain
Pulmonary
 Pulmonary emboli
 Pneumothorax
 Penumonia with pleural involvement
Pleurisy
Psychogenic
 Axiety/depression/cardiac psychosis etc
11th ed Hurst’s the heart 2005
Non Angina Pain
Hanya terasa pada sebagian kecil dada
kiri/kanan (bisa di tunjuk)
 Berkahir berjam jam sampai berhari hari.
 Biasanya tidak berkurang dengan
nitrogliserin
 Mungkin dicetuskan oleh debaran.
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ESC guidelines for SAP 2006
ESC AMI ST elevation guidelines 2008
Nyeri dada khas SKA
Angina awitan baru derajat 3 menurut
klasifikasi kanada kardiovaskuler group
( nyeri dada timbul pada aktifitas ringan
sehari-hari)
 Angina saat istirahat > 20 menit
 Perburukan derajat angina menjadi derajat
3 dalam beberapa hari – 1 bln terakhir
(Crescendo angina)
 Atypical
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Pemeriksaan Fisik
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Sadar-Koma
TD: Hypertensi-Normal-Hypoptensi
HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
RR: Tachypnea-apnea
Cor: Regular-iregular, murmur, gallop
Pulmo: Normal-Rales- wheezing
Ext: dingin/hangat, edema+/-, etc.
EKG
Secepat mungkin – 10’ setelah pasien tiba
 Diulang apabila meragukan adanya
kenaikan segmen ST (ST televasi)
 Bandingkan denga EKG sebelumnya
 Pasang monitor EKG
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EKG : Gambaran aktifitas listrik jantung
EKG pada SKA
EKG dapat menentukan adanya:
 Old/Recent/Acute infarction
 Pericarditis
 Arrhythmias
 Pembesaran jantung
Gambaran EKG pada Iskemik/IMA
UAP/Acute NSTEMI
Acute NSTEMI
Acute STEMI- Evolution
Acute STEMI-Q wave
Occluded artery
Anterior STEMI
ECG demonstrates large anterior infarction
Inferior STEMI
Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6
with precordial ST depression
Inferior STEMI
Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
EKG
Gangguan Irama
 Infark baru atau lama
 Perikarditis
 Pembesaran jantung dll
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1st degree
2nd degree Type 1
2nd degree Type II
3rd degree
Ventricular Tachycardia (VT)
Ventricular Tachycardia (V T)
Unable to determine rhythm
 Regular ventricular rate (100-250)
 No P waves present
 QRS complex > 0.10 sec
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Ventricular Fibrillation (VF)
Coarse
Fine
Peningkatan Enzym jantung
Troponin T/Troponin I
 CKMB
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Chest x-ray
CTR 62%
Aorta elongation
Po normal
Cardiac Waist (+)
Apex lat downward
Congestion (+)
Non Invasif
Invasif
Universal Definition of Myocardial Infarction
Diagnosa AMI ditegakkan apabila min memenuhi 2
dari kriteria:
 Gejala Ischemic
 Perubahan EKG
 Kenaikan/penurunan Troponin T/I
Stratifikasi Resiko
High risk
Intermediate risk
Low risk
Angina saat Istirahat
Angina > 20 kurang
dengan istirahat
Angina dengan aktivitas
ALO
Riwayat CVD
LBBB/RBBB baru
Ada Q, ST depresi
ENZYME (+)
Sedikit meningkat
ENZYM (-)
MR ATAU S3 Baru,
HYPOTENSI,
BRADIKARDI,
TAKIKARDI. VT
Usia > 70 tahun
ST DEPRESI> 0.5
T inversi
EKG TETAP
Prinsip Terapi
Cepat (time responsif), obati penyebab 
buka sumbatan
 Terlambat: Fatal
 Monitor ketat tanda vital sejak awal
 Antisipasi dini tanda tanda perburukan dan
komplikasi
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Terapi Awal SKA
Atasi keadaan kegawat daruratan :
asistol, apney, syock, lung edema,
gagal jantung dll.
 Terapi reperfusi : PCI, Fibrinolitik,
heparin
 Antiischemic
 Terapi komorbid; hipertensi, DM, dll
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Pentingnya Reperfusi
Sumbatan total15-30 menit tanpa
kolateral IMA
 Reperfusion  selamatkan miorkard
 Kematian1 bulan: 25-30% 4-6% dengan
reperfusi (PCI, fibrinolytic, antithombotic)
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ESC AMI ST elevation guidelines 2008
Kerusakan Miokard Irreversibel
Miokard tidak mengalami regenerasi
 Terlambat/tidak dibuka  Miokard mati 
Gagal Jantung  rawat ulang  biaya
besar, kualitas hidup kurang baik
 Obat gagal Jantung hanya mencegah
perburukan, tidak memperbaiki miokard
yang mati/infark
 Alternatif terapi : Stem cell
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The time is muscle
Terapi NSTEMI
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O2
Bed rest
Pain killer
Nitrate and anti-ischemia
Antiplatelet : Aspirin, Clopidogrel
Heparin
HTN
Hyperglicemia
Treat the complication etc
Terapi STEMI
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O2
Bed rest
Pain killer
Nitrate and anti-ischemia
Antiplatelet : Aspirin, Clopidogrel
Fibrinolytic time to neddle : 30 m/PCI
HTN
Hyperglicemia
Treat the complication etc
Fibrinolitik
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Manfaat bila onset < 12 jam, optimal bila onset <
3 jam
Bila dikirim ke RS dengan PCI > 90 menit,
fibrinolitik
Konsep baru : Fibrinolitik di Ambulan menuju RS
Perhatikan kontraindikasi fibrinolitik
Awasi ketat komplikasi fibrinolitik seperti
perdarahan, stroke, syok dll
Perhatikan tanda tanda keberhasilan: nyeri
hilang, ST elevasi turun >50%, Junctional
VES(+), bila gagal rescue PCI
Kontra Indikasi Absolut
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Any prior ICH
Known structural cerebral vascular lesion (eg, AVM)
Known malignant intracranial neoplasm (primary or
metastatic)
Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head or facial trauma within 3 months
Kontra Indikasi Relatif
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History of chronic severe, poorly controlled hypertension
Severe uncontrolled hypertension on presentation (SBP greater than
180 mm Hg or DBP greater than 110 mm Hg)†
History of prior ischemic stroke greater than 3 months, dementia, or
known intracranial pathology not covered in contraindications
Traumatic or prolonged (greater than 10 minutes) CPR or major
surgery (less than 3 weeks)
Recent (within 2 to 4 weeks) internal bleeding
Noncompressible vascular punctures
For streptokinase/anistreplase: prior exposure (more than 5 days
ago) or prior allergic reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the INR, the higher the risk
of bleeding
Treatment of STEMI
Percutaneous Coronary Intervention
•Primary PCI : Pasien langsung di lakukan tindakan
reperfusi dengan membuka sumbatan di
arteri koroner tanpa dilakukan fibrinilotik
terlebih dahulu
•Rescue PCI : Dilakukan PCI setelah gagal dengan terapi
fibrinolitik
•Facilitated PCI : Pasien dilakukan fibrinolitik terlebih
dahulu meskipun sudah ada rencana PCI
•Urgent PCI: As soon as possible
•Early PCI : Dalam waktu 24 jam pertama
Early/urgent PCI: Resiko tinggi, hemodinamik tidak stabil,
aritmia maligna, angina (+) dgn terapi, EF <40%,Gagal
jantung, Riwayat PCI, CABG dl 6 bl
Tim PCI
Target
1. Time to balloon : 90 m
2. Yang dibuka hanya Culprit lesion (pembuluh
darah tersumbat yang menyebabkan IMA kali ini)
saja
3. Aliran darah yang diintervensi kembali lancar
Primary PCI Case
A 53 yo man reffered from a private
hospital for primary PCI
 A typical chest after exercise 2 hr prior to
admission
 ECG send by fax
 PCI appointment via phone
 Patient directly transfer red to cath lab
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Komplikasi MI
Mechanical
 Electrical
 Ischemia
 Embolic
 Inflammation
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Komplikasi Mekanik
Ventricular Septal Rupture
 Mitral Regurgitation
 Cardiac free wall rupture
 Large ventricular aneurysms
 LV pump failure and cardiogenic shock
 Dynamic LVOT obstruction
 RV failure
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Gagal Jantung (Kriteria Framingham)
Major
 Acute pulmonary edema
 PND or orthopnea
 Crackles
 S3 gallop
 HJR/Increased JVP
 Cardiomegaly
 Wt loss >4.5 kg 5d into
Rx
Minor
 Night cough
 Tachycardia >120
 Pleural effusion
 Hepatomegaly
 Ankle edema
 Vital capacity decrease
>1/3 from max
*Two major or one major and two minor*
Komplikasi Elektrik
SA Dysfunction
 Atrial Fibrillation
 First-Second degree AV block
 Total AV Block
 Left Bundle Branch Block
 Right Bundle Branch Block
 Ventricular Tachycardia
 Ventricular Fibrillation
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Komplikasi Ischemik
Perluasan Infark
 Angina Post-infark
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Komplikasi Emboli
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Systemic embolism ;
stroke, limb ischemia, renal infarction,
intestinal ischemia
Komplikasi Inflamasi
Early Pericarditis
 Late Pericarditis (Dresslers syndrome)
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Primary PCI Case
CASE 2
CABG
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Failed PCI with persistent pain or hemodynamic
instability in patients with coronary anatomy suitable for
surgery.
Persistent or recurrent ischemia refractory to medical
therapy in patients who have coronary anatomy suitable
for surgery, have a significant area of myocardium at
risk, and are not candidates for PCI or fibrinolytic
therapy.
At the time of surgical repair of postinfarction ventricular
septal rupture (VSR) or mitral valve insufficiency.
CABG
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Cardiogenic shock in patients less than 75 years old with
ST elevation, LBBB, or posterior MI who develop shock
within 36 hours of STEMI, have severe multivessel or left
main disease, and are suitable for revascularization that
can be performed within 18 hours of shock
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Life-threatening ventricular arrhythmias in the presence
of greater than or equal to 50% left mainstenosis and/or
triple-vessel disease.
Tips
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Obat anti ischemik atau anti nyeri segera di berikan
Anti platelet dan heparin dimasukkan secepatnya
setelah diagnosis ACS-NSTEMI ditegakkan, jangan
di tunda
Turunkan kebutuhan/kerja jantung dengan berikan
rasa nyaman dan aman pasien dan bed rest total
Setengah duduk pada pasien dengan gagal
jantung
Pikirkan immediate/urgent PCI pada pasien resiko
tinggi/hemodinamik tidak stabil/nyeri
berkepanjangn/aritmia maligna dll
Yang sering di lupakan…..
Edukasi pasien mengenai :
 Mengapa bisa sampai sakit….. Pola hidup
 Kepatuhan untuk merubah pola hidup
 Faktor resiko di kendalikan, rokok, HT, dll
 Kepatuhan minum obat
 Mencegah serangan jantung berikutnya
dengan…..merubah pola hidup, atur pola
makan, olah raga teratur dan terukur
 Reperfusi adalah awal dimulainya hidup baru
…agar koroner tetap terbuka
Simpulan
Tegakkan diagnosa dengan cepat dan
tepat
 Terapi dengan cepat dan tepat : Reperfusi
 Monitor ketat
 Cegah komplikasi
 Edukasi untuk prevensi dan rehabilitasi
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…..…….Kerja keras di awal……
Pesan Penting
Tambah ilmu…..3X ..amalkan…
Semoga menjadi ilmu yang bermanfaat
Pengabdian dengan ilmu dan ikhlas