Angina Pectoris :

Focus on ACS

Adi Purnawarman MD,FIHA
Department of Cardiology and Vascular Medicine, Faculty of
Medicine, Unsyiah / Zainoel Abidin Hospital Banda Aceh
Pendahuluan
70 Juta orang US(1 dari 4)
Penyakit Kardiovaskuler

Penyebab terbesar
penyebab kematian (38%)

1,2 Juta Kasus baru & Serangan
berulang/Thn

2020 25 Juta krn PJ & akibat
PJK


65 Juta
Hipertensi
13 juta
Penyakit
Arteri
Koroner
5,4 Juta Stroke

4,9 juta
Penyakit
jantung
Kongestif
AHA. Heart disease and stroke statistics; 2012 update. Dallas, TX

Indonesia ?
Kusmana D and Team : Jakarta Cardiovasculer Study; The city that promotes Indonesia Healthy Heart , Report I; 2006 *
Kusmana D : Pengaruh tidak/stop merokok disertai olah raga teratur dan/atau pengaruh kerja fisik terhadap daya survival penduduk
di Jakarta ; penelitian kohort selama 13 tahun. Disertasi, program studi Ilmu kedokteran S3 FK UI, Jakarta, 2002**



0.00%
10.00%
20.00%
30.00%
1975
1981
1986
1995
2004
Angka Kematian Penyakit
Kardiovaskuler *
0
10
20
30
40
50
PJK
Stroke
Paru &
Asma
Kanker
Pyk
Lain
Studi Kohort 13 tahun (3 kecamatan Mampang),
Jak Sel)
Penyebab Kematian
**
Profil Kesehatan NAD Berdasarkan
Riset Kesehatan Dasar 2007
7,2%
1,1%
0,8% 11,6%
1,7%
16,6% 12,8%
53,3%
48,2%
0,5%
14,1%
18,5%
Riset Kesehatan Dasar Prov NAD, 2007
Penyakit Kardiovaskular di Aceh
Delima, Mihardja L, Siswoyo H. Prevalensi dan faktor determinan penyakit jantung di Indonesia.
Bul Penelit Kesehat 2009; 37 (3): 142-59.
Sindroma Koroner Akut (SKA)
Sekumpulan gejala klinis yang biasanya
disebabkan oleh trombosis /
aterosklerotik pada pembuluh koroner
sehingga menyebabkan sumbatan
sebagian atau seluruh lumen pembuluh
tersebut
Subset-nya :
Angina Tidak Stabil
Non STEMI
Infark STEMI
Cumulative 6-month mortality
from ischemic heart disease
0 1 2 3 4 5 6
5
10
0
15
20
25
Months after hospital admission
D
e
a
t
h
s

/

1
0
0

p
t
s

/

m
o
n
t
h

Acute MI
Unstable angina
Stable angina
Duke Cardiovascular Database
N = 21,761; 1985-1992
Diagnosis on adm to hosp
Tanda-Tanda Serangan Jantung Akut
Sifat nyeri
Rasa sakit, seperti ditekan, rasa terbakar,
ditindih benda berat, seperti ditusuk, rasa
diperas dan dipelintir
Lokalisasi
Dada kiri (Substernal prekordial) dan ulu hati
( epigastrium)
Penjalaran
ke
Leher, lengan kiri, rahang (mandibula), gigi,
punggung
Faktor
pencetus
Exercise, stres emosi, udara dingin dan sesudah
makan
Gejala
penyerta
Mual, muntah, sulit bernafas, keringat dingin
dan lemas. Nyeri membaik atau hilang dengan
istirahat

Angina klasik :
Tanda-tanda Serangan jantung
Angina Equivalent :
Tidak ada nyeri / rasa tidak
enak di dada yang khas,
namun pasien menunjukkan
gejala gagal jantung
mendadak (sesak napas),
atau aritmia ventrikular
(palpitasi, presinkop, sinkop)

Dibelakang
tulang dada
Dibelakang tulang
dada menjalar ke
leher
Dari dada menjalar
ke bahu dan lengan
Dari dada menjalar
ke rahang
Didada bawah di ulu hati
(sering ditafsirkan
sebagai penyakit maag)
Didareah punnggung
di antara kedua belikat
Differential Diagnosis Chest Pain
Cardiac
ACS : Infarct,angina
MVP
Aortic Stenosis
Hypertrophic cardio-
myopathy
Pericarditis
Lungs
Lung Emboli
Pnemonia
Pneumothorax
Pleuritis
Gastrointestinal
Reflux esofagus
Ruptur esofagus
Gall bladder disease
Peptic Ulcer
Pancreatitis

Vascular
Aortic dissection/aneurysma

Others
Musculoskeletal
Herpes zoster
Genetik
Obesitas
Diabetes
Hemosisteinemia
Hiperkoagubilitas
Aterosklerosis
Gaya Hidup (merokok dll)
Hiperlipidemia
Hipertensi
Infeksi?
Umur
Jenis Kelamin
Manifestasi Aterotrombosis
Faktor Resiko untuk PJK
Pengenalan dini, Kenali Faktor Resiko !!!
Sequence of Events in Ischemic
Heart Disease
Risk Factor
Endothelial dysfunction
CAD
Ischemia
Angina
Silent
MI
Arrythmias
Lost of muscle
Remodeling
Progresif dilatation
Heart Failure
Death
Foam
cells
Fatty
streaks
Intermediate
lesion
Atheroma
Fibrous
plaque
Complicated
lesion rupture
From First Decade From 3rd decade From 4th decade
Atherosclerosis Timeline
Growth mainly by lipid accumulation

Smooth
muscle and
collagen
Thrombosis
hematoma
Endothelial Dysfunction
ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007
Prognosis with Troponin
1,0
1,7
3,4
3,7
6,0
7,5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9,0
Cardiac troponin I (ng/ml)
M
o
r
t
a
l
i
t
y

a
t

4
2

D
a
y
s

831 174 148 134 50 67

%
%

%
%
%
%
ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007
ACS dengan
ischemia atau terlihat resiko tinggi
atau direncanakan untuk PCI
Aspirin

+
IV heparin/SC LMWH

+
IV GP IIb/IIIa antagonist

Diduga ACS
Aspirin

Didiagnosa ACS
Aspirin

+
SC LMWH
or
IV heparin
ACC/AHA 2002 Guidelines Update
UA & NSTEMI

+ Clopidogrel + Clopidogrel
*
During hospital care

Clopidogrel should be administered to hospitalized patients who are unable to take ASA
because of hypersensitivity or major GI intolerance

Class IIa: enoxaparin preferred over unfractionated heparin, unless CABG is planned within 24 hours
Rekomendasi Class I
1. Braunwald E et al. American College of Cardiology (ACC) and the American Heart Association
(AHA) Guidelines, USA: ACC/AHA; 2002.
2011-2012
2012
Current Medical Management of
Unstable Angina & NSTEMI
Morphin, O2, Bed Rest,
ECG,Monitoring
Nitroglycerin
Antiplatelet Therapy
Beta Blockers
Ace-Inhibitor/ARB
Anticoagulant Therapy
Antiplatelet Therapy
Beta Blockers
Calcium Chanel Blockers
Lipid Lowering Agent
Ace-Inhibitors/ARB
Acute Therapy Maintenace Therapy
Definition of Myocardial Infarction
Third universal definition of myocardial
infarction (ESC 2012)
Rise/fall of cardiac biomarker (specifically
troponin) with at least one of:
Symptoms of ischemia
New or presumed new ST-T change or LBBB in ECG
Development of Q pathological waves in ECG
Imaging evidence of new regional wall motion
abnormality
Intracoronary thrombus by angiography or autopsy
Cardiac death with symptoms of ischemia with
new ECG changes BUT death occuring before
cardiac value are released
Definition of STEMI
Third universal definition of myocardial
infarction (ESC 2012)
New ST elevation at J-point in at least two
contiguous leads with the cut-points > 0.1mV

Except V
2
-V
3
(male, >40 years old)
>0.2mV
Except V
2
-V
3
(male, <40 years old)
>0.25mV
Except V
2
-V
3
(female) 0.15mV
Except V
7
-V
9
& V
3
R-V
4
R 0.05mV
ST Elevation
Evolution of ST Elevation
Management of Patients with ST
Elevation
28
ST elevation
12 h
Aspirin
Beta-blocker
Eligible for
fibrinolytic therapy
> 12 h
Fibrinolytic therapy
contraindicated
Not a candidate
For reperfusion
therapy
Persistent
symptoms ?
Fibrinolytic therapy
Primary
PTCA or CABG
Other medical therapy:
ACE inhibitors
? Nitrates
Anticoagulants
Consider
Reperfusion
Therapy
No Yes
Modified from Antman EM. Atlas of Heart Disease, VIII; 1996
29
Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
EMS Transport
Onset of
symptoms of
STEMI
9-1-1
EMS
Dispatch
EMS on-scene
Encourage 12-lead ECGs.
Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.
GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Inter-
Hospital
Transfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysis
EMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Dispatch
1 min.
5
min.
8
min.
TROMBOLITIK
Indikasi, Kontra Indikasi, Prosedur
Kontra Indikasi Trombolitik (absolut)
Riw Stroke hemoragik (waktu tak terbatas)
Riw stroke lain / cerebrovaskular event dalam 6
bulan
Keganasan intrakranial atau kerusakan saraf
pusat
Trauma kepala dalam 3 minggu terakhir
Perdarahan internal aktif (tidak termasuk mens)
Diketahui adanya gangguan pembekuan darah
curiga diseksi aorta
Hipertensi berat 180/110 mmHg, atau kronis &
uncontrolled
Dalam antikoagulan INR > 2 - 3
Trauma kepala, CPR > 10 mnt, operasi besar ( dalam 3
minggu terakhir )
TIA (dalam 6 bulan terakhir)
Riw pemberian Streptokinase antara 5 hari - 2 tahun
Kehamilan atau 1 mgg post partum
Ulkus peptikum aktif
Infektif Endokarditis
Penyakit hati stadium lanjut
Kontra Indikasi Trombolitik (relatif)
Komplikasi / Efek samping Trombolitik
Perdarahan ringan berat
( hematom ringan s/d stroke hemoragik )
Aritmia ringan berat
( Ekstra sistol jarang s/d VT VF )

Harus dijelaskan pada pasien & keluarga !!

Persiapan Thrombolitik
1. Penjelasan terinci : tujuan
, manfaat & kemungkinan
efek samping obat
2. Monitor ECG
3. Defibrilator
4. Obat-obatan emergensi /
resusitasi
5. Syringe Pump 100 ml
1,5 juta UI streptokinase
(1 amp) dlm 100 ml Nacl
0,9% atau D5%

2
1
4
3
5
Primary PCI
ACS risk criteria
Low Risk ACS

No intermediate or high
risk factors

<10 minutes rest pain

Non-diagnositic ECG

Non-elevated cardiac
markers

Age < 70 years

Intermediate Risk ACS
Moderate to high likelihood
of CAD

>10 minutes rest pain,
now resolved

T-wave inversion > 2mm

Slightly elevated cardiac
markers

High Risk ACS
Elevated cardiac markers
New or presumed new ST depression
Recurrent ischemia despite therapy
Recurrent ischemia with heart failure
High risk findings on non-invasive stress
test
Depressed systolic left ventricular function
Hemodynamic instability
Sustained Ventricular tachycardia
PCI with 6 months
Prior Bypass surgery


Low
risk
High
risk
Conservative
therapy
Invasive
therapy
Chest Pain
center
Intermediate
risk
Nurses Mini Course
39
Symptom
Recognition
Call to
Medical System
ED
Cath Lab
PreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment Denied
Summary
ACS includes UA, NSTEMI & STEMI

Management guideline focus
Immediate assessment/intervention
(MONACO+BAH)
Risk stratification (UA/NSTEMI vs. STEMI)
RAPID reperfusion for STEMI (PCI vs.
Thrombolytics)
Conservative vs Invasive therapy for UA/NSTEMI

Aggressive attention to secondary prevention
initiatives for ACS patients
Beta blocker, ASA, ACE-I, Statin
Terimeng Gaseh Beh.....