Penyakit Jantung Koroner

Dept. of Cardiology & Vascular Medicine

Dr.Soetomo Teaching Hospital, Faculty of Medicine,
Airlangga University
Surabaya.
PENDAHULUAN
Penyakit jantung koroner ( PJK ) merupakan problema
kesehatan utama di dunia
Penyebab utama kematian
Prevalensi PJK 6,8 - 36,1% meningkat sesuai umur
(NHANES,20052006)
Indonesia Penyebab mortalitas dan morbiditas no 1
(SKRT, Depkes,1992)
AS 1,5 juta pasien MRS per tahun

Didasari oleh proses progresif atherosklerosis mulai
anak-anak
28.7
17.8
12.6
9.1
6
5.1
0 5 10 15 20 25 30
Atherothrombosis*
Infectious disease
Cancer
Injuries
Pulmonary disease
AIDS
Atherothrombosis* is a
Leading Cause of Death Worldwide
1
1. The World Health Report, 2002, WHO Geneva, 2002
Mortality (%)
* Ischemic heart disease, cerebrovascular disease, inflammatory heart disease and hypertensive heart
disease

Worldwide defined as Member States by WHO Region (Africa, Americas, Eastern Mediterranean,
European, South-East Asia and Western Pacific)
1. Fatty streak
2. Fibrous plaque
3. Advance (complicated) plaque
ATEROSKLEROSIS
Definisi : penyakit kronis yang ditandai dengan
penebalan dan pengerasan dinding arteri.
Monocyte
LDL-C
Adhesion
molecule
Macrophage
Foam cell
Oxidized
LDL-C
Plaque rupture
Smooth muscle
cells
CRP
Faktor Risiko PJK
Faktor Risiko
Modifikasi
Merokok
Hypertension
Diabetes
Dislipidemia
Obesitas
Kurang Aktivitas
Stress



Framingham Heart Study
Manifestasi Klinik dari PJK
Silent Ischemia/asymptomatic
Angina pectoris stabil (Stable Angina)
Sindroma Koroner Akut (Non-STEMI/UA
and STEMI)
Prinzmetal Angina
Gagal Jantung
Sudden Death
Angina Pectoris

Nyeri dada retrosternal, menjalar ke rahang,
punggung, atau lengan kiri.
Nyeri digambarkan seperti rasa panas,
tertindih benda berat, diremas-remas dan
tidak dapat ditunjuk.
Angina Spesifik
Angina Tidak Spesifik
Nyeri dada kanan
Nyeri epigastrium
Distribusi nyeri pada iskemia miokard
Distribusi nyeri pada iskemia miokard
Daerah nyeri yang jarang dijumpai pada
Iskemia miokard
Sisi kanan
Epigastrium
Rahang
Punggung
Diagnosa Banding Nyeri dada
1. Kelainan pada esophagus : esofagitis oleh karena
refluks
2. Kolik Bilier
3. Sindroma Kostosternal inflamasi pada tulang
rawan kosta
4. Radikulitis servikal
5. Kelainan pada paru : pneumonia, emboli paru
6. Nyeri psikogenik
Asymptomatik (Silent Myocardial Ischemia)
Diketahui secara kebetulan (check up)
Tidak terdapat keluhan
EKG dapat menunjukkan depresi segment ST
Pemeriksaan lain dalam batas normal
Mekanisma diduga karena
nilai ambang nyeri meningkat,
neuropati otonomik (px DM),
meningkatnya produksi endomorfin,
derajat stenosis yang moderate,
adanya aliran kolateral

Angina Pectoris Stabil (Stable Angina)
Nyeri dada yang bersifat kronis (>6 minggu), tidak ada
perubahan kualitas dan kuantitas
Faktor pencetus (4E):
Exercise ( Olahraga)
Emotion ( Emosi )
Eating ( Setelah makan banyak )
Exposure to cold ( Paparan dingin )

Mekanisme terjadinya iskemia
Gangguan keseimbangan antara suplai dan
kebutuhan oksigen miokard karena adanya stenosis
pada pembuluh darah koroner
Angina Pectoris Stabil (Stable Angina)
Diagnosis
Anamnesis: spesifik dan non spesifik
Pemeriksaan fisik biasanya normal
EKG di luar serangan dalam batas normal
Pemeriksaan Penunjang ( Treadmill,
Echocardiography, MSCT, Coronary
Angiography )


Duke treadmill score
Exercise time in minute : n
mm ST depression x 5 : -n
Non limiting angina x 4 : -n
Limiting angina x 8 : -n
Risk 1 year mortality
Low risk : 5 0,25 %
Intermediate : 4 to -10 1,25 %
High : -11 5,25 %

Angina Pectoris Stabil (Stable Angina)
Terapi
Prinsip
Menyeimbangkan suplai oksigen dengan kebutuhan
oksigen miokard
A. Penanganan faktor-faktor risiko PJK
B. Medikamentosa
Gol. Nitrat
Calsium antagonis (Diltiazem)
Beta blocker (Bisoprolol)
Anti-platelet (ASA, Clopidogrel)
Statin (Simvastatin, Atorvastatin)
C. Revaskularisasi ( Intervensi Bedah CABG / Non
Bedah PTCA)
Gibbons et al. ACC/AHA/ACPASIM Guidelines for the Management of Patients With Chronic Stable Angina: Executive
Summary and Recommendations. Circulation. 1999; 99:2829-2848
Sindroma Koroner Akut
Definisi:
Keadaan iskemia miokard yang terjadi akut,
dengan beberapa presentasi iskemia
- Angina pektoris tidak stabil (UA)
- Infark miokard tanpa elevasi segment ST
(NSTEMI)
- Infark miokard dengan elevasi segment ST
(STEMI)
Sindroma Koroner Akut
ACS is an Important Manifestation of
Atherothrombosis
1
1. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.
Antithrombotic
therapy
Stable
angina
UA Non-
Q-wave MI

Thrombolysis
primary PCI
Q-wave
MI
Minutes
hours
Days
weeks
STEMI UA/NSTEMI Atherothrombosis New term
Old term
Plaque
rupture/erosion
UA=unstable angina; NSTEMI=non-ST-segment elevation myocardial
infarction; PCI=percutaneous coronary intervention
Pathophysiology of Unstable Angina
The primary pathophysiologic event in
Unstable Angina is a reduction in
coronary blood flow due to plaque
erosion or eruption followed by transient
platelet aggregation, coronary
thrombosis, or coronary artery spasm

Plaque Vulnerability, Rupture and Thrombosis

Acute Coronary Syndrome Handbook for Clinical Practice. ESC. 2006
Acute Coronary Syndrome
( ACS )
ST-segment
Depression
ST-segment
Elevation
Biomarkers of
Cardiac Injury (-)
Biomarkers of
Cardiac Injury (+)
UA
( Unstable Angina )
NSTEMI
( Non ST-Elevation
Myocardial Infarction )
Biomarkers of
Cardiac Injury (+)
STEMI
( ST-Elevation
Myocardial Infarction )
European Heart Journal (2007) 28,882
Presentasi Klinis UA / NSTEMI
Nyeri angina saat istirahat (>20 min)
Onset baru angina ( > 6 minggu )
Angina crescendo
Angina pasca Infark (MI)
Admission
Working
Diagnosis
ECG
Biochemistry
Risk
Stratification
Diagnosis
Treatment
C H E S T P A I N
Troponin (+) Troponin 2x (-)
High Risk Low Risk
STEMI
Invasive / Non-Invasive
Reperfusion
Suspicion of Acute Coronary Syndrome ( ACS )
Normal /
Undetermined ECG
Persistent
ST-Elevation
ST/T-abnormalities
Guideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14
th
, 2007
NSTEMI
UA
Management Chest Pain
Stratifikasi Risiko
Penting untuk menetapkan penderita dalam kondisi
risiko tinggi atau risiko rendah,
sehingga menentukan
rencana pengobatan ( invasif / non invasif )
Tabel 1. Risiko kematian jangka pendek dan terjadinya
nonfatal infark miokard pada angina pektoris tidak stabil
Feature
History
Character of pain
Clinical findings
ECG findings
Cardiac markers
CABG indicates artery bypass graft; CAD, coronary artery disease;
CCS, Canadian Cardiovascular Society, ECG, electrocardiogram
MI, myocardial; MR, mitral regurgitation;
Ta T, troponin T; and TnI, tropinin I
Elevated (eg. TnT or TnI > 0.1 ng/Ml)
Slightly elevated (eg, TnT
> 0.01 but < 0.1 NG/mL)
Normal
Angina at rest with transient
ST-segment changes >0,05 mV
Bundle-branch block, new or
presumed new
Sustained ventricular tachycardia
T-wave intervensions >0.2 mV
Pathological Q-waves
Normal or unchanged ECG
During an episode of chest
discomfort
Pulmonary edema, most likely
related to ischemia. New or
worsering MR murmur S3 or
new/wosering rales Hypotension,
bradycardia, Age >75 years
Age > 70 years
Prolonged on going (>20 min)
rest pain
Prolonged (>20 min) rest angina,
now resolved, with moderate or
high likehood of CAD.Rest angina
(<20 min or relieved with rest or
Sublingual nitroglycerin)
New-onset or progressive
CCS Class III or IV angina
in the past 2 weeks with
moderate or high likehood
Of CAD
Accelerating tempo of ishemic
Symptoms in preceding 48 h
Prior MI, peripheral or cerebro
vascular disease, or CABG ;
Prior aspirin use
High Risk Intermediate Risk
Low Risk
(At least 1 of the Following
Features Must Be Present)
(No High-Risk Feature but Must
Have 1 of the Following Features)
(No High, or Intermediate
-Risk Feature but May Have
any of the Following
Features)
Anderson et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation Myocardial InfarctionExecutive
Summary. JACC Vol. 50, No. 7, 2007
Anderson et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-
Elevation Myocardial InfarctionExecutive Summary. JACC Vol. 50, No. 7, 2007
Clinical suspicion of ACS
Physical examination
ECG monitoring, blood samples
Undetermined
diagnosis
Persistent
ST-segment elevation
No persistent
ST-segment elevation
ASA,
Fonda/Enox/UHF,ticagrelor,prasugrel
clopidogrel*,beta-blockers, nitrates
Thrombolysis
PCI
High risk Low risk
GPIIb/IIIa,
coronary angiography
Stress test,
coronary angiography
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.
2. ESC 2011 UA/NSTEMI Guidelines


Second troponin measurement
Positive Twice negative
ASA
PCI, CABG or medical management
depending upon clinical and angiographic features
*Omit clopidogrel if
the patient is likely
to go to CABG
within 5 days
Management Strategy in UA/NSTEMI

Oxygen, bed rest, ECG
monitoring
Nitroglycerin
Antiplatelet Therapy
Anticoagulant Therapy
Beta Blockers
ACE Inhibitors
Statins
Medical Management of UA / NSTEMI
Acute Therapy Maintenance Therapy
Antiplatelet Therapy
Beta Blockers
Statins
ACE Inhibitors
Calcium Channel Blockers


Menurut WHO, bila terdapat 2 dari


Kriteria diagnostik
1. Nyeri dada yang spesifik
2. Perubahan EKG
Gelombang Q patologis, dg
Elevasi segmen ST
3. Peningkatan kadar enzim jantung
Infark Miokard Akut (STEMI)
Cemas dan gelisah
Perfusi dingin
Bradikardia/ Takikardia
Aritmia
Pulse pressure turun
Tekanan diastolik meningkat
Syok Kardiogenik

Pemeriksaan fisik
Infark Miokard Akut (STEMI)
S1 melemah
Sering timbul S3 / S4
Bising sistolik blowing di apeks (ruptur katup
mitral)
Bising pansistolik parasternal (ruptur septum
ventrikel)
Friction rub , 6 30%
Auskultasi jantung
Infark Miokard Akut (STEMI)
Kadar enzim jantung
1. CK isoenzim (CK-MB)
Meningkat dalam 3-12 jam, normal dalam 3-4 hari, puncak pada 18-36 jam
2. Cardiac troponin (cTnI, cTnT)
Meningkat dalam 3-12 jam, normal dalam 10-14 hari, puncak pada 24 jam
3. Myoglobin
Meningkat dengan cepat dalam 1-2 jam, waktu paruh dalam plasma 9 menit,
kurang spesifik
4. Creatin Kinase (CK)
Meningkat dalam 4-8 jam, normal dalam 2-3 hari, kadar puncak pada 24 jam
5. Serum Glutamic Oxaloacetic Transaminase (SGOT)
Meningkat dalam 24 jam, kadar puncak dalam 2 hari, normal dalam 4 hari
6. Lactic Dehidrogenase (LDH)
Meningkat dalam 10 jam, normal dalam 10-14 hari, puncak pada 24-48 jam


Laboratorium
Prinsip
a. Perbaikan aliran darah koroner
b. Mengurangi kebutuhan oksigen
Penanganan harus cepat dan tepat
Segera pasang infus life-line
Oksigen 2 lt/menit
Istirahat total
Monitor EKG 24 jam
Di ICCU
Manajemen
MONA-Co
Morphin IV
O
2
4 l/m
Nitrat sublingual/ spray
Aspirin 160-320 mg per os
Clopidogrel 300-600 mg per os 75 mg/
hari
Manajemen
Anti platelet ( ASA, Clopidogrel, Prasugrel,
Ticagrelor )
Anti koagulan ( Fondaparinux,
Enoxaparin,UFH )
Beta blocker
ACE Inhibitor
Calcium Channel Blocker
Statin
Laxantia
Diet
Modifikasi faktor resiko


Manajemen
Time is muscle (myocardium)
Door to needle (trombolitik) < 30 menit
Door to balloon (primary PCI) < 60-90
menit
Manajemen
Clinical suspicion of ACS
Physical examination
ECG monitoring, blood samples
Undetermined
diagnosis
Persistent
ST-segment elevation
No persistent
ST-segment elevation
ASA,
Fonda/Enox/UHF,ticagrelor,prasugrel
clopidogrel*,beta-blockers, nitrates
Thrombolysis
PCI
High risk Low risk
GPIIb/IIIa,
coronary angiography
Stress test,
coronary angiography
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.
2. ESC 2011 UA/NSTEMI Guidelines


Second troponin measurement
Positive Twice negative
ASA
PCI, CABG or medical management
depending upon clinical and angiographic features
*Omit clopidogrel if
the patient is likely
to go to CABG
within 5 days
Management Strategy in UA/NSTEMI

Revaskularisasi
Farmakologik/ Trombolitik
Streptokinase 1.5 juta IU dalam 100 cc
NaCl 0.9% atau D5%, dalam 1 jam
tPA
TNK-tPA
Selama tindakan dilakukan pemantauan
irama jantung, tekanan darah, kesadaran, &
keluhan
Mekanik/ Angioplasty/ PTCA
?
Reperfusion Strategies for STEMI
Widely Available
Quickly Administered
Less Effective
Bleeding Risk
Re-occlusion Risk
Less costly


Limited Availability
Treatment Delay
More Effective
Bleeding Risk Very Low
Better Outcome
Higher cost


PCI
Pharmacology
Gagal jantung akut
Edema paru akut
Aritmia
Ruptur dinding ventrikel, septum (IVS)
Regurgitasi mitral akut
Syok kardiogenik
Sudden death

Komplikasi IMA
CABG
Pencegahan Sekunder
Perubahan Gaya Hidup
Berhenti merokok
Diet rendah garam, lemak jenuh, & tinggi
serat
Olahraga 3-4 x seminggu, @30-60 menit
Menurunkan BB
Farmakoterapi
ASA
Penyekat beta
ACE inhibitor
Statins
Variant Angina (prinzmetal`s angina)
Ditemukan th 1959
Nyeri selalu saat istirahat
Terjadi karena spasme koroner, bersifat lokal
Bukan karena peningkatan kebutuhan oksigen oleh miokard
Manifestasi klinis
1. Sering pada usia muda
2. Tanpa faktor resiko
3. Nyeri sering pada tengah malam 8 pagi
4. Nyeri sangat hebat
EKG
1. Depresi segmen ST/ elevasi segmen ST
2. Bisa disertai aritmia jantung
Tidak bermanfaat
Nitrat
Calsium antagonist
Alfa blocker
Beta blocker
Antitrombotik
Respon baik dengan
Variant Angina (prinzmetal`s
angina)

Anderson et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-
Elevation Myocardial InfarctionExecutive Summary. JACC Vol. 50, No. 7, 2007
75
Recommendations for the use of
Thienopyridines
A loading dose of thienopyridine is recommended for
STEMI patients for whom PCI is planned. Regimens
should be one of the following:
MODIFIED
Recommendation
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
Clopidogrel at least 300 mg to 600mg should
be given as early as possible before or at the
time of primary or non-primary PCI.
76
Recommendations for the use of
Thienopyridines
Prasugrel 60 mg should be given as
soon as possible for primary PCI.
MODIFIED
Recommendation
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
General Guidelines to Differentiate Chest
Paint of Myocardial Infarction, Unstable and
Chronic Stable Angina
Chest Pains Myocardial infarction Unstable Angina Chronic Stable Angina
Severity Very severe Moderate severe Mild
Duration > 30 minutes 15 - 30 minutes < 15 minutes
Frequency Persistent pain Increasing frequency Stable, less frequent
Timing At rest At rest or with exertion With exertion
Relief With No Usually no yes
Nitroglycerine
Other anxiety, diaphoresis, Less than MI Less than MI
symptoms dyspnea, nausea
Hyperacute phase of extensive
anterior myocardial infarction
HEART ATTACK !!!!
Anderson et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-
Elevation Myocardial InfarctionExecutive Summary. JACC Vol. 50, No. 7, 2007
Management of STEMI
Diagnosa
NSTEMI/UA
High risk Low risk
GPIIb/IIIa,
coronary angiography
Stress test,
coronary angiography
Second troponin measurement
Positive Twice negative
PCI, CABG or medical management
depending upon clinical and angiographic features
MRS dengan tambahan terapi:
Nitrogliserin
Beta bloker
Heparin (UFH/LMWH)
GpIIb/IIIa inhibitor
Tatalaksana
ACS
Case: STEMI
Clinical presentation
Prolonged Chest pain > 2
hours
ECG: ST-elevation
II,III,AVF
Arrived at PCI center
Cor-Angiography
PROBLEMS in Reperfusion Therapy
for STEMI
Reperfusion Therapy restricted by
Contraindication to Thrombolytic
Late presentation
Limited access for Reperfusion
Therapy or PCI not available
Lack of economic resources

Proportion of STEMI patients Not
Receiving Reperfusion Therapy
NRMI 2-3 (376 753 pts) : 31 %
GRACE registry : 30 %
Other Clinical Trials : 21-46 %
STEMI Management: ESC Guidelines 2008
Recommendations for Anticoagulation
ESC Guideline 2007
Anticoagulation is recommended for all patients in addition
to antiplatelet therapi
( I-A )

Anticoagulation should be selected according to the risk of both
ischaemic and bleeding events ( I-B )

Several anticoagulants are available namely UFH, LMWH,
Fondaparinux, Bivalirudin.
The choice depends on the initial strategy
( urgent invasive, early invasive, or conservative strategies )
( I-B )

In an urgent invasive strategy,
UFH ( I-C ), or Enoxaparin ( IIa-B ) or Bivalirudin ( I-B ) should be immediately
started
Anticoagulants as Ancillary Therapy
Patients undergoing reperfusion with
fibrinolytics should receive
anticoagulant therapy for a minimum
of 48 hours, and preferably for the
duration of the index hospitalization,
up to 8 days.
New Recommendation

Regimens other than UFH are
recommended if therapy is given for
more than 48 hours because of risk
of heparin-induced
thrombocytopenia.
New Recommendation

Regimens with established efficacy
include:
UFH, enoxaparin, fondaparinux
(see full text Update for dosing recommendations)


I I I
IIa IIa IIa
IIb IIb IIb
III III III I I I
IIa IIa IIa
IIb IIb IIb
III III III I I I
IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
2007 ACC/AHA Guidelines- Management of STEMI
Anticoagulants as Ancillary Therapy
For patients undergoing PCI after having received an anticoagulant, the
following dosing recommendations should be followed:

For prior treatment with:
1. UFH - administer additional boluses of UFH as needed to support
the procedure

2. Enoxaparin if last dose was administered within prior 8 hours,
no additional enoxaparin should be given; if last dose was 8 to 12
hours earlier an IV dose of 0.3 mg per kg should be given

3. Fondaparinux administer additional IV treatment with an
anticoagulant possessing anti-IIa activity
New recommendations

Because of the risk of catheter thrombosis, fondaparinux should not
be used as the sole anticoagulant to support PCI. An additional
anticoagulant with anti-IIa activity should be administered
New recommendation
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
I I I IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
I I I
IIa IIa IIa
IIb IIb IIb
III III III
IIa IIa IIa
IIb IIb IIb
III III III
2007 ACC/AHA Guidelines- Management of STEMI
Acute Coronary Syndrome
Non -ST Elevation
ST- Elevation
NSTEMI
Myocardial Infarction
NQMI Unstable Angina QwMI
European Heart Journal doi :10.1093.14 June 2007
Risk Stratification ACS
Feature
High Risk
At least of the following features must be present :
History
Accelerating tempo of ischemic symptoms in preceding
48 hours
Characteristic of pain Prolonged ongoing (> 20 minutes) rest pain
Clinical Findings
Pulmonary edema, most likely due to ischaemia
New or worsening MR murmur
S3 or new / worsening rales
Hypotension, bradycardia, tachycardia
Age > 75 years
ECG
Angina at rest with transient ST-segment changes > 0.05
mV
Bundle-branch block, new or presume new
Sustained ventricular tachycardia
Cardiac Markers Elevated (eg. TnT or TnI >0.1 ng/mL)
Feature
Intermediate Risk
At least No high-risk feature but must have 1 of the
following :
History
Prior MI, peripheral or cerebrovascular diseases, or
CABG, prior Aspirin use.
Characteristic of pain
Prolonged ( > 20 min) rest angina, now resolved, with
moderate or high likehood of CAD.
Rest angina ( < 20 min) or relieved with rest or sub-
lingual NTG.
Clinical Findings Age > 70 years
ECG
T-wave inversions > 0.2 mV
Pathological Q-waves
Cardiac Markers Slightly elevated (eg. TnT > 0.01 but < 0.1 ng / mL
Feature
Low Risk
At least No high- or intermediate-risk feature but may
have any of the following features :
History
Characteristic of pain
New-onset or progressive CCS Class-III or IV angina the
past 2 weeks without prolonged ( > 20 min) rest pain but
with moderate or high likelihood of CAD.
Clinical Findings
ECG
Normal or unchanged ECG during an episode of chest
discomfort.
Cardiac Markers Normal
Clinical suspicion of ACS
Physical examination
ECG monitoring, blood samples
Undetermined
diagnosis
Persistent
ST-segment elevation
No persistent
ST-segment elevation
ASA, Fonda/Enox/UHF
clopidogrel*, beta-blockers, nitrates
Thrombolysis
PCI
High risk Low risk
GPIIb/IIIa,
coronary angiography
Stress test,
coronary angiography
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.
Second troponin measurement
Positive Twice negative
ASA
PCI, CABG or medical management
depending upon clinical and angiographic features
*Omit clopidogrel if
the patient is likely
to go to CABG
within 5 days
ESC : Management Strategy in ACS Patients

Gradasi Angina Pektoris
( Canadian Cardiovascular Society )
1. Aktivitas sehari-hari tidak menimbulkan
serangan angina.
2. Aktivitas sehari-hari terganggu sedikit.
3. Aktivitas sehari-hari sangat terganggu.
4. Angina timbul dalam setiap aktivitas fisik.
Angina dapat timbul pada saat istirahat.
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)


European Heart Journal (2007) 28,882
1. Analgetik
Morfin 2,0-2,5 mg iv, titrasi
2. Nitrat
a. Sublingual dilanjutkan peroral/ intravena
b. Efek venodilatasi
Menurunkan venous return
Menurunkan preload
c. Efek dilatasi koroner
3. Aspirin
Menurunkan angka kematian

Obat-obat yang diberikan
INFARK MIOKARD AKUT
Terapi trombolitik (bila onset < 12 jam)
a. Streptokinase
b. r-TPA
(recombinant tissue plasminogen activator
complex)
c. Urokinase
d. ASPAC
(Anisolated plasminogen streptokinase activator)
e. Scu-PA
(single chain urokinase-type plasminogen
activator)

INFARK MIOKARD AKUT
ACS is an Important Manifestation of
Atherothrombosis
1
1. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.
Antithrombotic
therapy
Stable
angina
UA Non-
Q-wave MI

Thrombolysis
primary PCI
Q-wave
MI
Minutes
hours
Days
weeks
STEMI UA/NSTEMI Atherothrombosis New term
Old term
Plaque
rupture
UA=unstable angina; NSTEMI=non-ST-segment elevation myocardial
infarction; PCI=percutaneous coronary intervention
Acute Coronary Syndrome
( ACS )
ST-segment
Depression
ST-segment
Elevation
Biomarkers of
Cardiac Injury (-)
Biomarkers of
Cardiac Injury (+)
UA
( Unstable Angina )
NSTEMI
( Non ST-Elevation
Myocardial Infarction )
Biomarkers of
Cardiac Injury (+)
STEMI
( ST-Elevation
Myocardial Infarction )
European Heart Journal (2007) 28,882
Clinical suspicion of ACS
Physical examination
ECG monitoring, blood samples
Undetermined
diagnosis
Persistent
ST-segment elevation
No persistent
ST-segment elevation
ASA, Fonda/Enox/UHF
clopidogrel*, beta-blockers, nitrates
Thrombolysis
PCI
High risk Low risk
GPIIb/IIIa,
coronary angiography
Stress test,
coronary angiography
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.
Second troponin measurement
Positive Twice negative
ASA
PCI, CABG or medical management
depending upon clinical and angiographic features
*Omit clopidogrel if
the patient is likely
to go to CABG
within 5 days
ESC : Management Strategy in ACS Patients

Variant Angina (prinzmetal`s angina)
Ditemukan th 1959
Nyeri selalu saat istirahat
Terjadi karena spasme koroner, bersifat lokal
Bukan karena peningkatan kebutuhan oksigen oleh miokard
Manifestasi klinis
1. Sering pada usia muda
2. Tanpa faktor resiko
3. Nyeri sering pada tengah malam 8 pagi
4. Nyeri sangat hebat
EKG
1. Depresi segmen ST/ elevasi segmen ST
2. Bisa disertai aritmia jantung
Tidak bermanfaat
Nitrat
Calsium antagonist
Alfa blocker
Beta blocker
Antitrombotik
Respon baik dengan
Variant Angina (prinzmetal`s
angina)