CURRICULUM VITAE

Nama

: Dr. dr. Budi Yuli Setianto SpPD (K) SpJP (K)

Tempat, tanggal lahir

: Purworejo, 14 Juli 1957

Current Education :

Internist

: Universitas Gadjah Mada (1995)

Cardiologist-KKV

: Universitas Indonesia (1999) (2001)

Intervensionist-Cardiologist

: Universitas Indonesia (2005)

Current Position:

Kepala Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah

Mada/RSUP dr. Sardjito Yogyakarta

Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP

dr. Sardjito Yogyakarta

Guidelines of Implementation for

the Management of ACS: Focus on
Coronary Intervention
Budi Yuli Setianto
Department of Cardiology and Vascular
Medicine Faculty of Medicine Gadjah Mada
University Sardjito Hospital Yogyakarta

Spectrum of ACS
Clinical
Presentation

Chest Pain

Working
diagnosis

Acute coronary syndrome

ECG

ST
Elevation

ST-T
Abnormalities

ECG-N
Unclear

Biomarker

Diagnosis

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Management choice

STEMI
Revascularization
Antithrombotic
Antiischemic

NSTEMI/UAP
Antiischemic
Antithrombotic
Revascularization
4

MANAGEMENTSTRATEGY of NSTEMI / UAP

1. Initial treatment and evaluation in the ER
2. Validation of the diagnosis and determination of risk (risk
of ischemic vs. the risk of bleeding)

3. Invasive strategy

4. Revascularization modality
5. At and post discharge management
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
5

Determining Invasive Strategy

Invasive or conservative strategy is determined by the
risk criteria, namely:

Criteria for high risk profile

Criteria GRACE (GRACE score> 140 high)
Very high risk criteria (very high risk)
Does not meet the criteria of high risk

Criteria for high risk profile

The increase/ decrease in the levels of troponin

ST and T wave changes (symptomatic/ silent)
Diabetes mellitus
Renal insufficiency (CCT <60)
LV function decreases (<40%)
Post new infarcts
History PCI within 1 month
History CABG
GRACE score showed intermediate-high risk

Validasi Cepat diagnosis NSTEMI-ACS

dengan Hs Troponin

10

Very high risk criteria (very high risk)

12

Refractory angina
Acute heart failure
Life-threatening ventricular arrhythmias
Hemodynamically unstable

Timing angiography based on the determination

of four categories of strategies.
Urgent invasive strategy, if it meets one of the criteria
is very high risk
Early invasive strategy within 24 hours, if the GRACE
score> 140 plus one high-risk criteria
Early Invasive strategy in 72 hours if it meets one of
the criteria for high risk
Conservative strategy or elective angiography if not
found a high risk criteria

13

Invasive strategy

Revascularization modalities

If the angiogram showed atheromatous lesions but no

lesions are critical, then treated with medication

In patients with single-vessel disease, then performed

PCI

In patients with multi-vessel disease, PCI or CABG

decision made according to individual circumstances.

If the option CABG decided, the anti-platelet drugs must

stop 5 days to CABG done.

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

MANAGEMENTSTRATEGY of STEMI
1. Initial treatment and evaluation in the ER
2. Validation of the diagnosis and determination of risk (risk
of ischemic vs. the risk of bleeding)

3. Invasive strategy

4. Revascularization modality
5. At and post discharge management
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
16

ACS registrys patient distribution

Consecutive ACS
N=2797

No reperfusion
N= 510 (59%)

STEMI
N= 869 (31,1%)

NSTEMI
N= 789 (28,2%)

Fibrinolytic
N= 96 (11%)

Primary PCI
N= 263 (30%)

UAP
N= 1139 (40,7%)

Source: JAC registry data base 2010, NCCHK

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259

Description of STEMI patient without

reperfusion (N=510, 59%)
Variables

Description

Source of referral, n (%)

Walk in / ambulance
Primary physician

145 (28,4)
24 (4,7)

Inter-hospital

294 (57,6)

Intra-hospital

47 (9,2)

Location of STEMI, n (%)

Anterior

333 (65,3)

Non anterior

177 (34,7)

Onset of STEMI, n (%)

< 12 hour
12 hour

90 (17,6)
416 (81,6)
Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)

In-hospital mortality
P<0.001
P<0.03
13,3

Percentage
(%)

6,2
5,3

PPCI

Fibrinolytic

No reperfusion

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)

Prevent delay is an important part in the management

of STEMI

ECG evolution in STEMI

5- 30 min after the onset

1-2 hours

2-6 hours

Resolution segment - anterior to 2 weeks;

posterior> 2 weeks
T wave resolution: months

21

Morris F, Brady WJ. BMJ 2012;324;831-834

Set area descriptor | Sub level 1

Findings "Left bundle branch block"

STEMI in RBBB

Patients with signs and symptoms of

myocardial ischemia and atypical ECG

24

LBBB
Ventricular pacemaker rhythm
Diagnostic patients without ST segment elevation,
but no symptoms of ischemia
Isolated posterior myocardial infarction
ST segment elevation in the "lead" aVR

Observation and continuous monitoring

Revascularization
Fibrinolytic

VS.

PCI

Start adjuvant therapy

ADP antagonist
Ticagrelor
Clopidogrel
Anti-ischemic
Nitrate
Beta receptor blockers

FIBRINOLYTIC vs. PRIMARY PCI

FIBRINOLYTIC
Onset of symptoms <12
hours
Primary PCI> 90 minutes.
Contraindications (-)
30 min (door-to-needle
time)

Primary PCI
Performed in 120 minutes
Contraindications
fibrinolytic
"Door-to-balloon" 90
minutes
STEMI patients and
cardiogenic shock and
severe heart failure
The diagnosis of STEMI
doubt

1.Steg PG, et al. European Heart Journal. 2012;33:2569-2619 ; 2. Anderson JL, et al. Circulation. 2007;116:e148-e304.

STEMI Management

Revascularization

Anti-Platelets

Fibrinolytic

VS.

PCI

Aspirin

Aspirin

ADP antagonist
(Loading)

ADP antagonist
(Loading)

Clopidogrel
<75 yrs 300 mg
>75 yrs (-)

Ticagrelor 180 mg
maintenance 90 mg
bid
600 mg clopidogrel
maintenance 75 mg
bid

The target of the treatment of STEMI

management
Delay

Target

FMC to diagnosis and ECG

< 10 minute

FMC to fibrinolysis (FMC - needle)

< 30 minute

FMC to Primary PCI (balloon) at the

hospital with PCI facilities

<60 minute

Circumstances where primary PCI is

selected from fibrinolysis

<90 minute
(< 60 minute, when patients with
extensive-risk areas)

Circumstances where primary PCI can < 120 minute

still be selected from fibrinolysis
(< 90 minute, when the patient
presents early with extensive risk
areas)
when the target can not be achieved,
consider fibrinolysis
Expected angiography performed after 3-24 hours
successful fibrinolysis

Co therapy for primary percutaneous coronary

intervention
Antiplatelet
Aspirin

Loading doses of 150-300 mg po, followed by a maintenance

dose of 75-100 mg / day.

Ticagrelor

Loading dose of 180 mg po, followed by a maintenance dose of

90 mg bid

Clopidogrel

Loading dose of 600 mg po, followed by a maintenance dose of

75 mg / day.

The main problem in the capital, what

about your place?

Source: www.google.co.id

Impact of delay PPCI

Modified from Nallamothu and Bates. Am J Cardiol 2003;92:824-6 (305).

The importance of immediate reperfusion