Acute Coronary Syndrome

Sindroma Koroner Akut

Toni Mustahsani Aprami, dr., SpPD, SpJP

Department of Cardiology and Vascular Medicine
Division of Cardiovascular, Department of Internal Medicine
Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung
2
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.
3
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
13
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
14
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
15
Pain Patterns with Myocardial
Ischemia
16
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
17
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 :
VPBs within first 4 hours
18
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 4
th
or 5
th
day
Respiration due to anxiety and pain, in LV failure : resp.
rate correlates with degree of heart failure
19
JUGULAR VENOUS PULSE
JVP usually normal
RV infarction : marked jug. venous distension

CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction
20
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
21
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
25
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
28
Current-of-injury patterns with acute
ischemia
ELEKTROKARDIOGRAM
29
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)
30
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

53
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.
Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.

Thank you for your attention
56
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
57
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