Professional Documents
Culture Documents
Syndromes-Trombolitik
Terapi
Introduction
ACS includes:
[1] STEMI
[2] NSTEMI & Unstable angina
Etiology
Key stages in the development of ACS
[1] Ischaemic cascade
[2] Plaque formation and rupture
[3] Coronary occlusion and MI
[4] Ventricular remodelling
Diastolic Dysfunction
Systolic Dysfunction
ECG Changes
MI
Unstable Angina
TIME
Plaque Rupture
Clinical Features
Cardiac Markers
Left ventricle.
Cardiac output.
Oxygen saturations.
Aorta.
Bypass grafts.
Intracardiac pressures.
Coronary Angiography
Occluded
Proximal
Stent implantation
& patent RCA
RCA
Diagnosis of STEMI
Management of STEMI On
Admission
IV access
Oxygen
Aspirin 300 mg (and 75 mg daily thereafter)
Pain relief (opiate)
Sublingual GTN
Urgent Thrombolysis (unless contraindicated)
Primary Angioplasty
blockers
Insulin/glucose regimen if plasma glucose 11 mmol/L
Thrombolysis
Thrombolytic Agents
Available Thrombolytic Agents
[1] Streptokinase
[2] tissue Plasminogen Activator (tPA)
Reteplase
Tenecteplase
Alteplase
Contraindications to Thrombolysis
R
P
> 2 mm
Q S
normal ECG
Fig. 16
HOMEOSTASIS
Definisi
KESEIMBANGAN HOMEOSTATIK
Potensi pembekuan
Potensi fibrinolitik
Potensi penghambatan
Potensi fibrinolitik
Potensi pembekuan
Potensi penghambatan
PEMBENTUKAN TROMBUS
Lesi Endothelium
Pelepasan Tromboplastin
jaringan
Activasi sistem
pembekuan
Pembentukan fibrin
Paparan thd
jaringan
Aktivasi platelet
Adhesi platelet
Aggregasi platelet
Trombus
Permulaan aterosklero
Pembentukan plaque
Pembentukan trombu
Ruptur/robekan pada
75 %
Stenosis 100 %
trombus
Faktor-faktor penyebab
pembentukan
trombus
Indikasi
Dosis
Kontraindikasi
History: Patient presenting with chest pain lasting > 15 min not rerponding
to sublingual nitroglycerine
Therapy: ASA (150 - 160 mg, to be chewed, Opioides (not intramuscular!)
Optional therapy: Antiemetics, Atropin, Naloxone, Nitrates,Beta-blockers,
Oxygen
Diagnosis: ECG (repeat, if equivocal) ST elevation or Bundle branch block
relative CI***
Stroke
Recent major
trauma/surgery/head injury
(within preceding 3 weeks
Gastro-intestinal bleding within
the last month
Known bleeding disorder
Dissecting aneurism
Recent (> 5 days < 1 year)
treatment with Streptokinase or
Anistreptase **
Therapy: Thrombolysis
Streptase: 1.5 mio IU intravenously/ within 60 min. ***
* In case of existing CI consider alternative therapy e.g. primary PTCA
** CI specific for use of Streptokinase or SK-containing products
*** CI listed according to the European Guidelines (6). For the use of Streptase
compare the contraindications and precautions of the approved prescribing
information (cf. package insert)
Monitoring
Location:
Anterior MI
SK
or rtPA
Non-Anterior MI
Risk:
High*
Intermediate*
SK
Low*
Complication:
Complicated
Inferior MI
Killip class 4
( Consider PTCA)
History
Prior CABG
Prior SK
Patient Age
Initial Examination
ECG
Hypotension (<100mm Hg)
+ tachycardia (>100)
Atrial Fibrillation
Anterior MI
Rales > 1/3
* Risk
Category
Low Risk:
Int Risk:
High Risk:
#
Factors
<1
2-3
>3
6 Week
Mortality
<3%
13%
17%
'High'intensity
regimen
'Medium' intensity
regimen
Expected
infarct size
(area at risk)
'Low' intensity
regimen
None
Small
12
P robability of intracranial
haem orrhage (%)
Alteplase
3
2
all patients
1
Streptokinase
0
0
Fig. 20: Risk factors : age > 65 Years, < 70 kg body weight, hypertension
CLINICAL STUDY
STREPTASE
Cumulative
Mortality
600 (No of patients)
Placebo13,2 %
ASA 10,7 %
SK 10,4 %
8,0 %
SK + ASA
500
400
300
200
100
0
0
14
21
28
Time (days)
Reduction of Mortality :
Cumulative Reduction:
Results of ISIS-2, mortality
35
%%Mortality
Mortality
Interval
Interval
elapsed
elapsedinin
hours
hours
Number
Numberof
of
Patients
(n)
Patients (n)
Streptokinase
Streptokinase
group
group
Control
Control
group
group
PP
<1
<1
1277
1277
8.2
8.2
15.4
15.4
0.0001
0.0001
6094
6094
9.2
9.2
12.0
12.0
0.0005
0.0005
3649
3649
11.7
11.7
14.1
14.1
0.03
0.03
1352
1352
12.6
12.6
14.1
14.1
NS
NS
594
594
15.8
15.8
13.6
13.6
NS
NS
11712
11712
10.7
10.7
n=
n=5860
5860
13.0
13.0
n=
n=5852
5852
0.0002
0.0002
</=3
</=3
>3
>3- -66
>6
>6- -99
>9
>9- -12
12
Overall
Overall
reslts
reslts
SK
n=13,607
tPA
13,569
APSAC
13,599
Thrombolysis alone
20,375
(%)
10.5
Thrombolysis +
heparin
20,400
(%)
10.3
Death
(%)
10.6
(%)
10.3
Stroke:
any
1.04*
1.39
1.26
1.28
1.18
Stroke:
haemorrhagic
0.24*
0.66
0.55
0.56***
0.40
Bleeds:
any
4.5*
5.2
5.4
6.3***
3.9
Bleeds:
major
0.9
0.8
1.0
1.0***
0.8
Reinfarction
3.47
2.93**
3.55
3.16
3.47
Allergic
reactions
0.3
0.1**
0.5
0.3
0.3
Hypotension
6.7
4.4**
7.0
6.0
5.9
(%)
10.6
*
significantly lower than tPA and APSAC
** significantly lower than SK and APSAC
*** significantly higher than thrombolysis alone
Kesimpulan
Pesan
Kemasan Streptase