PERAWATAN KLIEN

DENGAN SKA
(ACUTE CORONER
SYNDROME)

Harmayetty Moenaf

Silent Ischemia/asymptomatic
Stable Angina
Acute Coronary Syndrome (NonSTEMI/UA and STEMI)
Arrhythmias
Heart Failure
Sudden Death

TYPICAL ANGINA
Retro

sternal
Quality :
Precipitating factor (+) / (-)
Radiating to left neck, ear, jaw, back

Usual distribution of pain with

myocardial ischemia

Less common sites of pain with

myocardial ischemia

Right side

Jaw

Epigastrium

Back

HEART ATTACT !!!!

Diketahui secara kebetulan (check up)

Tidak terdapat keluhan
EKG menunjukkan depresi segment ST
Pemeriksaan lain dalam batas normal
Mekanisma diduga karena

Gejala Klinis
A.Nyeri dada saat aktifitas, stress
B.Bersifat kronis dan menetap dalam 30
hari
C.Nyeri precordial daerah retrosternal
D.Seperti tertekan benda berat atau
terasa panas
E. Seperti diremas atau tercekik

Mekanisme terjadinya iskemia

Karena gangguan keseimbangan
antara
suplai dan kebutuhan oksigen miokard

Prinsip Pengobatan
Menjaga agar suplai oksigen selalu seimbang
dengan kebutuhan oksigen miokard
Medikamentosa

Gol. Nitrat : ISDN

Calsium antagonis : Diltiazem
Beta blocker : Bisoprolol
Anti-trombotik : Aspirin
HMG Co A reduktase : Statin

2. ANGINA PEKTORIS STABIL (STABLE

ANGINA)
Penanganan faktor-faktor resiko
Perlu dipertimbangkan terapi
interventional

a.
b.

Percutaneus transluminal coronary

angioplasty (PTCA)
Coronary bypass surgery (CABG)

 Penyebab

Acute coronary
syndrome
adanya
penyempitan pembuluh
darah/plaque/pembuntua
n arteri sehingga aliran
darah
ke
jantung
terganggu
Plaque
terbentuk dari
kolesterol dan benda
lainnya
Pembentukan
plaque
didalam
tubuh
membutuhkan
waktu
yang lama

Wright, R. S. et al. J Am Coll Cardiol

2011;57:e215-e367

Acute Coronary Syndromes Algorithm.

O'Connor R E et al. Circulation 2010;122:S787S817

Copyright American Heart Association

Prehospital fibrinolytic checklist.

O'Connor R E et al. Circulation 2010;122:S787S817

Copyright American Heart Association

Silent Ischemia/asymptomatic
Stable Angina
Acute Coronary Syndrome (NonSTEMI/UA and STEMI)
Arrhythmias
Heart Failure
Sudden Death

Non -ST Elevation

ST- Elevation

NSTEMI

Myocardial Infarction

Unstable Angina

NQMI

QwMI

Acute Coronary Syndrome

( ACS )
ST-segment
Depression

Biomarkers of
Cardiac Injury ( - )

ST-segment
Elevation

Biomarkers of
Cardiac Injury ( + )

UA

NSTEMI

( Unstable Angina )

( Non ST-Elevation
Myocardial Infarction )

European Heart Journal (2007) 28,882

Biomarkers of
Cardiac Injury ( + )

STEMI
( ST-Elevation
Myocardial Infarction )

PATHOPHYSIOLOGY

European Heart Journal doi :10.1093.14 June 2007

Arterial Thrombosis
Endothelial Erosion
25% fatal coronary thrombosis

Plaque Rupture
75% major coronary thrombosis
Activation of Platelets

Activation of Coagulation System

Release Vasoactive Substances

ACUTE CORONARY SYNDROME

( ACS )
European Heart Journal (2007) 28,882

CHEST

Admission
Working
Diagnosis

ECG

Suspicion of Acute Coronary Syndrome ( ACS )

Persistent
ST-Elevation

Biochemistry
Risk
Stratification
Diagnosis

Treatment

PAIN

STEMI

ST/T-abnormalities

Normal /
Undetermined ECG

Troponin (+)

Troponin 2x (-)

High Risk

Low Risk

NSTEMI

UA

Reperfusion Invasive

Non-Invasive

Guideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14 th,
2007

Prolonged (>20 min) anginal pain at

rest
New onset (de novo) severe angina
(CCS class III)
Recent destabilization of previously
stable angina with at least CCS III
(crescendo angina) or
Post MI angina

Clinical suspicion of ACS

Persistent
ST-segment elevation

No persistent
ST-segment elevation

Thrombolysis
PCI

ASA, Fonda/Enox/UHF
clopidogrel*, beta-blockers,
nitrates

*Omit clopidogrel
if the patient is
likely to go to
CABG within 5
days

High risk

Low risk
Second troponin measurement
Positive

PCI, CABG or medical management

depending upon clinical and angiographic features
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.

ASA

Twice negative
Stress test,
coronary angiography

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 sublingual 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

Prolonged Chest pain

> 2 hours
ECG: ST-elevation
II,III,AVF
Arrived at PCI center

Clinical presentation

Cor-Angiography

Clinical suspicion of ACS

Physical examination
ECG monitoring, blood samples
Persistent
ST-segment elevation

No persistent
ST-segment elevation

Undetermined
diagnosis

Thrombolysis
PCI

ASA, Fonda/Enox/UHF
clopidogrel*, beta-blockers,
nitrates

ASA

*Omit clopidogrel
High risk
if the patient is
likely to go to
CABG within 5
GPIIb/IIIa,
days
coronary angiography

Low risk
Second troponin measurement
Positive

PCI, CABG or medical management

depending upon clinical and angiographic features
1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.

Twice negative
Stress test,
coronary angiography

Therapeutic Approach to STEMI

Antman et al. Circulation 2004;110:e82-

ESC Guidelines 2008

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
European Heart Journal (2007) 28,882

ALGORTMA SINDROME KORONER AKUT

(APTS/NSTEMI)
Nyeri dada
Segera lakukan pemeriksaan fisik < 10 menit :
- Periksa TTV, evaluasi saturasi O2
- Pasang IV line
- Periksa ECG 12 lead
- Periksa biomaker
-Ro dada < 30 menit

Segera diberikan pengobatan :

- M orphine IV bila nyeri dada tidak hilang
dg nitrogliserin
- O xygen 4L/menit, pertahankan saturasi
O2>90%
- N itrogliserin
- A spirin 300 mg (160-325 mg)

Review
ECG 12 lead
Biomaker
Segmen ST Elevasi

STEMI

Segmen ST Depresi
Gel T inversi
APTS/NSTEMI

MRS dg terapi :
Clopidogrel
Nitrogliserin
Heparin
Glycoprotein Iib/IIIa
inhibitor
APTS/NSTEMI

ECG non diagnostik

Biomaker (-)
Nyeri dada menetap
Ulangi ECG
Ulangi
biomaker
setelah
6-12
jam
onset nyeri dada
Ada perubahan segmen
ST
Biomaker (+)
Nyeri dada menetap