PUSAT

JANTUNG
Regional

ACUTE STEMI
Dr. MUHAMMAD SYUKRI, Sp JP (K), FAPSIC. FSCAI
PUSAT JANTUNG REGIONAL
REGIONAL CARDIVASCULAR CENTER
RS. DR. M DJAMIL, PADANG

JANTUNG SEBAGAI POMPA

Kanan

Kiri

Penyakit Kardiovaskuler :
Masalah Yang Berakibat Fatal
Lain-lain

Kondisi Ibu Hamil dan

Persalinan
&
defisiensi
nutrisi

Peny.Infeksi &
parasit

Kecelakaan
Peny.Respirasi
Non infeksi

Kanker

30%

Infeksi Respirasi

CV
Survey Kesehatan Indonesia 2001
WHO World Health Report, 2001

Penyebab kematian
nomor I di dunia dan
Indonesia

Sindroma Koroner Akut

Suatu Spektrum Klinis peny. Jantung
Koroner :

NON STEMI
unstable angina
non-Q wave MI
STEMI

Ditandai dengan adanya Plaque Ruptur

sebagai dasar Patofisiologi secara umum

5/98

MedSlides.com

Sindroma Koroner Akut

Ischemic Discomfort
Unstable Symptoms

No ST-segment
elevation (NTEMI)

Unstable
angina

5/98

History
Physical Exam

ST-segment
elevation ( STEMI )

Non-Q

Q-Wave
AMI

MedSlides.com

AMI

ECG

Acute
Reperfusion

Proses penyempitan/Penyumbatan pembuluh darah

(Atherothrombosis)
Normal

Garis lemak

Tumpukan
lemak

Penyempitan

Plak pecah
Dan tersumbat

UAP

MCI
MATI

STROKE

Gejala tersembunyi
Umur

Sakit dada

Meningkat sesuai umur

Critical Leg
Ischemia

MCI = Serangan Jantung

Patofisiologi SKA

Adhesion

Peran Platelets pada Proses

Atherothrombosis

Platelets

2
Plaque
rupture

Activation
Activated
platelets

3
TxA2
ADP

ASA, Clopidogrel

GP IIb/IIIa Inhibitors
Cannon, Braunwald, Heart Disease. 2001;1232-1263

Aggregation
Fibrinogen

Peran Platelets pada Proses

Atherothrombosis

AWAS !!!!
SERANGAN JANTUNG !!!

SAKIT DADA

Faktor Risiko
3. Diabetes/ Insulin Resistance

1. Lifestyle
Diet

4. Emerging Risk Factors :

Smoking
Obesity

- Plasma Homocysteine (tHcy)

Physical

inactivity
2. Blood Pressure
3. Plasma lipids
LDL-C
TG
HDL-C
Other Lipid Factors :
Apoliproprotein B
Lipoprotein (a)

-- Thrombogenic Factors
-- plasma fibrinogen
-- Plasminogen Activator Inhibitor

-- Markers of Inflammation
5. Genetics
Family history

(PAI-1)

Gangguan metabolisme
Faktor risiko
Kegemukan
( Lingkaran Perut )
Laki
Wanita
Trigliserida
HDL-C
Laki
Wanita
Tekanan Darah
Gula Puasa

Batas Nilai

>102 cm (>40 in)

>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg
110
mg/dL
JAMA. 2001;285:2486-2497.

FAKTOR RISIKO

SINDROMA KORONER AKUT

ACUTE STEMI
ST Segment Elevation Mycardial
Infarction
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge
Management

Diagnosis of Acute
STEMI History
Classic symptoms: intense, oppressive chest
pressure radiating to left arm
Other symptoms:
chest heaviness, burning
radiation to jaw, neck, shoulder, back,
arms
nausea, vomiting
diaphoresis
dyspnea
lightheadedness
Symptoms may be mild or subtle

Diagnosis of Acute
MI

Physical Examination

Tachycardia or bradycardia
Extrasystoles
S3 or S4, mitral regurgitation
murmur
Lung rales
Hypertension or hypotension
Pallor, distress

Diagnosis of Acute
MI Electrocardiogram
Defines location, extent, and prognosis of infarction
ST elevation diagnostic of coronary occlusion
Q-waves do NOT signify completed infarction
ST depression or T inversion: unlikely total
coronary occlusion
ST elevation in RV4 for RV infarction
Observe up to 24 hrs for non-diagnostic ECG
Differentiate from early repolarization in V1-2

Diagnosis of Acute
MI Echocardiography
Not diagnostic, but supportive
Identify regional wall motion abnormalities
Absence of contralateral wall hyperkinesia
suggests multivessel disease or IRA
recanalization
Assess LV function, prior infarcts
More sensitive than ECG for RV infarction

Diagnosis of Acute
MI
Differential Diagnosis
Ischemic Heart Disease
angina, aortic stenosis, hypertrophic CMP
Nonischemic Cardiovascular Disease
pericarditis, aortic dissection
Gastrointestinal
esophageal spasm, gastritis, PUD,
pancreatitis, cholecystitis
Pulmonary
pulmonary embolism, pneumothorax, pleurisy

Management of Acute
MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge
Management

Acute MI - Risk
Stratification
ECG
Classification - GUSTO I Outcome
Category

Occlusion Site

ECG

1-Year
Mortality

1.

Prox LAD

before septal

ST V1-6, I, aVL
fasicular or BBB

25.6%

2.

Mid LAD

before diagonal

ST V1-6, I, aVL

12.4%

3.

Distal LAD
Diagonal

beyond diagonal
in diagonal

ST V1-4 or
ST I, aVL, V5-6

10.2%

4.

Moderate-to- proximal RCA

large inferior
or LCX
(post, lat, RV)

ST II, III, aVF and

V1, V3R, V4R or
V5-6 or
R > S V1-2

8.4%

5.

Small inferior distal RCA or

LCX branch

ST II, III, aVF only

6.7%

Acute MI - Risk Stratification

Ejection Fraction
50% Mortality

(2-Year)

40%
30%
20%
10%
0

20
20

30
30

40
40

50
50

Ejection
Ejection Fraction (%)
(%)

60
60

Gottlieb et al. Am J Cardiol 1992;69:977-984

70
70

Acute MI - Risk Stratification

Hemodynamic Subgroups - Killip Class

Killip
Class
Mortality

Definition

GISSI-1 (%)
Incidence Control
Lytic
Mortality

No CHF

71

7.3

5.9

II

S3 gallop or
basilar rales

23

19.9

16.1

III

Pulmonary edema
(rales >1/2 up)

39.0

33.0

IV

Cardiogenic shock

70.1

69.9

Management of Acute
MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge
Management

PENANGANAN
STEMI
DI RUMAH
RUMAH SAKIT
SAKIT
PENANGANAN
ACS DI
TUJUAN UTAMA

STRATEGI PENGOBATAN

45 % 75 %
Pasien dilakukan penanganan secara NON STENT / Non PC

Dasar THERAPY pada THROMBOSIS

Berdasarkan pada PATOFISIOLOGIS
PATHOGENESIS

THERAPY

RISK FACTORS

PREVENTION

- PLATELET ADHESION

ANTIPLATELET
-PLATELET AGGREGATION

-BLOOD COAGULATION

ANTICOAGULANT

-THROMBOSIS

THROMBOLYTIC

Acute MI
Management

Pharmacologic Therapy on Hospital Discharge

Aspirin indefinitely (ticlopidine or clopidogrel for
aspirin allergy or intolerance)
Beta blockers for at least 2-3 years
ACE inhibitors for CHF, LVEF<40%, or large
infarction (even with preserved LVEF)
Lipid lowering agents
Coumadin for mural thrombus, extensive anterior
infarct, DVT, atrial fibrillation

Thrombolysis in Acute
MIRelative Contraindications
Uncontrolled HTN (BP > 180/110) on presentation
History prior CVA beyond 1 yr
Anticoagulant Rx with INR > 2-3; bleeding
diathesis
Recent trauma (within 2-4 wks)
Noncompressible vascular punctures
Recent internal bleeding (within 2-4 wks)
Pregnancy
Active peptic ulcer
Prior exposure (5 day - 2 yr) for SK or APSAC

Thrombolysis in Acute
MIAbsolute Contraindications
Previous hemorrhagic stroke
CVA within previous yr
Intracranial neoplasia or AVM
Active internal bleeding (not
menses)
Suspected aortic dissection

Myocardial Reperfusion
The Original Paradigm

Re-establish
Infarct Vessel
Patency

Limit Infarct
Size

Mortality

Thrombolytic: PlaceboControl Meta-Analysis

Agent

Trial Name

Deaths/Patients
Active
Control

Odds
Odds Ratio Reduction
(& 95% Cl) ( s.d.)

Streptokinase

GISSI
ISAM
ISIS-2

495/4865
50/842
471/5350

623/4878
61/868
648/5360

23% 6
16% 18
30% 5

APSAC

AIMS

32/502

61/502

50% 16

t-PA

ASSET

182/2516

245/2495

Overall: any thrombolytic1230/140751623/14103

Patients < 6 hours
8.7%
11.6%
0.0

28% 9
27% 3

0.5
1.0
1.5
2.0
Lytic better
Lytic worse

Thrombolysis for Acute

TimeMI
to Therapy and Mortality Reduction
Pooled Analysis of Randomized Trials
Absolute Mortality Reduction per 1000 Patients

40

30

20

10

12

18

24

Time from Symptom Onset to Randomization (h)

Fibrinolytic Therapy Trialists. Lancet 1994;343:311.

Aspirin in Acute
MI
ISIS-2
20

35 Day Mortality (%)

15
10

13.2

10.7

10.4

5
0

4300

Placebo

4295

ASA

4300

SK

8
4292

SK + ASA

ISIS-2 Collaborative Group, Lancet 1988;2:349.

Aspirin in Acute
MI
Recommendations
Indicated in ALL patients with acute MI,
except for true aspirin allergy (not
intolerance)
Initiate orally with chewable compound, at
least 160 mg stat
some data suggest first dose should be
650 mg to achieve full antiplatelet effect
Continue 325 mg per day indefinitely

Acute
MIHeparin
Intravenous heparin recommended with t-PA
(intial bolus 5000 U, infusion 1000 U/hr, adjust
for weight < 50 kg)
No clear data for benefit with streptokinase
and increased bleeding
Discontinue after 24 hrs, except for:
atrial fibrillation
recurrent ischemia
anteroapical MI for CVA prophylaxis

ACE Inhibitors in Acute MI

Pooled Analysis of Randomized Trials
Study

Agent

ISIS-4

Captopril

58,050

Lisinopril

19,394

During GISSI-3
MI
CONSEN II

Post
MI

Mortality Odds Ratio & 95% CI

Enalaprilat

6,090

SAVE

Captopril

2,231

AIRE

Ramipril

2,006

TRACE

Trandolapril 1,749

Rx Better

Hennekens et al. NEJM 1996;335:1660.

Control Better

Adjunctive Therapy for Acute

MI Calcium Channel Antagonists
Agent

Nifedipine

1358

Verapamil

1775

Diltiazem

2466

Verapamil/
Diltiazem

4241

Pooled

5599

Ca+2Ant Control

Odds Ratio & 95% CI

Less Mortality

More Mortality

15.0%

13.0%

10.8%

13.3%

13.5%

13.5%

12.4%

13.4%

13.0%

13.3%

Held et al, in Topol: Text Int Cardiol 2nd Ed 1993, p.52.

Management of Acute
MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge
Management

Complications of Acute
MI
Extension / Ischemia

Expansion / Aneurysm

Mechanical

Arrhythmia

Acute MI

Heart Failure

Pericarditis

RV Infarct

Mural Thrombus

Management of Acute
MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge
Management

Acute
MI Management
Pre-Discharge
Risk stratification
Catheterization and revascularization
strategy
Electrophysiologic evaluation for VT or VF
Lifestyle modification: diet, exercise,
tobacco
Pharmacologic therapy

GUIDELINE PENANGANAN PASIEN

ACS NON STENT

BAGAIMANA GUIDELINES MENURUT ESC & ACC-AHA

NEW ACLS - ACS ALGORITHM

ACC / AHA
Update 2007

a
n
o

o
C
_

ACC/AHA ACLS ACS

Algorithm 2006
1
Nyeri dada (kecurigaan ischemia)

2
Diagnosa, penatalaksanaan dan persiapan/pre hospital oleh EMS :
- Monitor, support ABC. Persiapan untuk CPR dan defibrilasi
- Berikan oksigen, aspirin, nitroglycerin dan morphine bila dibutuhkan
- Jika tersedia, periksa ECG 12 lead, jika terdapat ST-Elevasi :
Hubungi rumah sakit yang dituju dengan DX pasien
Mulai membuat fibrinolytic checklist
- RS yang dituju harus menyaiapkan Mobilize Hospital Resources untuk
merespon pasien STEMI

3
Diagnosa cepat oleh Emergency Departemen
E.D
(<10min)
-

Check vital signs, evaluasi saturasi O2

Pasang IV line
ECG 12 lead
Anamnese singkat, terarah, pemeriksaan fisik

- Periksa awal level cardiac marker, elektrolit

tidak
Dan faal hemostatis
- Periksa Rontgen dada (<30 m)

Penatalaksanaan umum cepat oleh

Morphin IV jika nyeri tidak berkurang dengan

nitroglycerin
O2 4 L/mnt, pertahankan saturasi O2 > 90%
- Nitroglycerin SL atau spray atau IV
-

Aspirin 160 samapai 325 mg (jika

diberikan oleh EMS)

Ulang pemeriksaan ECG 12 lead

13

ST Elevasi atau LBBB baru atau

diasumsikan baru; dicurigai kuat
ST-Elevasi MI (STEMI)

ST depresi atau T inverted;

dicurigai kuat suatu ischemia
Resiko tinggi unstable angina / Non
ST Elevation MI (AU/NSTEMI)

Normal atau tidak ada perubahan

segmen ST atau gelombang T
Resiko rendah atau sedang untuk
unstable angina

6
14

10

Mulai terapi tambahan sesuai

indikasi. Jangan menunda
reperfusi

-Clopidogrel
-Nitroglycerin
--adrenergic reseptor blockers
-Heparin (UFH or LMWH)
-Glycoprotein IIb/IIIa inhibitor

-Clopidogrel
--adrenergic reseptor blockers
-Heparin (UFH or LMWH)

11
7

Opname di ruangan dgn

monitoring bed
Tentukan status resiko

Onset gejala < 12 jam

Berlanjut memenuhi kriteria

sedang atau tinggi (tabel
3,4)atau troponin positive?

Mulai terapi tambahan sesuai

indikasi

15

Pertimbangkan opname di ED
chest paint unit atau monitored
bed di ED
Lanjutkan dengan :
Serial cardiac marker (termasuk
troponin)
Ulang ECG, monitor segmen ST
Pertimbangan stress test

12

Strategi reperfusi:
Terapi ditetapkan berdasarkan
keadaan pasien dan center
criteria
Menyadari tujuan terapi reperfusi:
Door-to-balloon inflation (PCI) =
90 mnt
Door-to-needle (fibrinolysis) = 30
mnt
Lanjutkan dengan terapi:
ACE inhibitor/angiotensi receptor
blocker (ARB) 24 jam dari onset
HMG CoA reductase inhibitor
(statin therapy)

Pasien High-risk:
Refractory ischemic chest pain
Recurrent/persistent ST deviation
Ventricular tachycardia
Hemodynamic tachycardia
Signs of pump failure
Strategi invasive awal termasuk
kateterisasi & revaskularisasi
penderita IMA dgn syok dlm 48 jam
Lanjutkan pemberian ASA, heparin &
terapi lain sesuai indikasi:
ACE inhibitor / ARB
HMG CoA reductase inhibitor (statin
therapy)
Tidak pada resiko tinggi: penentuan
penggolongan resiko dari cardiology

16

Berlanjut memenuhi kriteria

resiko tinggi atau sedang
(tabel 3,4)
atau
troponin-positive

17

Jika tidak ada ischemia atau

infare, maka dapat pulang
dengan rencana kontrol

ACC/AHA 2007 Guidelines Update

untuk UA / NSTEMI
Rekomendasi untuk Antiplatelet dan Anticoagulant
Low Risk ACS

Intermediate Risk ACS

High Risk ACS

Early Conservative Management

Aspirin* (Class IA)

Early Invasive Management

Aspirin* (Class IA)

Clopidogrel# (Class IA)

Clopidogrel (Class IA)

LMWH (enoxaparin)/UFH (Class

IA)

* Or Clopidogrel if contraindicated (IA)

#
For at least 1 month (IA) and for up to 9 months (IB)
Gibler, WG, et al. Circul. 2005; 111: 2699-2710
03/23/16

LMWH (enoxaparin)/UFH (Class

IA)

ESC Guidelines 2007

ASA ( Klas 1 A )
Direkomendasikan pada semua pasien NSTE-ACS bila tidak
ada kontra indikasi, dengan initial LD 160-325 (non enteric)
dan dosis pemeliharaan 75 100 mg untuk jangka panjang

CLOPIDOGREL ( Klas 1A )
Untuk semua pasien ACS, SEGERA berikan Clopidogrel
300mg LD, dilanjutkan dengan 75mg/ hari, Clopidogrel harus
dilanjutkan hingga 12 bulan, kecuali ada resiko tinggi
perdarahan.
Untuk pasien yang kontra indikasi terhadap ASA, Clopidogrel
harus digunakan sebagai penggantinya ( 1B )

GUIDELINE 2007
AUSSIE ( Australia & New Zealand )
Non STEMI
In Hospital ( Early Initiation )

Pengobtan awal segera harus dimulai dengan ASA dan Clopidogrel

( 300 mg LD and 75 mg/hari) dengan mempertrimbangkan:

Clopidogrel harus dihindari pada pasien yang akan menjalani emergency

coronary bypass surgery
Jika memungkinkan, clopidogrel, harus dihentikan 5 hari sebelum coronary
bypass surgery.

Long-term management (Discharge Medication)

Semua pasien harus diberikan ASA 75 150 mg/hari kecuali kontra

indikasi
Clopidogrel harus diberikan selama 12 months setelah diagnosa ACS,
khususnya setelah pemasangan stent, dengan lamanya therapy
tergantung tipe stent dan keadaan lokasi pemasangan
Clopidogrel juga dapat diberikan sebagai alternative kontraindikasi thd
ASA, atau sebagai tambahan ASA, pada pasien UA atau kejadian
Kardiovaskular berulang

GUIDELINE 2007

AUSSIE ( Australia & New Zealand )

STEMI
Semua pasien yang mendapatkan reperfusion therapy
pada STEMI ( PCI atau Fibrinolysis ) harus diberikan
ASA dan CLOPIDOGREL kecuali ada kontra indikasi.

- Fibrinolytic Therapy
Pada pasien dengan fibrinolytic therapy, Clopidogrel
(300 mg LD ) harus ditambahkan pada ASA, kecuali
kontraindikasi, Clopidogrel (75 mg/hari ) harus
dilanjutkan paling tidak 1 bulan setelah fibronolytic
therapy

CRUSADE

Kepatuhan pada Guidelines

Menurunkan angka Mortality di Rumah Sakit

In-hospital Mortality (%)

Increased Adherence to Guidelines Decreases

Mortality

CRUSADE is a national quality improvement initiative of the Duke Clinical Research Institute. Partial funding
for CRUSADE is provided by the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.
CRUSADE Data Q3 2006. Cumulative CRUSADE data through September 2003.
Duke Clinical Research Institute. Available at: http://www.crusadeqi.com. Accessed February 13, 2007.

LEARNING FROM GUIDELINES

1. Clopidogrel di indikasikan pada pasien dengan UA, NSTEMI, dan
STEMI dan diberikan bersama ASA. Clopidogrel diberikan tunggal
jika ASA kontraindikasi.
2. Efek yang cepat dan

Co
_
a
on
M
memberikan perlindungan

yang lebih besar

jika pemberian clopidogrel therapy dimulai dengan loading dose

300-mg. dosis
3. Clopidogrel direkomendasikan sebagai antiplatelet Class 1 untuk
penanganan ACS baik STEMI maupun NON STEMI. ( ACC-AHA /
ESC / AUSSIE )

BALON ANGIOPLASTI

STENTING ( CINCIN )

OPERASI BYPASS KORONER

OSAMA BIN LADEN