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SIDROMA KORONER AKUT

UMAR F SHIBLY

SPESIALIS JANTUNG DAN PEMBULUH DARAH

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Atherosclerotic Plaque Stability

SUPPLY DEMAND

Adapted from Weissberg. Atherosclerosis. 1999;147:S3–S10

 Characteristics of the
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Lipid core

Adventitia
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SAKIT DADA

JANTUNG NON JANTUNG

ANGINA ATIPIKAL

STABIL TAK STABIL

KEDARURATAN
 FEATURES NOT CHARACTERISTIC
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OF MYOCARDIAL ISCHEMIA (CONT’D)


 Pain reproduced with movement or palpation
of the chest wall or arms

 Very brief episodes of pain that last a few

seconds or less

 Pain that radiates into the lower extremities

 FEATURES NOT CHARACTERISTIC
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Pleuritic pain (i.e., sharp or knife-like pain

brought on by respiratory movements or cough)

Primary or sole location of discomfort in the

middle or lower abdominal region

Pain that may be localized at the tip of 1 finger,

particularly over the LV apex
 UA/NSTEMI
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EMERGENCY ROOM TRIAGE
• Chest pain or severe epigastric pain, typical of myocardial
ischemia or MI:

• Substernal compression or crushing chest pain

• Pressure, tightness, heaviness, cramping, aching
sensation
• Unexplained indigestion, belching, epigastric pain
• Radiating pain to neck, jaw, shoulders, back or to one
or both arms

• Associated dyspnea, nausea and/or vomiting, diaphoresis

IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG

 UA/NSTEMI
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THREE PRINCIPAL PRESENTATIONS
Rest Angina* Angina occurring at rest and
prolonged, usually > 20 minutes

New-onset Angina New-onset angina of at least CCS

Class III severity

Increasing Angina Previously diagnosed angina that has

become distinctly more frequent,
longer in duration, or lower in
threshold (i.e., increased by > 1 CCS)
class to at least CCS Class III severity.
* Pts with NSTEMI usually present with angina at rest.
Braunwald
Circulation 80:410; 1989
 RISK STRATIFICATION IN
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EMERGENCY DEPARTMENT

HIGH RISK-FEATURES (RISK RISES WITH NUMBER)

History Prolonged ischemic discomfort (>20 min), ongoing
rest pain, accelerating tempo of ischemia
Clinical findings Pulmonary edema; S3 or new rales
New MR murmur
Hypotension, bradycardia, tachycardia
Age >75 years
ECG
Rest pain with transient ST-segment changes
> 0.05 mV; new bundle-branch block, new
sustained VT
Cardiac markers
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ACUTE CORONARY SYNDROME

No ST Elevation ST Elevation

NSTEMI

Unstable Angina NQMI QwMI

Myocardial Infarction
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 PURSUIT TRIAL: DEATH OR MI
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0.98
Prob of Event-Free Survival

0.96
0.94
0.92
0.9
0.88
0.86
0.84
0.82
0.8
0 30 60 90 120 150 180

Days

N Engl J Med. 339:436-43, 1998

 RECOMMENDATION
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Class I
1. Patients with suspected ACS with chest
discomfort at rest for >20 min, hemodynamic
instability, or recent syncope or presyncope
should be referred immediately to an ED or a
specialized chest pain unit.

Other patients with a suspected ACS may be

seen initially in an ED, a chest pain unit, or
an outpatient facility.
 ANTI - ISCHEMIC Rx
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Class I
1. Bed rest with continuous ECG monitoring in pts with
ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.
3. Supplemental O2 for pts with hypoxemia, cyanosis or
respiratory distress; finger pulse oximetry or arterial
blood gas determination to confirm SaO2>90%.
4. Morphine sulfate IV when symptoms are not immediately
relieved with NTG or when acute pulmonary congestion
and/or severe agitation is present.
 ANTI - ISCHEMIC Rx (cont’d)
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Class I
5. A β -blocker with the first dose administered IV if there
is ongoing chest pain, followed by oral administration.
6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or
diltiazem) as initial therapy in pts with continuing or
frequently recurring ischemia when β -blocker is
contraindicated.
7. An ACEI when hypertension persists despite treatment
with NTG and a β -blocker in pts with LV systolic
dysfunction or congestive heart failure and in ACS
patients with diabetes.
 ANTIPLATELET Rx
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Class I
1. Administer ASA as soon as possible after
presentation and continue indefinitely.
2. A thienopyridine (clopidogrel or ticlopidine) in pts
unable to take ASA.
3. Add IV UFH or subcutaneous LMWH to antiplatelet
therapy with ASA, clopidogrel, or ticlopidine.
4. Add platelet GP IIb/IIIa receptor antagonist in pts
with continuing ischemia or with other high-risk
features and in pts in whom early PCI is planned.
 ANTIPLATELET Rx
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Class I
Definite ACS with continuing
Possible ACS Likely/Definite ACS Ischemia or Other High-Risk
Features or planned PCI
Aspirin Aspirin Aspirin
+ +
Subcutaneous LMWH IV heparin/LMWH
or +
IV heparin IV platelet GP IIb/IIIa antagonist
 BIOCHEMICAL CARDIAC MARKERS IN
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PTS WITH SUSPECTED ACS WITHOUT STE

Advantages

CK-MB Myoglobin Troponins

1. Rapid, cost- 1. High sensitivity 1. Powerful for stratification

efficient, accurate
2. Useful in early 2. Greater sensitivity and
assays
detection of MI specificity than CK-MB
2. Ability to detect
3. Detection of 3. Detection of recent MI up
early reinfarction
reperfusion to 2 weeks after onset
4. Most useful in 4. Useful for selection of
ruling out MI therapy
5. Detection of reperfusion
 COCAINE
UA/NSTEMI 9/00 CLINICAL CHARACTERISTICS

 Ischemic chest pain

 Usually male < 40 years
 Cigarette smokers, but no other risk factors for
atherosclerosis
 Associated with all routes of administration
 Not dose dependent
 Often associated with use of cigarettes and/or
alcohol
Adapted from Pitts et al.
Prog. Cardiovasc. Dis. 40:65, 1997
 SPECIAL GROUPS
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Class I
1. NTG and oral Ca2+ blocker for pts with ST
deviation that accompanies ischemic chest
discomfort.

2. Immediate coronary arteriography in pts with ST

elevation after NTG and Ca2+ blocker;
thrombolysis if a thrombus is detected.
 ED MANAGEMENT OF UA/NSTEMI
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ST  ?

NO YES

Nondiagnostic ECG ST and/or T wave changes

Normal serum cardiac markers Ongoing pain
+ cardiac markers
Observe Hemodynamic abnormalities
Follow-up at 4-8 hours: ECG, cardiac markers
Evaluate
for
No recurrent pain; Recurrent ischemic pain or Reperfusion
Neg follow-up studies + UA/NSTEMI follow-up studies
Diagnosis of UA/NSTEMI
Stress study to provoke confirmed
ischemia prior to discharge
or as outpatient

Neg: nonischemic
discomfort;low-risk UA/NSTEMI + UA/NSTEMI confirmed ADMIT

Outpatient follow-up
 POST-HOSPITAL DISCHARGE CARE
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A Aspirin and Anticoagulants

B Beta blockers and Blood Pressure
C Cholesterol and Cigarettes
D Diet and Diabetes
E Education and Exercise
 MEDICATIONS AT HOSPITAL DISCHARGE
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Class I
1. Aspirin 75 to 325 mg/d
2. Clopidogrel 75 mg/qd for patients with
contraindication to ASA
3. β -Blocker
4. Lipid-lowering agent and diet in patients with LDL
cholesterol >130 mg/dL
5. Lipid-lowering agent if LDL cholesterol level after
diet is > 100 mg/dL
6. ACEI for patients with CHF, LV dysfunction (EF<0.40)
hypertension, or diabetes
 INSTRUCTIONS AT HOSPITAL DISCHARGE
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RISK FACTOR MODIFICATION

Class I
1. Smoking cessation and achievement or maintenance of optimal weight, daily
exercise, and diet.
2. HMG-CoA reductase inhibitor for LDL cholesterol > 130 mg/dL.
3. Lipid-lowering agent if LDL cholesterol after diet is > 100 mg/dL.
4. Hypertension control to a BP < 130/85 mm Hg.
5. Tight control of hyperglycemia in diabetics.
6. Consider referral of smokers to a smoking cessation program.

1. Gemfibrozil or niacin for patients with HDL cholesterol < 40 mg/dL and
triglycerides > 200 mg/dL.
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