Dr.

Muh A Sungkar, SpPD, KKV, SpJP

Divisi Kardiologi, Departemen Ilmu Penyakit Dalam

Departemen Penyakit Jantung dan Pembuluh Darah
FK Undip / Rumah Sakit Dr Kariadi Semarang
 Penyakit Jantung Koroner
● Penyakit arteri koroner adalah salah satu
yang paling sering dan pengaruh serius dari
penuaan.
● Timbunan lemak terjadi di dinding
pembuluh darah dan mempersempit jalan
untuk aliran darah.
● Kondisi yang dihasilkan, yang disebut
“aterosklerosis” sering mengawali kejadian
dari arteri koroner dan dikenal sebagai
"serangan jantung".
 Faktor-faktor Risiko untuk
Penyakit Jantung Koroner
Faktor Risiko yang tak dapat dimodifikasi :
● Keturunan
● Jenis Kelamin
● Umur
● Kepribadian tipe “A”
Faktor Risiko yang dapat dimodifikasi :
● Merokok
● Kolesterol (Total, LDL tinggi, HDL rendah)
● Hipertensi
● Obesitas
● Diabetes
● Aktifitas fisik (sedentary lifestyle)
 Atherosclerosis Timeline
Foam Fatty Intermediate Fibrous Complicated
Cells Streak Lesion Atheroma Plaque Lesion/Rupture

Endothelial dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen haematoma

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

 Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment

Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
Guidelines for the Identification of ACS Patients
Chief Complaint
• Chest pain typical of myocardial ischemia or MI
• Associated : dyspnea, nausea and/or vomiting
diaphoresis
Medical History
• CABG, angioplasty, CAD, angina on effort, or AMI
• NTG use to relieve chest discomfort
• Risk factors
Special Considerations
• Women
• Diabetic
• Elderly patients
Differential Diagnosis of Prolonged Chest Pain
● Chest wall
● Pulmonary disease
● Pericarditis
● Esophageal, other upper gastrointestinal,
or biliary tract disease
● Atypical anginal pain associated with
hypertrophic cardiomyopathy
● Aortic dissection
● AMI
● Hyperventilation syndrome
● Psychogenic
 Grading of Angina Pectoris According to
CCS Classification
Class Description of Stage

I “Ordinary physical activity does not cause . . . angina,” such as

walking or climbing stairs. Angina occurs with strenuous,
rapid, or prolonged exertion at work or recreation.
II “Slight limitation of ordinary activity.” Angina occurs on
walking or climbing stairs rapidly; walking uphill; walking
or stair climbing after meals; in cold, in wind, or under
emotional stress; or only during the few hours after
awakening. Angina occurs on walking .2 blocks on the
level and climbing .1 flight of ordinary stairs at a normal
pace and under normal conditions.
III “Marked limitations of ordinary physical activity.” Angina
occurs on walking 1 to 2 blocks on the level and climbing
1 flight of stairs under normal conditions and at a normal
pace.
IV “Inability to carry on any physical activity without
discomfort—anginal symptoms may be present at rest.”
 UA/NSTEMI
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
 CAUSES OF UA/NSTEMI
Thrombosis Mechanical
Obstruction

Dynamic  MVO2
Obstruction
Inflammation/
Infection
Mechanical
Thrombosis
Obstruction

Dynamic  MVO2
Obstruction

Inflammation/
Infection
Braunwald, Circulation 98:2219, 1998
 Algorithm for Initial Assessment and Evaluation
of the Patient with Acute Chest Pain

Chest pain consistent with coronary ischemia

Within 10 minutes

• Initial evaluatioon • 12 lead ECG

• Establish IV • Aspirin 160-325 mg - chewed
• Establish continuous ECG monitoring
• Blood for baseline serum cardiac markers

Therapeutic/Diagnostic tracking according 12-lead ECG results

Nondiagnostic / normal ECG ECG suggestive of ischemia - ST segment elevation or new

T wave inversion or ST depression bundle branch block
 UA/NSTEMI
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
 Patient with Acute Chest Pain with
T-wave inversion or ST depression

ECG suggestive of ischemia - Differential diagnosis

T wave inversion or ST depression
• Anti-ischemia Therapy
• Analgesia
Admit to unit of
appropriate intensity
Admission blood work
• CBC
• Electrolytes, BUN,
creatinine
• Lipid profile
• Ischemia
• Acute posterior MI
• Ventricular hypertrophy
• Digoxin effect
• Pericarditis
• Pulmonary embolus
• LBBB
• Hyperventilation
• Anxiety
• Normal variants
The Estimation of Early Risk
at Presentation
Boersma et al.
 Age
 Heart rate
 Systolic blood pressure
 ST-segment depression,
 Signs of heart failure
 Elevation of cardiac markers
 The Estimation of Early Risk
at Presentation
Antman et al.
 Age > 65 years
 More than 3 coronary risk factors
 Prior angiographic coronary obstruction
 ST-segment deviation
 More than 2 angina events within 24 hours
 Use of aspirin within 7 days
 Elevated cardiac markers
0 to 2 points
0 to: low-risk
2 points stratum
: low-risk stratum
3 to 4 points
3 to: intermediate-risk
4 points : intermediate-risk
stratum stratum
5 to 7 points
5 to: high-risk
7 points stratum
: high-risk stratum
ST Depression or Dynamic T wave
Inversions
 ED Management of UA/NSTEMI
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
Recurrent ischemic pain or Reperfusion
No recurrent pain;
+ UA/NSTEMI follow-up studies
Neg follow-up studies
Diagnosis of UA/NSTEMI
confirmed
Stress study to provoke
ischemia prior to discharge
or as outpatient

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

Outpatient follow-up
 Initial General Therapy for ACS
Oxygen
- Administer oxygen to all patients with overt pulmonary
congestion or arterial oxygen saturation 90% (Class I)
Aspirin
- Single chewed dose of aspirin (160 to 325 mg)
out-of-hospitalor ED setting for patients with
suspected ACS (Class I)
Nitroglycerin (or Glyceryl Trinitrate) (Class I)
• Ongoing ischemic chest discomfort
● Management of hypertension
● Management of pulmonary congestion
Morphine Sulfate
- 2 to 4 mg IV dose, and give additional doses of
- 2 to 8 mg IV at 5 to 15 minute intervals.
 MEDICATIONS AT HOSPITAL DISCHARGE

Class I
1. Aspirin 75 to 325 mg/d
2. Clopidogrel 75 mg/qd for patients with
contraindication to ASA
3. -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
The Management of Patients with
Acute Myocardial Infarction

Initial Assessment
and Evaluation
 Emergency Department Algorithms/Protocol
for Patients with Symptoms and Signs of AMI
Onset of
symptoms

Ambulance presents Patient presents

patient to ED lobby to ED lobby

ED triage or charge nurse triages patient

• AMI symptoms and signs
• 12-lead ECG
• Brief, targeted history

Emergency nurse initiates emergency Emergency Physician

nursing care in acute care area of ED evaluates patient
• Cardiac monitor • Blood studies • History
• Oxygen therapy • Nitroglycerin • Physical exam
• IV D5W • Aspirin • Interpret ECG

AMI
patient?
 Electrocardiogram
 Carries diagnostic and prognostic value
 Especially valuable if captured during pain
 ST-segment depression or transient ST-segment
elevation are primary ECG markers of UA/NSTEMI
 75% of patients with + CK-MB do not develop Q waves
 Differentiation between UA and NSTEMI relies upon
positive biomarkers
 Inverted T-waves suggestive of ischemia, particularly
with good chest pain story
Time course of Serum Protein Markers

MB2/MB1
Myoglobin

0 4 8 16 24 36 48
Hour post-AMI
 Serum Cardiac Markers

• CK-MB subfomes for Dx within 6 hrs of

MI onset
• cTnI and cTnT efficient for late Dx of MI
• CK-MB subform plus cardiac-specific
troponin best combination
• Do not rely solely on troponins because
they remain elevated for 7-14 days and
compromise ability to diagnose
recurrent infarction
Enzymatic Criteria for
Diagnosis of Myocardial Infarction

• Serial increase, then decrease of plasma CK-MB,

with a change >25% between any two values
• Increase in MB-CK activity >50% between any
two samples, separated by at least 4 hrs
• If only a single sample available, CK-MB elevation
>twofold
• Beyond 72 hrs, an elevation of troponin T or I or
LDH-1>LDH-2
TIMI risk score for STEMI
for predicting 30-day mortality

40 1) Age 65-74 /  75 2/3 points

35.9
2) Systolic Blood Pressure < 100 3 points
35 3) Heart rate > 100 2 points
4) Killip II-IV 2 points
5) Anterior STE or LBBB 1 point 26.8
30
6) Diabetes,h/o HTN, or h/o angina 1 point
7) Weight < 67 kg 1 point23.4
25
8) Time to treatment > 4 hours 1 point
20
Risk Score 0 – 14 possible
16.1points

15 12.4

10 7.3
4.4
5 1.6 2.2
0.8

0
0 1 2 3 4 5 6 7 8 >8

Risk Score :
%at risk : 12% 22% 16% 16% 14% 9% 6% 3% 2% 1%

Morrow.Circ 2000;102:2031-2037
 Assessment of Reperfusion Options for
Patients With STEMI
Step 1: Assess Time and Risk
■ Time since onset of symptoms
■ Risk of STEMI
■ Risk of fibrinolysis
■ Time required for transport to a skilled PCI
laboratory
Step 2: Determine Whether Fibrinolysis or an
Invasive Strategy Is Preferred

If presentation is less than 3 hours and there is no delay to

an invasive strategy,there is no preference for either strategy
Evolution of electrocardiographic changes
in myocardial infarction
 Acute Inferior Wall MI

http://homepages.enterprise.net/djenkins/ecghome.html
10/00 medslides.com 35
Acute Posterior Wall MI
AMI in the Presence of LBBB
 Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable

Onset of 9-1-1 EMS on-scene Inter-

symptoms of EMS • Encourage 12-lead ECGs. Hospital
STEMI Dispatc • Consider prehospital fibrinolytic if Transfer
h capable and EMS-to-needle within
30 min.
PCI
capable
GOALS
5 8 EMS Transport
min. min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007.
 Assessment of Reperfusion Options for
Patients With STEMI
Step 1: Assess Time and Risk
● Time since onset of symptoms
● Risk of STEMI
● Risk of fibrinolysis
● Time required for transport to a skilled PCI
laboratory
Step 2: Determine Whether Fibrinolysis or an
Invasive Strategy Is Preferred

If presentation is less than 3 hours and there is no delay to

an invasive strategy, there is no preference for either strategy
 Contraindications and Cautions for
Fibrinolytic Used in Myocardial Infarction
Cautions / Relative Contraindications
• Severe uncontrolled HTN on • Noncompressible vascular
presentation (BP >180/110 punctures
mmHg) • Recent (within 2-4 weeks)
• History of prior CVA or internal bleeding
known intra-cerebral • For streptokinase/ anistreplase:
pathology not covered in prior exposure (especially
contraindications within 5d-2 yrs) or prior allergic
• Current use of reaction
anticoagulants in • Pregnancy
therapeutic doses (INR  2-
• Active peptic ulcer
3); no bleeding diathesis
• History of chronic hypertension
• Recent trauma (within 2-4
weeks) including head
trauma
Reperfusion Checklist for Evaluation of the
Patient With STEMI
Reperfusion Checklist for Evaluation of
the Patient With STEMI (Cont’)
The Management of Patients with
Acute Myocardial Infarction

Initial Management
 Management of Patients with ST
Elevation
ST elevation

Aspirin
Beta-blocker

 12 h > 12 h

Eligible for Fibrinolytic therapy Not a candidate for Persistent

fibrinolytic therapy contraindicated reperfusion therapy symptoms ?

No Yes
Primary
Fibrinolytic therapy PTCA or CABG
Consider
Reperfusion
Other medical therapy: Therapy
ACE inhibitors
? Nitrates
Anticoagulants

Modified from Antman EM. Atlas of Heart Disease, VIII; 1996

 Primary Percutaneous Transluminal
Coronary Angioplasty Recommendations
Class I Recommendations
1. As an alternative to fibrinolytic therapy if:
– ST segment elevation or new or presumed new LBBB
– Within 12 hrs of symptoms or > 12 hrs of persistent pain
– In a timely fashion (90  30 min)
– By experienced operators
– In appropriate environment
2. In cardiogenic shock patients < 75 yrs or within 36 hrs of AMI
and revascularization can be performed within 18 hrs of onset of
shock
Class IIa Recommendations
1. As reperfusion strategy in candidates for reperfusion who have
contraindications to fibrinolytic therapy
 Primary Percutaneous Transluminal
Coronary Angioplasty Recommendations
Class IIb Recommendations
1. In patients with AMI who do not present with ST elevation but
who have reduced (< TIMI grade 2) flow of the infarct-related
artery and when angioplasty can be performed within 12 hrs of
onset of symptoms
Class III Recommendations
1. This classification applies to patients with AMI who:
• undergo elective angioplasty in the non-infarct-related artery at
the time of AMI
• are beyound 12 hrs after the onset of symptoms and have no
evidence of myocardial ischemia
• have received fibrinolytic therapy and have no symptoms of
myocardial ischemia
• are fibrinolytic-eligible and are undergoing primary angioplasty
by and unskilled operator in a laboratory that does not have
surgical capability
 Advantages of Fibrinolytic Therapy

• More universal access

• Shorter time to treatment
• Greater clinical trial evidence of:
– reduction in infarct size
– improvement of LV function
• Results less dependent on physician
experience
• Lower system costs
The Management of Patients with Acute
Myocardial Infarction

Hospital Management
 Sample Admitting Orders
Condition Serious
IV NS or D5W to keep vein open
Vital signs q 1/2 hr until stable, the q 4 hrs and p.r.n.
Notify if HR <60 or >110; BP <90 or >150;
RR <8 or >22. Pulse oximetry x 24 hrs
Activity Bed rest with bedside commode and progress as
tolerated after approximately 12 hrs
Diet NPO until pain free, then clear liquids. Progress to
a heart-healthy diet
Medications Nasal O2 2L/min x 3 hrs
Enteric-coated aspirin daily (165 mg)
Stool softener daily
Beta-adrenoreceptor blockers ?
Consider need for nalgesics, nitroglycerin, anxiolytic
The Management of Patients with
Acute Myocardial Infarction

MI Management
Summary
 Initial Management in ED
• Initial evaluation with 12-lead ECG in < 10 minutes
– targeted history (for AMI inclusion, thrombolysis
exclusion)
– vital signs, focused examination
• Continual ECG, automated BP, HR monitoring
• IV access
• Draw blood for serum cardiac markers, electrolytes,
magnesium, hematology,
lipid profile panel
 Initial Management in ED
• Aspirin165-325 mg (chew and swallow)
• Sublingual NTG unless SBP <90 or HR <50 or >100:
test for prinzmetal’s angina, reversible spasm, anti-ischemic,
antihypertensive effects
• O2 by nasal prolongs, first 2-3 h in all; continue if PaO2 <90%
• Analgesia: small doses of morphine (2-4 mg) as needed
• Fibrinolysis or PCI if ST elevation > 1mV or LBBB
(Goal: door-needle < 30 min or door-dilatation < 60-90 min)
 MI Management in 1st 24 Hours
• Limited activity for 12 hours, monitor  24
hours
• No prophylactic antiarrhythmics
• IV heparin if: a) large anterior MI; b) PTCA; c)
LV thrombus; or d) alteplase/reteplase use
(for ~48 hours)
• SQ heparin for all other MI (7,500 u b.I.d.)
• Aspirin indefinitely
• IV NTG for 24-48 hrs if no / HR or BP
• IV beta-blocker if no contraindications
• ACE inhibitor in all MI if no hypotension
 In-Hospital Management
• Aspirin indefinitely
• Beta-blocker indifinitely
• ACE inhibitor (DC at ~6 wks if no LV dysfunction)
• If spontaneous or provoked ischemia - elective
cath
• Suspected pericarditis - ASA 650 mg q 4-6 hrs
• CHF - ACE inhibitor and diuretic as needed
• Shock - consider intra-aortic balloon pump + cath
with PCI or CABG
• RV MI - fluids (NS) + inotropics if hypotensive
 Clinical Indications of High Risk At Predischarge
Present Absent Absent

Strategy I Strategy II Strategy III

Submaximal Exercise Test

Symptom-Limited Exercise Test
at 5-7 Days
at 14-21 Days

Markedly Abnormal Mildly Abnormal Negative

Markedly Mildly
Negative
Abnormal Abnormal
Exercise Imaging Study

Exercise Imaging Study

Reversible Ischemia No Reversible Ischemia

Reversible No Reversible
Ischemia Ischemia Strenuous Leisure Activity or Occupation

Medical Treatment Symptom-Limited Exercise Test at 3-6 Weeks

Markedly Mildly
Negative
Abnormal Abnormal

Cardiac
Catheterization Exercise Imaging Study

Reversible No Reversible
Ischemia Ischemia

Medical Treatment