ACUTE CORONARY

SYNDROME

Overview

Definition of ACS
ACS refer to a constellation of clinical
symptoms and findings that represent
acute myocardial ischemia.
Common pathophysiological origins related
to coronary plaque progression, instability,
or rupture with or without luminal
thrombosis and vasospasm
ACS Classification :
ST-elevation myocardial infarction (STEMI)
Non-ST-elevation ACS (NSTE-ACS) : NSTEMI and UA
American Heart Association Heart Disease and Stroke Statistics-2008 Update
Hurst's The Heart, 12th Edition, Mayo clinic cardiology 3rd edition

Risk Factors of Coronary Heart

Disease

Diagnostic Tools
Clinical symptom and physical
examination
ECG
Cardiac Biochemical markers
Echocardiography
Imaging of the coronary anatomy

Assessing Chest Pain (Classic Angina)

Location : usually retrosternal
Radiation : neck, throat, lower jaw,
teeth, ulnar arm, left shoulder,
interscapular, infrascapular,
epigastric
Character :
Tightness,pressure,burning,
heaviness, aching, strangling,
compression Dull & deep
Time of onset, duration,
frequency
Exacerbating & alleviating factors
4 Es : Exercise, Emotional Stress,
Exposure to Cold/Hot humid, Eating
Relieved by : rest, relax, SL/NTG
Associated symptoms : breath
shortness, sweating, dizziness,
syncope, fatique

Angina Pectoris
SUPPLY

DEMAND

Stable : There is no substantial deterioration in

symptoms over several weeks. Stability or

quiescence of an atherosclerotic plaque;
depending on increased oxygen demand
Unstable : symptom pattern worsen abruptly
without an obvious caused of increased oxygen
consumption, decreased supply . Unstable
Adapted from Weissberg. Atherosclerosis. 1999;147:S3S10
plaque: ACS

Variant/Printzmetal Angina : focal coronary artery

spasm without overt atherosclerotic lesions (may

involve endothelial dysfunction-vasodilator response
low & increased symphatetic activity)
Syndrome X : typical symptoms of angina without
evidence of significant coronary stenoses (due to
inadequate vasodilator reserve of coronary
resistance vessels, microvascular dysfunction,
vasospasm or hypersensitive pain perception

UA/NSTEMI
THREE PRINCIPAL PRESENTATIONS
Rest Angina*

Angina occurring at rest and

prolonged, usually > 20

minutes

New-onset AnginaNew-onset angina (de novo) of

at
severity

least CCS Class III

Increasing (Crescendo) Angina

Previously diagnosed angina
that has
become distinctly more
frequent,
longer in
Alexander et al
or lower
in present with angina at rest. threshold
*duration,
Pts with NSTEMI
usually
Circulation 2007;115;2549-2569
(i.e., increased by > 1 CCS)

ECG diagnosis of ACS

Management of Acute Coronary

Syndrome

STEMI

UAP/NSTEM
I

Therapeutic Option NSTEACS (UA/NSTEMI)

Anti-ischemic agents
Anticoagulants
Antiplatelet agents
Coronary revascularization
Long-term management

ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection

Tension pneumothorax

Pulmonary

Boerhaave syndrome

embolus

(esophageal rupture with

Perforating ulcer

mediastinitis)

ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other
Cardiovascular and Nonischemic
Pericarditis
Atypical angina
Early repolarization
Wolff-Parkinson-White
syndrome
Deeply inverted Twaves suggestive of
a central nervous
system lesion or
apical hypertrophic
cardiomyopathy

LV hypertrophy with
strain
Brugada syndrome
Myocarditis
Hyperkalemia
Bundle-branch blocks
Vasospastic angina
Hypertrophic
cardiomyopathy

ED Evaluation of
Patients With STEMI

Differential Diagnosis of STEMI: Other Noncardiac

Gastroesophageal
reflux (GERD) and
spasm

Cervical disc or
neuropathic pain

Chest-wall pain

Somatization and
psychogenic pain
disorder

Pleurisy
Peptic ulcer disease
Panic attack

Biliary or pancreatic pain

Fibrinolytics :Contraindications

NSTEMI:
Clinical Presentation:
-Prolonged (>20) angina pain at rest
-New onset angina
-Cresendo angina
Physical examination:
Most often normal, including chest
examination, auscultation and
measurement of HR and BP

ECG:
Jika ada ECG lama, bandingkan
ST depresi > 1mm (0-1mV)
sedikitnya pada 2 lead
T inverted > 1mm
Bundle branch block
Biochemical markers:
CK-MB
Trop T

STEMI:
Gejala IMA:
Nyeri dada > 20,retrosternal, berlokasi di
tengah atau dada kiri, menjalar ke rahang,
punggung atau lengan kiri. Rasa nyeri
dapat digambarkan oleh penderita seperti
tertekan benda berat, diremas, terbakar,
tertusuk, kadang kala nyeri epigastrium.
Nyeri dada ini biasanya diikuti keringat
dingin, mual dan muntah, lemas, pusing,
perasaan melayang dan pingsan.

ECG:
Pada IMA perubahan ECG meliputi
hiperakut T, ST elevasi diikuti Q wave, ST
isoelektris, T inv.
Perubahan ini minimal pada 2 sandapan
berdekatan. Terbentuknya BBB baru atau
yg dianggap baru yang menyertai nyeri
dada yang khas.
Pada infark inferior, harus curigai
kemungkinan infark posterior dan infark
ventrikel kanan. Karena itu pemeriksaan
ECG harus dilakukan pada sandapan V3RV4R dan V7-V9 harus dilakukan.

TERAPI STEMI

Aspirin 160 mg, diikuti 1x80 mg per hari

Clopidogrel 300 mg diikuti 1x75 mg per hari
Oksigen 2-4 ltr/menit
ISDN 5mg SL
Terapi reperfusi :
- fibrinolitik : alteplase, reteplase,
tenecteplase, streptokinase
- PCI

TERAPI UAP/NSTEMI

Aspirin 160 mg, diikuti 1x80 mg per hari

Clopidogrel 300 mg diikuti 1x75 mg per hari
Oksigen 2-4 ltr/menit
ISDN 5mg SL