Acute Coronary Syndrome

Sindroma Koroner Akut

Toni Mustahsani Aprami, dr., SpPD, SpJP

Department of Cardiology and Vascular Medicine

Division of Cardiovascular, Department of Internal Medicine

Padjadjaran University School of Medicine/Hasan Sadikin Hospital , Bandung

 DEFINISI
Suatu sindroma klinik yang menandakan
adanya iskemia miokard akut, terdiri dari :
Infark miokard akut Q wave (STEMI)
Infark miokard akut non-Q (NSTEMI)
Angina pektoris tidak stabil (UAP)

Ketiga kondisi ini sangat berkaitan erat, berbeda

hanya dalam derajat beratnya iskemi dan
luasnya miokard yang mengalami nekrosis.
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 PATOGENESIS
Umumnya disebabkan oleh aterosklerosis
koroner
Plak aterosklerosis ruptur terbentuk
trombus diatas ateroma yang secara akut
menyumbat lumen koroner
Apabila sumbatan terjadi secara total
hampir seluruh dinding ventrikel akan
nekrosis
3
 Risk Factors

Uncontrollable Controllable

Sex High blood pressure

Hereditary High blood cholesterol

Race Smoking

Age Physical activity

Obesity
Diabetes
Stress and anger
 The cardiovascular continuum of events

Ischemia = oxygen supply

and demand imbalance
Myocardial
Ischemia

CAD
plaque
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
 The cardiovascular continuum of events

Coronary
Thrombosis

Myocardial
Ischemia

CAD

Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
 The cardiovascular continuum of events
ACS

Coronary
Thrombosis

Myocardial
Ischemia

CAD

Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
Coronary
Plaque
Stable
UA/NSTEMI
STEMI
thrombosis
rupture
angina
 Penyempitan
Pembuluh darah
Clinical Spectrum of Acute Coronary Syndrome

Acute Coronary Syndrome

Non-ST Segment ST Segment

Elevation Elevation

STEMI

NSTEMI
Unstable Non-Q-wave Q-wave
Angina Pectoris Acute Myocardial Infarction
 Unstable
NSTEMI STEMI
Angina

Occluding thrombus Complete thrombus

Non occlusive occlusion
sufficient to cause
thrombus
tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG
ST depression +/-
T wave inversion on Elevated cardiac
Normal enzymes
ECG
cardiac
enzymes More severe
Elevated cardiac
enzymes symptoms
 Diagnosis

Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
HISTORY
PRODROMAL SYMPTOMS
History very valuable to establish D/. Prodoma : chest discomfort
unstable angina
1/3 symptoms for 1 4 wks
20% symptoms for < 24 hrs
Malaise, exhaustion

NATURE OF PAIN
Most patients
severe prolonged, 30 minutes - hours
Constricting, crushing, oppressing, compressing
heavy weight or squeezing in chest
Choking, vise-like, heavy pain or stabbing, knife-like, boring or
burning discomfort
Location : retrosternal, spreading frequently to both sides of the
chest with predilection to the left side
Often pain radiates down ulnar aspect of left arm, producing
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tingling sensation in left wrist, hand and fingers
NATURE OF PAIN
SOME INSTANCES : pain begins in epigastrium, and simulates
abdominal disorder
Sometimes pain radiates to shoulders, upper extremities, neck, jaw
and interscapular region favoring the left side
Elderly : no chest pain but acute left ventricular failure and chest
tightness or marked weakness or syncope
Pain arises from nerve endings in ischemic or injured, but not necrotic,
myocardium

OTHER SYMPTOMS
50% nausea or vomiting in transmural infarcts
Occasionally diarrhea, profound weakness, dizziness, palpitation, cold
perspiration, sense of impending doom
Occasionally : cerebral embolism or systemic arterial embolism
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Pain Patterns with Myocardial
Ischemia

15
Anamnesis untuk UAP

3 kategori presentasi klinik UAP:

Angina saat istirahat (resting angina)
Angina awitan baru (new onset angina)
Angina yang bertambah berat (increasing
angina)

Riwayat penyakit dahulu :

Riwayat angina on effort, infark atau
operasi pintas
Riwayat penggunaan nitrogliserin
Identifikasi faktor-faktor risiko
16
 PHYSICAL EXAMINATION
GENERAL APPEARANCE
Anxious, considerable distress, restless, fist on chest
(Levine sign)
LV failure & symp. stimulation : cold perspiration, pallor,
dyspnea, cough with frothy pink or blood-streaked
sputum.
Shock : cool, clammy skin, facial pallor, cyanosis,
confusion or disorientation

HEART RATE
Variable depending on underlying rhythm and degree or
ventr. failure
Most commonly, HR 100 110/min; > 95% patients :
VPBs within first 4 hours 17
BLOOD PRESSURE
Majority normotensive, but syst. BP may decline and diast.
BP may rise
Half of pts with inferior MI parasympathetic stimulation
: hypotension, bradycardia or both (Bezold Jarisch
reflex)
half of pts with anterior MI, sympathetic excess :
hypertension, tachycardia or both

TEMPERATURE AND RESPIRATION

Most pts with extensive MI fever within 24-48 hrs, fever
resolves by 4th or 5th day
Respiration due to anxiety and pain, in LV failure : resp.
rate correlates with degree of heart failure
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JUGULAR VENOUS PULSE
JVP usually normal
RV infarction : marked jug. venous distension

CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction

19
CHEST
LV failure and/or LV compliance : moist rales
Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification

Class I : patients free of rales or S3

II : rales < 50% lung fields +/- S3
III : rales > 50% lung fields, frequently
pulm. edema
IV : cardiogenic shock

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Pemeriksaan Penunjang

Pemeriksaan EKG

Gambaran EKG infark miokard akut Q-wave (STEMI) :

Elevasi segmen ST 1 mm pada 2 sadapan

extremitas

Atau 2 mm pada 2 sadapan prekordial yang

berurutan

Atau gambaran LBBB baru atau diduga baru

21
ST-segment elevation
Gambaran EKG infark miokard akut non-Q-
wave (NSTEMI) atau angina pektoris tidak
stabil (UAP) :

Depresi segment ST atau gelombang T

terbalik pada 2 sadapan berurutan

Inversi gelombang T minimal 1 mm pada 2

sadapan atau lebih yang berurutan.

Perubahan segment ST saat keluhan dan

kembali normal saat keluhan hilang
sangat menyokong UAP 25
ST-segment depression
T-wave inversion
 ELEKTROKARDIOGRAM

Current-of-injury patterns with acute

ischemia

28
 Pemeriksaan Penanda Jantung/Enzim jantung
(Cardiac Markers):

Yang lazim adalah CKMB, dapat pula troponin T (TnT)

atau troponin I (TnI)

Peningkatan marka jantung akan terlihat pada infark

miokard akut Q-wave (STEMI) dan non-Q-wave
(NSTEMI)

29
Plot of the appearance of cardiac markers in
blood versus time after onset of symptoms

A myoglobin C CK-MB
30
B troponin D troponin in UA
 Diagnosis Banding
1. Diseksi aorta
2. Perikarditis
3. Nyeri angina atipikal pada kardiomiopati
hipertrofi
4. Penyakit esofageal, GI atas atau traktus biliaris
5. Penyakit paru-paru : pneumotoraks, emboli,
pleuritis
6. Sindroma hiperventilasi
7. Gangguan dinding dada : muskuloskeletal,
neurogen
8. Psikogen 31
Manajemen
 The cardiovascular continuum of events
ACS
Coronary
Thrombosis Arrhythmia and
Loss of Muscle

Myocardial
Ischemia Remodeling

Ventricular
CAD Dilatation

Atherosclerosis Congestive
Heart Failure

Risk Factors End-stage Heart

( DYSLIPIDEMIA , BP, DM, Disease
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
 DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation
ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
 ISCHEMIC CHEST PAIN

TYPICAL ANGINA EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT 2. LOCATION
2. LOCATION 3. INDIGESTION
3. RADIATION 4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS 5. DIAPORESIS
6. SHORTNESS OF BREATH
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min) Immediate ED general treatment

Vital sign O2 at 4 L/min (maintain O2 sat 90%)
Oxygen saturation Aspirin 160-325 mg
Obtain IV access Nitroglycerin SL, spray, or IV
Obtain ECG 12 lead Morphine IV 2-4 mg repeated every
Brief history and physical exam 5-10 minutes (if pain not relieved
Check contraindication for fibrinolytic with nitroglycerine)
Initial serum cardiac markers
Initial electrolyte and coagulation Memory: MONA greets all patients
study
Portable chest x-ray ( 30 minutes)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or

presumably new LBBB dynamic T-wave
strongly suspicious for inversion strongly
injury suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

presumably new LBBB
strongly suspicious for
injury (STEMI)
Start adjunctive treatment
dynamic T-wave diagnostic changes
inversion strongly in ST-segment or T-
suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 ADJUNCTIVE TREATMENT
(Do not delay reperfusion)

1. Beta-adrenergic receptor blocker

2. Clopidogrel

3. Heparin (UFH or LMWH)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment

Time from onset of

symptoms
12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment

Time from onset of

symptoms
12 hours
- Reperfusion strategy: PCI (90 min)
or fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Adjunctive treatment

Heparin (UFH/LMWH)

Glycoprotein IIb/IIIa receptor inhibitors

-Adrenoreceptor blockers

Clopidogrel

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment

Time from onset of 12 hrs Admit to monitored bed

symptoms Assess risk status
12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
min) or fibrinolysis (30 min) strategy
- ACE-I/ARB within 24 h of - Continue ASA, heparin,
symptom onset) ACE-I, statin
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 VERY HIGH-RISK PATIENT

1. Refractory chest pain

2. Recurrent/persistent ST deviation

3. Ventricular tachycardia

4. Hemodynamic instability

5. Sign of pump failure

6. Shock within 48 hours

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment Develops high or

Time from onset of
symptoms
12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
intermediate risk criteria
or troponin-positive
12 hrs Admit to monitored bed
Assess risk status
Monitored bed in ED
- High risk: early invasive
strategy Develops high or
- Continue ASA, heparin, intermediate risk criteria
ACE-I, statin or troponin-positive
No evidence of ischemia and MI: discharge with follow-up
 Pengobatan Pasca Perawatan
Obat-obat untuk mengontrol keluhan iskemia
harus dilanjutkan
Aspirin
Beta-blocker
ACE inhibitor

Modifikasi Faktor Risiko

Berhenti merokok
Pertahankan BB optimal
Aktivitas fisik sesuai dengan hasil treadmill
Diet
Rendah lemak jenuh dengan kolesterol, bila perlu
dengan target LDL < 100 mg/dL
Pengendalian hipertensi
Pengendalian ketat gula darah pada penderita DM 53
Get regular medical checkups.
Control your blood pressure.
Check your cholesterol.
Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.
Thank you for your attention
Anamnesis
Nyeri dada atau nyeri epigastrium hebat yang mengarah
pada iskemia miokard :
Seperti dihimpit benda berat
Terasa tercekik
Rasa ditekan, ditinju, ditikam
Rasa terbakar
Biasanya dirasakan dibelakang stenum seluruh dada
terutama kiri, dapat ke tengkuk, rahang, bahu,
punggung, lengan kiri atau kedua lengan

Terutama laki-laki > 35 tahun dan Wanita > 40 tahun

Seringkali disertai mual atau muntah, dapat pula rasa

tidak enak disertai sesak nafas, lemah, penurunan
kesadaran, dan keringat banyak 56
Pemeriksaan Fisik

Biasanya penderita tampak cemas, gelisah, pucat, dan

keringat dingin
Periksa tanda-tanda vital :
Denyut nadi cepat, reguler tetapi dapat pula bradi
atau tachycardia, irama ireguler
Tekanan darah biasanya normal bila belum terjadi
komplikasi, dapat pula terjadi hipo atau hipertensi
Bunyi jantung dapat terdengar redup
S3 dapat terdengar bila kerusakan miokard luas
Paru-paru dapat terdengar ronkhi basah dan atau
wheezing yang menandakan terjadinya bendungan
paru tergantung ada tidaknya gangguan fungsi
ventrikel kiri 57