Acute Coronary Syndrome
Practical Aspect
Outline
CASE
INTRO DIAGNOSTIC THEURAPETIC
DISCUSSION
INTRO
Faktor Resiko PJK:
- Hipertensi
- Diabetes Melitus
- Dislipidemia Injury endotelium
- Merokok (Hipotesis response-to-injury)
- dll
Disfungsi endotil
ATEROSKLEROSIS
PJK
Different Stage of Atherosclerosis Development
Figure 1
Diagnostic algorithm
and triage in acute
coronary syndrome.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
ANGINA PADA ACS
DIAGNOSTIC
SINDROMA KORONER AKUT/
ACUTE CORONARY SYNDROME
Spektrum sindroma klinis yg mencakup angina tak stabil hingga non ST
elevasi MI dan ST elevasi MI
Sindroma Koroner Akut
Tanpa elevasi ST Dengan Elevasi ST
UAP / (Non STEMI) (STEMI)
SKA disertai elevasi SKA tanpa elevasi
segment ST persisten segmen ST
Troponin ↑↑ Troponin dapat ↑ atau tidak
Spektrum SKA
Presentasi Nyeri Dada Penilaian Cepat Pengobatan Cepat
klinis UGD (<10 mnt) UGD
• Tanda Vital & Saturasi • Oksigen 4 L/min,
target SaO2 > 95%
Diagnosa Kerja Sindroma • EKG 12 lead monitor
koroner Akut • Aspirin 160 to 325 mg
• Anamnesa & PF terarah
• Nitrat SL IV
EKG 12 lead
• Kontra indikasi FIBRINOLITIK
• Morfin, bila nitrat tidak
• Ambil darah : berhasil mengatasi
• petanda enzim jantung,
• elektrolit
• studi koagulasi
Biokimia
• Rontgent thoraks (<30 min)
Diagnosa
Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054
Non STE-ACS
“UAP dd NSTEMI”
Strategi Tatalaksana ACS nstemi/uap
1. Pengobatan awal dan evaluasi di IGD (loading)
2. Stratifikasi RESIKO
3. Strategi Invasif
4. Modalitas revaskularisasi
5. Perawatan saat pulang dan pengobatan pasca perawatan di RS
Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054
Figure 6
Antithrombotic
treatments in non-ST-
segment elevation acute
coronary syndrome
patients: pharmacological
targets. Drugs with oral
administration are shown
in black letters and drugs
with preferred parenteral
administration in red.
Abciximab (in brackets) is
not supplied anymore.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Figure 5
Determinants of
antithrombotic
treatment in
coronary artery
disease.
Intrinsic (in blue: patient’s
characteristics, clinical presentation
& comorbidities) and extrinsic (in
yellow: co-medication & procedural
aspects) variables influencing the
©ESC
choice, dosing, and duration of
antithrombotic treatment.
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Figure 13 (1) Central illustration. Management strategy
for non-ST-segment elevation acute coronary syndrome
patients.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Figure 13 (3) Central illustration. Management strategy
for non-ST-segment elevation acute coronary syndrome
patients.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Figure 13 (4) Central illustration. Management strategy
for non-ST-segment elevation acute coronary syndrome
patients.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
STEMI
KHAS STEMI
RECIPROCAL
!!
THEURAPETIC
Obat standar ACS (1)
Antiplatet (kombinasi)
• Aspirin loading 160 mg, lanjut 1x80 mg
• Clopidogrel 300 mg, lanjut 1x75 mg jika PCI, loading 300 mg lagi
Antikoagulan (pilih salah satu)
• Enoxaparin loading 1x0.3cc IV, lanjut 2x0.6cc SC
• kecuali usia >75 dan tanpa PCI, tidak perlu loading
• Jika GFR 15 – 30 turunkan jadi 1x sehari, jika GFR < 15 ganti UFH / Heparin
• UFH (Heparin) bolus 70U/kg IV, lanjut drip 12U/kg/jam selama 24-48 jam
• Target APTT 50—70s atau 1.5-2x baseline
• Monitor APTT pada 3,6,12,24 jam
• Fondaparinux 1x2,5 mg SC
Obat standar ACS (2)
Statin Nitrat
• Simvastatin 1x40 mg / Atorvastatin 1x • ISDN 5 mg SL / drip atau nitrokaf / NTG
40 mg
Beta blocker PPI & Laxative
• Lansoprazole 1x 30 mg IV
• Bisoprolol 1x1.25 – 10 mg / Carvedilol
2x3.125 mg – 25 mg • Laxadyn 3x15 ml
ACE/ARB Anti nyeri / sedative
• Captopril 3x6.25 – 25 mg / Ramipril • Morphin 2mg IV kalau perlu
1x2.5 – 10 mg / Valsartan 2x40 -160 mg • Diazepam 5mg kalau perlu
/ Candesartan 1x4-32 mg
Fibrinolitik
Streptokinase 1.5 juta unit dalam 1 jam
• 1 vial (10 cc) diencerkan dalam aquabides 10 cc (dibagi 2 @ 5cc)
• 5 cc + D5% 45 cc 50 cc dalam 30 menit (kec 100cc/jam)
• 5 cc + D5% 45 cc 50 cc dalam 30 menit (kec 100cc/jam)
TRICKY PART
KLINIS MERUPAKAN HAL UTAMA ANAMNESIS
Tidak semua
EKG normal tidak Tidak semua ST
peningkatan Cardiac
mengekslusi ACS elevasi adalah STEMI
Marker adalah ACS
Pada onset awal,
Klinis tidak terlalu
cardiac marker BISA
jelas observasi,
normal Serial jika
EKG serial !!
ada kemungkinan ACS
Penyebab lain peningkatan troponin selain SKA
NON KARDIAK PENYEBAB KARDIAK
Emboli paru • Kontusio
Hipertensi pulmonal • Operasi kardiak
Gagal ginjal • Kardioversi
Stroke
• Biopsi endomyocardial
Penyakit infiltratif
Obat kardiotoksik • Gagal jantung
Penyakit kritis • Diseksi aorta
Sepsis • Kardiomiopati hipertrofi
Luka bakar • Takiaritmia
• Bradiaritmia
• Apical ballooning syndrome
• Post PCI
• Myocarditis Jaffe, AS, et al. J Am Coll
Cardiol 2006;48:1-11
DD ST ELEVASI
MIMICKING ECG
CASE DISCUSSION
Real CASE
• 70-year-old male History of :
• Chief complaint typical chest pain DOE (+), PND (-), orthopneu (-), ankle
edema(-)
Past Medical History :
Hypertension uncontrolled
Past Medication :
Not known
Social History :
smoking (+) 1 pack/day , alcohol (-)
Physical Examination
• Vital sign: General status: BW : 70 kg
Height : 170 cm
LOC : Compos mentis (E4V5M6) JVP : PR + 4 cmH2O BMI: 24.2kg/m2
BP : 160/100 mmhg Cor : S1S2 normal, regular heart sound, Basal Calorie consumption : 1.750
murmur (-) kkal
HR : 45 bpm reguler Fluid requirement : 1.312 ml
Lung : vesicular sound, rhonki --+/--+
RR : 22 x/mnt wheezing ---/---
SaO2: 98% on NC 3 lpm Abdomen : distention (-) Bowel Sound
(Normal)
Vas : 3/10
Extremities warm ++/++, edema --/--
Axillary temp : 36.8 °C
ECG at Private Hospital TAVB dd high degree AV block, LAFB, ischemia inferio anterior
ECG at Sanglah Hospital TAVB dd high degree AV block, LAFB, ischemia inferio anterior (evolusi)
Chest X-Ray Examination
AP position
Heart Cor prominent, CTR 58%
Lung Consolidation at upper zone left lung
Increased bronchovascular pattern (+)
Sharped Left and Right Sinus Costophrenicus
IMPRESSION : Cor prominent, congestive pulmonum.
ECHOCARDIOGRAPHY BEDSIDE
IVSd : 1.1 cm IMPRESSION :
LVIDd : 5.0 cm • Normal cardiac chamber dimension
LVPWd : 0.8 cm
• LVH (+) concentric
EF BP : 39 %
TAPSE : 2.1 cm • Normal left ventricle systolic function EF 39 %
RWT : 0.42 • Normal right ventricular systolic function TAPSE 2.1 cm
LVMI : 118 g/m2 • Hypokinetic at basal mid inferoseptal, basal mid apical
anterior, mid anterolateral
IVC min : 1.3 cm • Valve: seems normal
IVC max : 1.7 cm
• eRAP 8 mmHg
eRAP : 8 mmHg
LVOT VTI : 19.9 cm
LVOT diam : 1.7 cm
SV : 45 mL
CO : 3.9 Lpm
SVR : 1572
What is the initial diagnosis of this patient ?
A. STEMI
B. UAP dd NSTEMI
C. Not sure
Laboratories Results
Cardiac Marker I Lipid Profile
CKMB 26.30 <25 ng/mL Total 223 140- mg/dL
Cholesterol 199
Troponin I 71.0 28.9- ng/mL
39.2 LDL 155 < 130 mg/dL
HDL 38 40-65 mg/dL
Triglyceride 101 < 150 mg/dL
Cardiac Marker II
Blood Chemistry
CKMB 28.50 <25 ng/mL
BUN 10.60 8 – 23 mg/dL
Troponin I 189.0 28.9- ng/mL
39.2 SC 1.00 0.7-1.2 mg/dL
Can we decide the final assessment now ?
What is the initial treatment for this patient ?
A. Loading antithrombotic
B. Fibrinolytic
C. Activate cathlab to do revascularization
What is the initial treatment for bradycardia in
this patient ?
A. SA 0,5 mg, max 3 mg
B. SA 1 mg, max 3 mg
C. Dopamine drip
D. Temporary Pace Maker Implantation
ACLS AHA 2021
ECG RS Sanglah (Post SA 1 mg)
After initial therapy, what can we do to this
patient ?
A. DAPT and anticoagulant for 5 days
B. SAPT and anticoagulant for 5 days
C. Immediate invasive strategy and TPM implantation
Early PCI REPORT
L/RCA graphy
• LM : Normal
• LAD : Stenosis 80-90% at proximal to mid
Stenosis 80-90% at mid to distal
• LCx : Stenosis 70 % at osteal
Stenosis 90-95% at proximal
• RCA : Long stenosis 70-80% at proximal to distal
Conclusion : CAD 3 VD Successful early PCI with 1 DES at
mid to distal LAD. 1 DES at proximal to mid LAD
Suggestion : Elective PCI at LCx, RCA
TPM REPORT
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