Angina Pectoris :Focus on ACS

Adi Purnawarman MD,FIAdi Purnawarman MD,FIHAHADepartment of Cardiology and Vascular Medicine, Faculty of

Medicine, Unsyiah / Zainoel Abidin Hospital Banda Aceh

Pendahuluan• 70 Juta orang US(1 dari 4)

Penyakit Kardiovaskuler

• Penyebab terbesar penyebab kematian (38%)

• 1,2 Juta Kasus baru & Serangan berulang/Thn

• 2020 25 Juta † krn PJ & ± ½ akibat PJK

4,9 juta Penyakit jantung

Kongestif

AHA. Heart disease and stroke statistics; ”2012 update. Dallas, TX

Indonesia ?

Kusmana D and Team : Jakarta Cardiovasculer Study; The city that promotes Indonesia Healthy Heart , Report I; 2006 *

Kusmana D : Pengaruh tidak/stop merokok disertai olah raga teratur dan/atau pengaruh kerja fisik terhadap daya survival penduduk di Jakarta ; penelitian kohort selama 13 tahun. Disertasi, program studi Ilmu kedokteran S3 FK UI,

Jakarta, 2002**

Profil Kesehatan NAD Berdasarkan Riset Kesehatan Dasar 2007

7,2%

1,1%0,8% 11,6%1,7%

16,6%12,8%

53,3%

48,2%

0,5%

14,1% 18,5%

Riset Kesehatan Dasar Prov NAD, 2007

Penyakit Kardiovaskular di Aceh

Delima, Mihardja L, Siswoyo H. Prevalensi dan faktor determinan penyakit jantung di Indonesia. Bul Penelit Kesehat 2009; 37 (3): 142-59.

Sindroma Koroner Akut (SKA)

• Sekumpulan gejala klinis yang biasanya disebabkan oleh trombosis / aterosklerotik pada pembuluh koroner sehingga menyebabkan sumbatan sebagian atau seluruh lumen pembuluh tersebut

• Subset-nya :– Angina Tidak Stabil– Non STEMI– Infark STEMI

Cumulative 6-month mortality from ischemic heart disease

0 1 2 3 4 5 6

5

10

0

15

20

25

Months after hospital admission

Dea

ths

/ 100

pts

/ m

onth

Acute MIUnstable anginaStable angina

Duke Cardiovascular Database

N = 21,761; 1985-1992Diagnosis on adm to hosp

Tanda-Tanda Serangan Jantung Akut

Sifat nyeri Rasa sakit, seperti ditekan, rasa terbakar, ditindih benda berat, seperti ditusuk, rasa diperas dan dipelintir

Lokalisasi Dada kiri (Substernal prekordial) dan ulu hati ( epigastrium)

Penjalaran ke

Leher, lengan kiri, rahang (mandibula), gigi, punggung

Faktor pencetus

Exercise, stres emosi, udara dingin dan sesudah makan

Gejala penyerta

Mual, muntah, sulit bernafas, keringat dingin dan lemas. Nyeri membaik atau hilang dengan istirahat

Angina klasik :

Tanda-tanda Serangan jantung

Angina Equivalent :

• Tidak ada nyeri / rasa tidak

enak di dada yang khas, • namun pasien menunjukkan

gejala gagal jantung

mendadak (sesak napas), • atau aritmia ventrikular

(palpitasi, presinkop, sinkop)

Dibelakang tulang dada

Dibelakang tulang dada menjalar ke

leher

Dari dada menjalar ke bahu dan lengan

Dari dada menjalar ke rahang

Didada bawah di ulu hati (sering ditafsirkan

sebagai penyakit maag)Didareah punnggung

di antara kedua belikat

Differential Diagnosis Chest Pain

Cardiac• ACS : Infarct,angina• MVP• Aortic Stenosis • Hypertrophic cardio- myopathy• Pericarditis

Lungs • Lung Emboli• Pnemonia• Pneumothorax• Pleuritis

Gastrointestinal•Reflux esofagus•Ruptur esofagus

•Gall bladder disease•Peptic Ulcer•Pancreatitis

Vascular•Aortic dissection/aneurysma

Others•Musculoskeletal

•Herpes zoster

GenetikObesitas

Diabetes

Hemosisteinemia

Hiperkoagubilitas

Aterosklerosis

Gaya Hidup (merokok dll)

Hiperlipidemia

Hipertensi

Infeksi?Umur

Jenis Kelamin

Manifestasi Aterotrombosis

Faktor Resiko untuk PJK

Pengenalan dini, Kenali Faktor Resiko !!!

Sequence of Events in IschemicSequence of Events in IschemicHeart DiseaseHeart Disease

Risk Factor

Endothelial dysfunction

CAD

Ischemia

• Angina• Silent

MI

• Arrythmias• Lost of muscle

Remodeling

Progresif dilatation

Heart FailureDeath

Foamcells

Fattystreaks

Intermediatelesion

Atheroma Fibrousplaque

Complicatedlesion rupture

From First Decade From 3rd decade From 3rd decade From 4th decade From 4th decade

Atherosclerosis Timeline

Growth mainly by lipid accumulation Smooth muscle and

collagen

Thrombosis hematoma

Endothelial Dysfunction

ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007

Prognosis with Troponin

1,01,7

3,4 3,7

6,0

7,5

0

1

2

3

4

5

6

7

8

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9,0

Cardiac troponin I (ng/ml)

Mor

talit

y at

42

Day

s

831 174 148 134 50 67

%%

%%

%

%

ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007

ACS dengan ischemia atau terlihat resiko tinggi

atau direncanakan untuk PCI

Aspirin†

+ IV heparin/SC LMWH‡

+IV GP IIb/IIIa antagonist

Diduga ACS

Aspirin†

Didiagnosa ACS

Aspirin†

+ SC LMWH

or IV heparin

ACC/AHA 2002 Guidelines Update UA & NSTEMI

+ Clopidogrel + Clopidogrel*During hospital care†Clopidogrel should be administered to hospitalized patients who are unable to take ASA because of hypersensitivity or major GI intolerance‡Class IIa: enoxaparin preferred over unfractionated heparin, unless CABG is planned within 24 hours

Rekomendasi Class I

1. Braunwald E et al. American College of Cardiology (ACC) and the American Heart Association (AHA) Guidelines, USA: ACC/AHA; 2002.

2011-2012

2012

Current Medical Management of Unstable

Angina & NSTEMI

• Morphin, O2, Bed Rest, ECG,Monitoring

• Nitroglycerin• Antiplatelet Therapy• Beta Blockers• Ace-Inhibitor/ARB• Anticoagulant Therapy

• Antiplatelet Therapy• Beta Blockers• Calcium Chanel Blockers• Lipid Lowering Agent• Ace-Inhibitors/ARB

Acute Therapy Maintenace Therapy

Definition of Myocardial Infarction

• Third universal definition of myocardial infarction (ESC 2012)– Rise/fall of cardiac biomarker (specifically

troponin) with at least one of:• Symptoms of ischemia• New or presumed new ST-T change or LBBB in ECG• Development of Q pathological waves in ECG• Imaging evidence of new regional wall motion

abnormality• Intracoronary thrombus by angiography or autopsy

– Cardiac death with symptoms of ischemia with new ECG changes BUT death occuring before cardiac value are released

Definition of STEMI

• Third universal definition of myocardial infarction (ESC 2012)– New ST elevation at J-point in at least two

contiguous leads with the cut-points > 0.1mV

• Except V2-V3 (male, >40 years old) >0.2mV

• Except V2-V3 (male, <40 years old) >0.25mV

• Except V2-V3 (female) 0.15mV

• Except V7-V9 & V3R-V4R 0.05mV

ST Elevation

Evolution of ST Elevation

Management of Patients with ST Elevation

28

ST elevation

12 h

AspirinBeta-blocker

Eligible forfibrinolytic therapy

> 12 h

Fibrinolytic therapycontraindicated

Not a candidate For reperfusion

therapy

Persistent symptoms ?

Fibrinolytic therapyPrimary

PTCA or CABGOther medical therapy:

ACE inhibitors? Nitrates

Anticoagulants

ConsiderReperfusion

Therapy

No Yes

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

29

Options for Transport of Patients With Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if

capable and EMS-to-needle within 30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage Plan

Inter-HospitalTransfer

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

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

8 min.

TROMBOLITIKTROMBOLITIK

Indikasi, Kontra Indikasi,Indikasi, Kontra Indikasi, ProsedurProsedur

Kontra Indikasi Trombolitik (absolut)

• Riw Stroke hemoragik (waktu tak terbatas)

• Riw stroke lain / cerebrovaskular event dalam 6 bulan

• Keganasan intrakranial atau kerusakan saraf pusat

• Trauma kepala dalam 3 minggu terakhir

• Perdarahan internal aktif (tidak termasuk mens)

• Diketahui adanya gangguan pembekuan darah

• curiga diseksi aorta

• Hipertensi berat 180/110 mmHg, atau kronis & uncontrolled

• Dalam antikoagulan INR > 2 - 3

• Trauma kepala, CPR > 10 mnt, operasi besar ( dalam 3 minggu terakhir )

• TIA (dalam 6 bulan terakhir)

• Riw pemberian Streptokinase antara 5 hari - 2 tahun

• Kehamilan atau 1 mgg post partum

• Ulkus peptikum aktif

• Infektif Endokarditis

• Penyakit hati stadium lanjut

Kontra Indikasi Trombolitik (relatif)

Komplikasi / Efek samping Komplikasi / Efek samping TrombolitikTrombolitik

• Perdarahan ringan – berat( hematom ringan s/d stroke hemoragik )

• Aritmia ringan – berat( Ekstra sistol jarang s/d VT – VF )

Harus dijelaskan pada pasien & keluarga !!

Persiapan Thrombolitik

1. Penjelasan terinci : tujuan , manfaat & kemungkinan efek samping obat

2. Monitor ECG3. Defibrilator4. Obat-obatan

emergensi / resusitasi

5. Syringe Pump 100 ml 1,5 juta UI streptokinase (1 amp) dlm 100 ml Nacl 0,9% atau D5%

21

4

3

5

Primary PCI

ACS risk criteria

Low Risk ACS

No intermediate or high risk factors

<10 minutes rest pain

Non-diagnositic ECG

Non-elevated cardiac markers

Age < 70 years

Intermediate Risk ACS

Moderate to high likelihood of CAD

>10 minutes rest pain, now resolved

T-wave inversion > 2mm

Slightly elevated cardiac markers

High Risk ACS

Elevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress

testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery

Low risk

High risk

Conservative Conservative therapytherapy

Invasive Invasive therapytherapy

Chest Pain Chest Pain centercenter

Intermediate risk

Nurses Mini Course

39

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied

Summary ACS includes UA, NSTEMI & STEMI

Management guideline focus Immediate assessment/intervention (MONACO+BAH) Risk stratification (UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMI

Aggressive attention to secondary prevention initiatives for ACS patients

Beta blocker, ASA, ACE-I, Statin

Terimeng Gaseh Beh.....