pjk 2012 baru final dr bb

Penyakit Jantung Koroner

Dept. of Cardiology & Vascular Medicine

Dr.Soetomo Teaching Hospital, Faculty of Medicine,

Airlangga University

Surabaya.

PENDAHULUAN

Penyakit jantung koroner ( PJK ) merupakan problema kesehatan utama di dunia

Penyebab utama kematian

Prevalensi PJK 6,8 - 36,1% meningkat sesuai umur (NHANES,20052006)

Indonesia Penyebab mortalitas dan morbiditas no 1 (SKRT, Depkes,1992)

AS 1,5 juta pasien MRS per tahun

Didasari oleh proses progresif atherosklerosis mulai

anak-anak

28.7

17.8

12.6

9.1

6

5.1

0 5 10 15 20 25 30

Atherothrombosis*

Infectious disease

Cancer

Injuries

Pulmonary disease

AIDS

Atherothrombosis* is a

Leading Cause of Death Worldwide1

1. The World Health Report, 2002, WHO Geneva, 2002

Mortality (%)

* Ischemic heart disease, cerebrovascular disease, inflammatory heart disease and hypertensive heart disease

Worldwide defined as Member States by WHO Region (Africa, Americas, Eastern Mediterranean, European, South-East Asia and Western Pacific)

1. Fatty streak

2. Fibrous plaque

3. Advance (complicated) plaque

ATEROSKLEROSIS

Definisi : penyakit kronis yang ditandai dengan

penebalan dan pengerasan dinding arteri.

Monocyte LDL-C Adhesion molecule

Macrophage

Foam cell

Oxidized LDL-C

Plaque rupture

Smooth muscle cells

CRP

Faktor Risiko PJK

Faktor Risiko Modifikasi

Merokok

Hypertension

Diabetes

Dislipidemia

Obesitas

Kurang Aktivitas

Stress

Framingham Heart Study

Manifestasi Klinik dari PJK

Silent Ischemia/asymptomatic

Angina pectoris stabil (Stable Angina)

Sindroma Koroner Akut (Non-STEMI/UA and STEMI)

Prinzmetal Angina

Gagal Jantung

Sudden Death

Angina Pectoris

Nyeri dada retrosternal, menjalar ke rahang, punggung, atau lengan kiri.

Nyeri digambarkan seperti rasa panas, tertindih benda berat, diremas-remas dan

tidak dapat ditunjuk.

Angina Spesifik

Angina Tidak Spesifik

Nyeri dada kanan

Nyeri epigastrium

Distribusi nyeri pada iskemia miokard

Distribusi nyeri pada iskemia miokard Daerah nyeri yang jarang dijumpai pada

Iskemia miokard

Sisi kanan

Epigastrium

Rahang

Punggung

Diagnosa Banding Nyeri dada

1. Kelainan pada esophagus : esofagitis oleh karena

refluks

2. Kolik Bilier

3. Sindroma Kostosternal inflamasi pada tulang rawan kosta

4. Radikulitis servikal

5. Kelainan pada paru : pneumonia, emboli paru

6. Nyeri psikogenik

Asymptomatik (Silent Myocardial Ischemia)

Diketahui secara kebetulan (check up)

Tidak terdapat keluhan

EKG dapat menunjukkan depresi segment ST

Pemeriksaan lain dalam batas normal

Mekanisma diduga karena

nilai ambang nyeri meningkat,

neuropati otonomik (px DM),

meningkatnya produksi endomorfin,

derajat stenosis yang moderate,

adanya aliran kolateral

Angina Pectoris Stabil (Stable Angina)

Nyeri dada yang bersifat kronis (>6 minggu), tidak ada perubahan kualitas dan kuantitas

Faktor pencetus (4E): Exercise ( Olahraga) Emotion ( Emosi ) Eating ( Setelah makan banyak )

Exposure to cold ( Paparan dingin )

Mekanisme terjadinya iskemia

Gangguan keseimbangan antara suplai dan kebutuhan oksigen miokard karena adanya stenosis pada pembuluh darah koroner


Diagnosis

Anamnesis: spesifik dan non spesifik

Pemeriksaan fisik biasanya normal

EKG di luar serangan dalam batas normal

Pemeriksaan Penunjang ( Treadmill, Echocardiography, MSCT, Coronary

Angiography )

Duke treadmill score

Exercise time in minute : n

mm ST depression x 5 : -n

Non limiting angina x 4 : -n

Limiting angina x 8 : -n

Risk 1 year mortality

Low risk : 5 0,25 %

Intermediate : 4 to -10 1,25 %

High : -11 5,25 %


Terapi

Prinsip Menyeimbangkan suplai oksigen dengan kebutuhan

oksigen miokard

A. Penanganan faktor-faktor risiko PJK

B. Medikamentosa Gol. Nitrat

Calsium antagonis (Diltiazem)

Beta blocker (Bisoprolol)

Anti-platelet (ASA, Clopidogrel)

Statin (Simvastatin, Atorvastatin)

C. Revaskularisasi ( Intervensi Bedah CABG / Non Bedah PTCA)

Gibbons et al. ACC/AHA/ACPASIM Guidelines for the Management of Patients With Chronic Stable Angina: Executive Summary and Recommendations. Circulation. 1999; 99:2829-2848

Sindroma Koroner Akut

Definisi:

Keadaan iskemia miokard yang terjadi akut, dengan beberapa presentasi iskemia

- Angina pektoris tidak stabil (UA)

- Infark miokard tanpa elevasi segment ST

(NSTEMI)

- Infark miokard dengan elevasi segment ST

(STEMI)

Sindroma Koroner Akut

ACS is an Important Manifestation of

Atherothrombosis1

1. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.

Antithrombotic therapy

Stable angina

UA Non-

Q-wave MI

Thrombolysis

primary PCI

Q-wave MI

Minutes hours

Days weeks

STEMI UA/NSTEMI Atherothrombosis New term

Old term

Plaque

rupture/erosion

UA=unstable angina; NSTEMI=non-ST-segment elevation myocardial infarction; PCI=percutaneous coronary intervention

Pathophysiology of Unstable Angina

The primary pathophysiologic event in

Unstable Angina is a reduction in

coronary blood flow due to plaque

erosion or eruption followed by transient

platelet aggregation, coronary

thrombosis, or coronary artery spasm

Plaque Vulnerability, Rupture and Thrombosis

Acute Coronary Syndrome Handbook for Clinical Practice. ESC. 2006

Acute Coronary Syndrome

( ACS )

ST-segment

Depression

ST-segment

Elevation

Biomarkers of

Cardiac Injury (-) Biomarkers of

Cardiac Injury (+)

UA

( Unstable Angina )

NSTEMI ( Non ST-Elevation

Myocardial Infarction )

Biomarkers of

Cardiac Injury (+)

STEMI ( ST-Elevation


European Heart Journal (2007) 28,882

Presentasi Klinis UA / NSTEMI

Nyeri angina saat istirahat (>20 min)

Onset baru angina ( > 6 minggu )

Angina crescendo

Angina pasca Infark (MI)

Admission

Working

Diagnosis

ECG

Biochemistry

Risk

Stratification

Diagnosis

Treatment

C H E S T P A I N

Troponin (+) Troponin 2x (-)

High Risk Low Risk

STEMI

Invasive / Non-Invasive Reperfusion

Suspicion of Acute Coronary Syndrome ( ACS )

Normal /

Undetermined ECG

Persistent

ST-Elevation ST/T-abnormalities

Guideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14th, 2007

NSTEMI UA

Management Chest Pain

Stratifikasi Risiko

Penting untuk menetapkan penderita dalam kondisi

risiko tinggi atau risiko rendah,

sehingga menentukan

rencana pengobatan ( invasif / non invasif )

Tabel 1. Risiko kematian jangka pendek dan terjadinya

nonfatal infark miokard pada angina pektoris tidak stabil

Feature

History

Character of pain

Clinical findings

ECG findings

Cardiac markers

CABG indicates artery bypass graft; CAD, coronary artery disease;

CCS, Canadian Cardiovascular Society, ECG, electrocardiogram

MI, myocardial; MR, mitral regurgitation;

Ta T, troponin T; and TnI, tropinin I

Elevated (eg. TnT or TnI > 0.1 ng/Ml) Slightly elevated (eg, TnT

> 0.01 but < 0.1 NG/mL) Normal

Angina at rest with transient

ST-segment changes >0,05 mV

Bundle-branch block, new or

presumed new

Sustained ventricular tachycardia

T-wave intervensions >0.2 mV

Pathological Q-waves

Normal or unchanged ECG

During an episode of chest

discomfort

Pulmonary edema, most likely

related to ischemia. New or

worsering MR murmur S3 or

new/wosering rales Hypotension,

bradycardia, Age >75 years

Age > 70 years

Prolonged on going (>20 min)

rest pain

Prolonged (>20 min) rest angina,

now resolved, with moderate or

high likehood of CAD.Rest angina

(

Anderson et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation Myocardial InfarctionExecutive Summary. JACC Vol. 50, No. 7, 2007

Clinical suspicion of ACS

Physical examination

ECG monitoring, blood samples

Undetermined

diagnosis

Persistent

ST-segment elevation

No persistent


ASA,

Fonda/Enox/UHF,ticagrelor,prasugrel

clopidogrel*,beta-blockers, nitrates

Thrombolysis

PCI

High risk Low risk

GPIIb/IIIa,

coronary angiography

Stress test,


1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840. 2. ESC 2011 UA/NSTEMI Guidelines

Second troponin measurement

Positive Twice negative

ASA

PCI, CABG or medical management

depending upon clinical and angiographic features

*Omit clopidogrel if

the patient is likely

to go to CABG

within 5 days

Management Strategy in UA/NSTEMI

Oxygen, bed rest, ECG

monitoring

Nitroglycerin

Antiplatelet Therapy

Anticoagulant Therapy

Beta Blockers

ACE Inhibitors

Statins

Medical Management of UA / NSTEMI

Acute Therapy Maintenance Therapy

Antiplatelet Therapy

Beta Blockers

Statins

ACE Inhibitors

Calcium Channel Blockers

Menurut WHO, bila terdapat 2 dari

Kriteria diagnostik

1. Nyeri dada yang spesifik

2. Perubahan EKG

Gelombang Q patologis, dg

Elevasi segmen ST

3. Peningkatan kadar enzim jantung

Infark Miokard Akut (STEMI)

Cemas dan gelisah

Perfusi dingin

Bradikardia/ Takikardia

Aritmia

Pulse pressure turun

Tekanan diastolik meningkat

Syok Kardiogenik

Pemeriksaan fisik


S1 melemah

Sering timbul S3 / S4

Bising sistolik blowing di apeks (ruptur katup mitral)

Bising pansistolik parasternal (ruptur septum ventrikel)

Friction rub , 6 30%

Auskultasi jantung


Kadar enzim jantung

1. CK isoenzim (CK-MB)

Meningkat dalam 3-12 jam, normal dalam 3-4 hari, puncak pada 18-36 jam

2. Cardiac troponin (cTnI, cTnT)

Meningkat dalam 3-12 jam, normal dalam 10-14 hari, puncak pada 24 jam

3. Myoglobin

Meningkat dengan cepat dalam 1-2 jam, waktu paruh dalam plasma 9 menit, kurang spesifik

4. Creatin Kinase (CK)

Meningkat dalam 4-8 jam, normal dalam 2-3 hari, kadar puncak pada 24 jam

5. Serum Glutamic Oxaloacetic Transaminase (SGOT)

Meningkat dalam 24 jam, kadar puncak dalam 2 hari, normal dalam 4 hari

6. Lactic Dehidrogenase (LDH)

Meningkat dalam 10 jam, normal dalam 10-14 hari, puncak pada 24-48 jam

Laboratorium

Prinsip a. Perbaikan aliran darah koroner

b. Mengurangi kebutuhan oksigen

Penanganan harus cepat dan tepat

Segera pasang infus life-line

Oksigen 2 lt/menit

Istirahat total

Monitor EKG 24 jam

Di ICCU

Manajemen

MONA-Co

Morphin IV

O2 4 l/m

Nitrat sublingual/ spray

Aspirin 160-320 mg per os

Clopidogrel 300-600 mg per os 75 mg/ hari

Manajemen

Anti platelet ( ASA, Clopidogrel, Prasugrel, Ticagrelor )

Anti koagulan ( Fondaparinux, Enoxaparin,UFH )

Beta blocker

ACE Inhibitor

Calcium Channel Blocker

Statin

Laxantia

Diet

Modifikasi faktor resiko

Manajemen

Time is muscle (myocardium)

Door to needle (trombolitik) < 30 menit

Door to balloon (primary PCI) < 60-90 menit

Manajemen




Undetermined

diagnosis

Persistent


No persistent


ASA,

Fonda/Enox/UHF,ticagrelor,prasugrel

clopidogrel*,beta-blockers, nitrates

Thrombolysis

PCI

High risk Low risk

GPIIb/IIIa,


Stress test,


1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840. 2. ESC 2011 UA/NSTEMI Guidelines



ASA





to go to CABG

within 5 days

Management Strategy in UA/NSTEMI

Revaskularisasi

Farmakologik/ Trombolitik Streptokinase 1.5 juta IU dalam 100 cc

NaCl 0.9% atau D5%, dalam 1 jam

tPA

TNK-tPA

Selama tindakan dilakukan pemantauan irama jantung, tekanan darah, kesadaran, &

keluhan

Mekanik/ Angioplasty/ PTCA

?

Reperfusion Strategies for STEMI

Widely Available Quickly Administered Less Effective Bleeding Risk Re-occlusion Risk Less costly

Limited Availability Treatment Delay More Effective Bleeding Risk Very Low Better Outcome Higher cost

PCI Pharmacology

Gagal jantung akut

Edema paru akut

Aritmia

Ruptur dinding ventrikel, septum (IVS)

Regurgitasi mitral akut

Syok kardiogenik

Sudden death

Komplikasi IMA

Pencegahan Sekunder

Perubahan Gaya Hidup

Berhenti merokok

Diet rendah garam, lemak jenuh, & tinggi serat

Olahraga 3-4 x seminggu, @30-60 menit

Menurunkan BB

Farmakoterapi

ASA

Penyekat beta

ACE inhibitor

Statins

Variant Angina (prinzmetal`s angina)

Ditemukan th 1959

Nyeri selalu saat istirahat

Terjadi karena spasme koroner, bersifat lokal

Bukan karena peningkatan kebutuhan oksigen oleh miokard

Manifestasi klinis

1. Sering pada usia muda

2. Tanpa faktor resiko

3. Nyeri sering pada tengah malam 8 pagi

4. Nyeri sangat hebat

EKG

1. Depresi segmen ST/ elevasi segmen ST

2. Bisa disertai aritmia jantung

Tidak bermanfaat

Nitrat

Calsium antagonist

Alfa blocker

Beta blocker

Antitrombotik

Respon baik dengan

Variant Angina (prinzmetal`s

angina)

75

Recommendations for the use of

Thienopyridines

A loading dose of thienopyridine is recommended for

STEMI patients for whom PCI is planned. Regimens

should be one of the following:

MODIFIED

Recommendation

I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III

Clopidogrel at least 300 mg to 600mg should be given as early as possible before or at the

time of primary or non-primary PCI.

76

Recommendations for the use of

Thienopyridines

Prasugrel 60 mg should be given as

soon as possible for primary PCI.

MODIFIED

Recommendation


General Guidelines to Differentiate Chest

Paint of Myocardial Infarction, Unstable and

Chronic Stable Angina

Chest Pains Myocardial infarction Unstable Angina Chronic Stable Angina

Severity Very severe Moderate severe Mild

Duration > 30 minutes 15 - 30 minutes < 15 minutes

Frequency Persistent pain Increasing frequency Stable, less frequent

Timing At rest At rest or with exertion With exertion

Relief With No Usually no yes

Nitroglycerine

Other anxiety, diaphoresis, Less than MI Less than MI

symptoms dyspnea, nausea

Hyperacute phase of extensive

anterior myocardial infarction

HEART ATTACK !!!!

Management of STEMI

Diagnosa

NSTEMI/UA

High risk Low risk

GPIIb/IIIa,


Stress test,






MRS dengan tambahan terapi:

Nitrogliserin

Beta bloker

Heparin (UFH/LMWH)

GpIIb/IIIa inhibitor

Tatalaksana

ACS

Case: STEMI

Clinical presentation

Prolonged Chest pain > 2 hours

ECG: ST-elevation II,III,AVF

Arrived at PCI center

Cor-Angiography

PROBLEMS in Reperfusion Therapy

for STEMI

Reperfusion Therapy restricted by

Contraindication to Thrombolytic

Late presentation

Limited access for Reperfusion Therapy or PCI not available

Lack of economic resources

Proportion of STEMI patients Not

Receiving Reperfusion Therapy

NRMI 2-3 (376 753 pts) : 31 %

GRACE registry : 30 %

Other Clinical Trials : 21-46 %

STEMI Management: ESC Guidelines 2008

Recommendations for Anticoagulation

ESC Guideline 2007

Anticoagulation is recommended for all patients in addition to antiplatelet therapi

( I-A )

Anticoagulation should be selected according to the risk of both ischaemic and bleeding events ( I-B )

Several anticoagulants are available namely UFH, LMWH, Fondaparinux, Bivalirudin.

The choice depends on the initial strategy

( urgent invasive, early invasive, or conservative strategies )

( I-B )

In an urgent invasive strategy, UFH ( I-C ), or Enoxaparin ( IIa-B ) or Bivalirudin ( I-B ) should be immediately

started

Anticoagulants as Ancillary Therapy

Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days.

New Recommendation

Regimens other than UFH are

recommended if therapy is given for more than 48 hours because of risk of heparin-induced thrombocytopenia.

New Recommendation

Regimens with established efficacy include:

UFH, enoxaparin, fondaparinux (see full text Update for dosing recommendations)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


2007 ACC/AHA Guidelines- Management of STEMI

Anticoagulants as Ancillary Therapy

For patients undergoing PCI after having received an anticoagulant, the following dosing recommendations should be followed:

For prior treatment with:

1. UFH - administer additional boluses of UFH as needed to support the procedure

2. Enoxaparin if last dose was administered within prior 8 hours, no additional enoxaparin should be given; if last dose was 8 to 12 hours earlier an IV dose of 0.3 mg per kg should be given

3. Fondaparinux administer additional IV treatment with an anticoagulant possessing anti-IIa activity

New recommendations

Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered

New recommendation





2007 ACC/AHA Guidelines- Management of STEMI


Non -ST Elevation ST- Elevation

NSTEMI

Myocardial Infarction

NQMI Unstable Angina QwMI

European Heart Journal doi :10.1093.14 June 2007

Risk Stratification ACS

Feature High Risk

At least of the following features must be present :

History Accelerating tempo of ischemic symptoms in preceding

48 hours

Characteristic of pain Prolonged ongoing (> 20 minutes) rest pain

Clinical Findings

Pulmonary edema, most likely due to ischaemia

New or worsening MR murmur

S3 or new / worsening rales

Hypotension, bradycardia, tachycardia

Age > 75 years

ECG

Angina at rest with transient ST-segment changes > 0.05

mV

Bundle-branch block, new or presume new

Sustained ventricular tachycardia

Cardiac Markers Elevated (eg. TnT or TnI >0.1 ng/mL)

Feature

Intermediate Risk

At least No high-risk feature but must have 1 of the

following :

History Prior MI, peripheral or cerebrovascular diseases, or

CABG, prior Aspirin use.

Characteristic of pain

Prolonged ( > 20 min) rest angina, now resolved, with

moderate or high likehood of CAD.

Rest angina ( < 20 min) or relieved with rest or sub-

lingual NTG.

Clinical Findings Age > 70 years

ECG T-wave inversions > 0.2 mV

Pathological Q-waves

Cardiac Markers Slightly elevated (eg. TnT > 0.01 but < 0.1 ng / mL

Feature

Low Risk

At least No high- or intermediate-risk feature but may

have any of the following features :

History

Characteristic of pain

New-onset or progressive CCS Class-III or IV angina the

past 2 weeks without prolonged ( > 20 min) rest pain but

with moderate or high likelihood of CAD.

Clinical Findings

ECG Normal or unchanged ECG during an episode of chest

discomfort.

Cardiac Markers Normal




Undetermined

diagnosis

Persistent


No persistent


ASA, Fonda/Enox/UHF

clopidogrel*, beta-blockers, nitrates Thrombolysis

PCI

High risk Low risk

GPIIb/IIIa,


Stress test,


1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.



ASA





to go to CABG

within 5 days

ESC : Management Strategy in ACS Patients

Gradasi Angina Pektoris ( Canadian Cardiovascular Society )

1. Aktivitas sehari-hari tidak menimbulkan

serangan angina.

2. Aktivitas sehari-hari terganggu sedikit.

3. Aktivitas sehari-hari sangat terganggu.

4. Angina timbul dalam setiap aktivitas fisik.

Angina dapat timbul pada saat istirahat.

REPERFUSION CLASS I

1. STEMI patients presenting to a hospital with PCI

capability should be treated with primary PCI within 90

minutes of first medical contact as a system goal

(Level of Evidence : A)

2. STEMI patients presenting to a hospital without PCI

capability and who cannot be transferred to a PCI

center and undergo PCI within 90 minutes of first

medical contact, should be treated with fibrinolytic

therapy within 30 minutes of hospital presentation as a

system goal unless fibrinolytic therapy is

contraindicated

(Level of Evidence : B)


1. Analgetik Morfin 2,0-2,5 mg iv, titrasi

2. Nitrat a. Sublingual dilanjutkan peroral/ intravena

b. Efek venodilatasi

Menurunkan venous return

Menurunkan preload

c. Efek dilatasi koroner

3. Aspirin Menurunkan angka kematian

Obat-obat yang diberikan

INFARK MIOKARD AKUT

Terapi trombolitik (bila onset < 12 jam)

a. Streptokinase

b. r-TPA

(recombinant tissue plasminogen activator complex)

c. Urokinase

d. ASPAC

(Anisolated plasminogen streptokinase activator)

e. Scu-PA

(single chain urokinase-type plasminogen activator)

INFARK MIOKARD AKUT

ACS is an Important Manifestation of

Atherothrombosis1

1. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.

Antithrombotic therapy

Stable angina

UA Non-

Q-wave MI

Thrombolysis

primary PCI

Q-wave MI

Minutes hours

Days weeks

STEMI UA/NSTEMI Atherothrombosis New term

Old term

Plaque

rupture

UA=unstable angina; NSTEMI=non-ST-segment elevation myocardial infarction; PCI=percutaneous coronary intervention


( ACS )

ST-segment

Depression

ST-segment

Elevation

Biomarkers of

Cardiac Injury (-) Biomarkers of

Cardiac Injury (+)

UA

( Unstable Angina )

NSTEMI ( Non ST-Elevation


Biomarkers of

Cardiac Injury (+)

STEMI ( ST-Elevation






Undetermined

diagnosis

Persistent


No persistent


ASA, Fonda/Enox/UHF

clopidogrel*, beta-blockers, nitrates Thrombolysis

PCI

High risk Low risk

GPIIb/IIIa,


Stress test,


1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.



ASA





to go to CABG

within 5 days

ESC : Management Strategy in ACS Patients

Variant Angina (prinzmetal`s angina)

Ditemukan th 1959

Nyeri selalu saat istirahat

Terjadi karena spasme koroner, bersifat lokal

Bukan karena peningkatan kebutuhan oksigen oleh miokard

Manifestasi klinis

1. Sering pada usia muda

2. Tanpa faktor resiko

3. Nyeri sering pada tengah malam 8 pagi

4. Nyeri sangat hebat

EKG

1. Depresi segmen ST/ elevasi segmen ST

2. Bisa disertai aritmia jantung

Tidak bermanfaat

Nitrat

Calsium antagonist

Alfa blocker

Beta blocker

Antitrombotik

Respon baik dengan

Variant Angina (prinzmetal`s

angina)

pjk 2012 baru final dr bb

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