soe medan 03 15 - acute coronary syndrome

Acute Coronary Syndrome

Sindroma Koroner Akut

2

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.

3

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

Uncontrollable •Sex

•Hereditary

•Race

•Age

Controllable

•High blood pressure

•High blood cholesterol

•Smoking

•Physical activity

•Obesity

•Diabetes

•Stress and anger

Risk Factors

CAD

Atherosclerosis

Risk Factors ( , BP, DM, Insulin Resistance, Platelets,

Fibrinogen, etc)

The cardiovascular continuum of events

DYSLIPIDEMIA

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

Myocardial Ischemia

plaque

Ischemia = oxygen supply

and demand imbalance

CAD

Atherosclerosis


Fibrinogen, etc)


DYSLIPIDEMIA


Myocardial Ischemia

Coronary Thrombosis

CAD

Atherosclerosis


Fibrinogen, etc)


DYSLIPIDEMIA


Myocardial Ischemia

Coronary Thrombosis

ACS

Stable angina Plaque rupture Coronary thrombosis UA/NSTEMI STEMI

Penyempitan Pembuluh darah

Clinical Spectrum of Acute Coronary Syndrome

Acute Coronary Syndrome

Non-ST Segment

Elevation

ST Segment

Elevation

Unstable

Angina Pectoris Non-Q-wave Q-wave

Acute Myocardial Infarction

STEMI

NSTEMI

Unstable Angina STEMI

NSTEMI

Non occlusive

thrombus

Non specific

ECG

Normal

cardiac

enzymes

Occluding thrombus

sufficient to cause

tissue damage & mild

myocardial necrosis

ST depression +/-

T wave inversion on

ECG

Elevated cardiac

enzymes

Complete thrombus

occlusion

ST elevations on

ECG or new LBBB

Elevated cardiac

enzymes

More severe

symptoms

Diagnosis

Anamnesis

Pemeriksaan Fisik

Pemeriksaan Penunjang :

1. Laboratorium

2. Elektrokardiografi

3. Thoraks Foto

13

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

tingling sensation in left wrist, hand and fingers

14

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

15

Pain Patterns with Myocardial Ischemia

16

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

17

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 : VPB’s within first 4 hours

18

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

19

JUGULAR VENOUS PULSE

JVP usually normal

RV infarction : marked jug. venous distension

CAROTID PULSE

Small pulse reduced stroke volume

Pulse alternans : severe LV dysfunction

20

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

21

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

ST-segment elevation

25

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

ST-segment depression

T-wave inversion

28

Current-of-injury patterns with acute

ischemia

ELEKTROKARDIOGRAM

29

• 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)

30

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

A myoglobin C CK-MB B troponin D troponin in UA

31

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

Diagnosis Banding

Manajemen

ACS

Coronary Thrombosis

Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors ( , BP, DM,

Insulin Resistance, Platelets, Fibrinogen, etc)



DYSLIPIDEMIA

Arrhythmia and Loss of Muscle

Remodeling

Ventricular Dilatation

Congestive Heart Failure

End-stage Heart Disease

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. CHEST DISCOMFORT

2. LOCATION

3. RADIATION

4. UNLIKELINESS

1. NO CHEST DISCOMFORT

2. LOCATION

3. INDIGESTION

4. UNEXPLAINED WEAKNESS

5. DIAPORESIS

6. SHORTNESS OF BREATH

Chest discomfort suggestive of ischemia

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

Immediate ED assessment and immediate ED general treatment

Acute coronary syndrome algorithm


Immediate ED assessment ( 10 min)

• Vital sign

• Oxygen saturation

• Obtain IV access

• Obtain ECG 12 lead

• Brief history and physical exam

• Check contraindication for fibrinolytic

• Initial serum cardiac markers

• Initial electrolyte and coagulation

study

• Portable chest x-ray ( 30 minutes)

Immediate ED general treatment

• O2 at 4 L/min (maintain O2 sat 90%)

• Aspirin 160-325 mg

• Nitroglycerin SL, spray, or IV

• Morphine IV 2-4 mg repeated every

5-10 minutes (if pain not relieved

with nitroglycerine)

Memory: “MONA” greets all patients


Review initial 12 lead ECG





ST elevation or new or presumably new LBBB strongly suspicious for

injury






ST-depression or dynamic T-wave

inversion strongly suspicious for injury


injury








(UA/NSTEMI)


injury (STEMI)





Normal or non-diagnostic changes in ST-segment or T-

waves (intermediate/ low-risk UA)


Start adjunctive treatment

Normal or non-diagnostic changes in ST-segment or T-

waves (intermediate/ low-risk UA)



(UA/NSTEMI)


injury (STEMI)






1. Beta-adrenergic receptor blocker

2. Clopidogrel

3. Heparin (UFH or LMWH)

ADJUNCTIVE TREATMENT

(Do not delay reperfusion)



Normal or non-diagnostic changes in

ST-segment or T-waves

ST-depression or dynamic T-wave inversion strongly

suspicious for injury


injury





Time from onset of symptoms

- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min)

- ACE-I/ARB - Statin

12 hours




- ACE-I/ARB within 24 hours of onset - Statin

12 hours







injury







• Heparin (UFH/LMWH)

• Glycoprotein IIb/IIIa receptor inhibitors

• -Adrenoreceptor blockers

• Clopidogrel

Adjunctive treatment




- ACE-I/ARB within 24 h of symptom onset)

- Statin

12 hours







injury






12 hrs Admit to monitored bed Assess risk status

- High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin

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





- ACE-I/ARB within 24 h of symptom onset)

- Statin

12 hours

12 hrs







injury





Admit to monitored bed Assess risk status

- High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin

Develops high or intermediate risk criteria

or troponin-positive

Monitored bed in ED

Develops high or intermediate risk criteria

or troponin-positive

No evidence of ischemia and MI: discharge with follow-up

53

Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan

Aspirin

Beta-blocker

ACE inhibitor

Pengobatan Pasca Perawatan

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

Modifikasi Faktor Risiko

•Get regular medical checkups.

•Control your blood pressure.

•Check your cholesterol.

•Don’t smoke.

•Exercise regularly.

•Maintain a healthy weight.

•Eat a heart-healthy diet.

•Manage stress.

Thank you for your attention

56

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

57

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

soe medan 03 15 - acute coronary syndrome

Documents