Tatalaksana Awal

Sindroma Koroner Akut

(SKA )

Siska Suridanda Danny

RS Jantung Nasional Harapan Kita Jakarta
2015

siskadanny@yahoo.com

Penyakit Arteri
Koroner

STEMI

Sindroma
Koroner Akut

Angina
Stabil

NSTEMI

Unstable
Angina

Tata laksana SKA

ACS with persistent
STEMI
ST segment
elevation

PROMPT DIAGNOSIS and

REVASCULARIZATION offers
greatest benefit for myocardial
salvage in the first hours of
STEMI

OConnor RE et al. Circulation. 2010;122[suppl ]:S787S817.)

ACS without persistent

UAP/NSTEMI
ST segment
elevation

EARLY MANAGEMENT and

RISK STRATIFICATION
reduces adverse events and
improves outcome

PROFIL PASIEN
Perempuan, 62 tahun
Faktor Risiko PJK
Hipertensi > 10 thn, kontrol dan minum obat tidak rutin
Menopause
Riwayat kolesterol tinggi
Diabetes
Obesitas
Riwayat Penyakit Sekarang
Sejak + 3 hr terakhir mengeluhkan rasa berat di dada dan ulu
hati, hilang timbul, yang dianggap pasien sebagai maag yang
kambuh
Nyeri dada hebat disertai sesak nafas, mual-muntah dan
keringat dingin 4 jam sebelumnya

Algoritma pendekatan terhadap SKA

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

ANGINA
Sakit dada (sakit, nyeri, rasa tertimpa beban, rasa
terbakar) di belakang tulang dada
Dipicu oleh aktivitas atau stres emosional
menghilang dengan istirahat atau nitrat
Dapat menjalar ke punggung, bahu, rahang atau
lengan.
Disertai rasa lemah, keringat dingin, rasa cemas dan
bahkan bisa pingsan.

Presentasi Angina pada SKA

Angina berat yang timbul saat istirahat dengan durasi
lebih dari 20 menit
Angina new onset (dalam 1 bulan terakhir), dengan
derajat CCS III (angina muncul dengan aktivitas
ringan sehari-hari)
Angina progresif (dirasakan lebih berat, lebih lama,
atau dicetuskan oleh aktivitas yang lebih ringan
dibandingkan biasanya)

Braunwald, et al. JACC 2000;36:3

ELEKTROKARDIOGRAM

EKG 12 Sandapan
Dalam 10 menit !!
Membuat dan menganalisa EKG
Tentukan:
Irama
Elevasi segmen ST ?
Depresi segmen ST ?
LBBB (BARU )?
Gelombang Q ?
Non diagnostik/EKG normal
Dapat diulang dalam 3-6 jam atau
jika pasien melaporkan keluhan lagi

ELEKTROKARDIOGRAM YANG NORMAL

TIDAK MENGEKSKLUSI ADANYA SINDROMA
KORONER AKUT

ANGINA TIDAK STABIL (UAP/APTS) ADALAH

DIAGNOSIS BERDASARKAN ANAMNESIS

Contoh perlepasan penanda jantung pada pasien

NSTE-ACS
(ESC 2007)

EKG dan BioMarker

TEST
Hs Troponin T

RESULT
585 ug/L (<14 ug/L)

Rhythm ?
Segmen ST elevation ?
Segmen ST depresssion?
LBBB (new )?
Q Wave?

REMARKS
Elevated consistent with myocardial
damage

DIAGNOSIS?
TATA LAKSANA?

SINDROMA KORONER AKUT

Non ST Elevasi

ST Elevasi

TATA LAKSANA AWAL YANG HAMPIR

SAMA

Validasi diagnosis
dan Stratifikasi risiko

Terapi reperfusi
secepatnya

Gejala dan Tanda sesuai dengan SKA

Pemeriksaan awal

Tanda Vital
Akses intravena
EKG 12 lead
Riwayat penyakit terfokus
Pemeriksaan fisik terfokus
Ambil sampel darah untuk
pemeriksaan biomarker
kardiak, ditambah dengan
darah rutin, fungsi ginjal dan
elektrolit
Chest X-Ray(<30 min)
Checklist fibrinolitik

Penanganan awal

Oksigen 4 L/menit jika

saturasi <95%
Morphine iv jika nyeri dada
hebat dan tidak berkurang
dengan nitrat
Nitroglycerin / Nitrat
Sublingual, spray atau IV. Hatihati pada TDS < 90 mmHg
Aspirin 160 to 325 mg
Clopidogrel 600 mg ATAU
Ticagrelor 180 mg

NSTEACS Management strategy

Step 1. initial evaluation

Step 2. Diagnosis validation and risk

assessment
Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge

and post-discharge management
Hamm CW et al. Eur Heart J 2011;32:2999 3054

Risk Stratification is important in NSTE-ACS

Management
1

CLINICAL CONDITION

TIMI SCORE

Less accurate in predicting events but

its simplicity makes it useful and
widely accepted

GRACE SCORE

recommended as the preferred

classification to apply on admission
and at discharge in daily clinical
routine practice

Hamm W et al. European Heart Journal 2007; 28:15981660; Hamm CW et al. Eur Heart J 2011;32:2999 3054

Clinical condition
HIGH RISK
PRIMARY
Relevant rise or fall in troponin
Dynamic ST- or T-wave changes
(symptomatic or silent)
SECONDARY
Diabetes mellitus
Renal insufficiency
(eGFR <60 mL/min/1.73 m)
Reduced LV function (EF <40%)
Early post infarction angina
Recent PCI
Prior CABG
Intermediate to high GRACE risk score

Hamm CW et al. Eur Heart J 2011;32:2999 3054

VERY HIGH RISK

Refractory angina
Severe heart failure
Life-threatening ventricular
arrhythmias, or Hemodynamic
instability

TIMI SCORE
Age 65 years or older?

Risk
Score

TIMI risk score for developing at

least 1 component of the primary
end point through 14 days after
randomization.1

0-1

4.7%

8.3%

13.2%

19.9%

26.2%

6- 7

40.9%

At least 3 risk factors for CAD?

Prior coronary stenosis of 50% or more?
ST-segment deviation on ECG 0.5mm?
Use of aspirin in prior 7 days
At least 2 anginal events in prior 24 hours?
Elevated serum cardiac markers?

Hamm W et al. European Heart Journal 2007;28:15981660

GRACE SCORE
Predictor

Score

Age, years

Predictor

Score

Predictor

Systolic Blood Pressure (mmHg)

Score

Killip class

< 40

< 80

63

40 - 49

18

80 99

58

II

21

50 - 59

36

100 - 119

47

III

43

60 - 69

55

120 - 139

37

IV

64

70 - 79

73

140 - 159

26

80

91

160 - 199

11

Predictor

Score

> 200

Cardiac
arrest at
admission

43

Elevated
cardiac
markers

15

ST Segment
deviation

30

Predictor

Score

Heart Rate , beats/min

Predictor

Score

Creatinine (mol/L)

< 70

0 - 34

70-89

35 70

90-109

13

71 105

110 - 149

23

106 140

11

150 - 199

36

141 176

14

> 200

46

177 353

23

354

31

Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 e30

Risk
category
(tertile)

GRACE
Risk Score

In-hospital
death
(%)

Low

108

<1

Intermediate

109 - 140

1-3

High

> 140

>3

Initial Treatment

Initial Therapeutic Measures

Hamm CW et al. Eur Heart J 2011;32:2999 3054

Checklist of treatments when an ACS

diagnosis appears likely

Activated platelets are central to thrombus

formation in ACS
Platelets do 3 things that promote thrombus formaton
- Adhesion
- Activation
Activated platelets aggregate
- Aggregation
and assemble a critical mass

2
1

Adherent platelet become activated

Plaque rupture leads

to platelet adhesion
to the exposed
subendothelium

Vorchheimer DA, et al. Mayo Clin Proc. 2006;81:59-68; Davies MJ. Heart. 2000;83:361-366.

of activated, pro-thrombotic
platelet membrane at the site
of injury

Antiplatelet recommendation in
Updated ACS Guidelines
Aspirin should be given to all patients without
contraindications at an initial loading dose of 150300 mg,
and at a maintenance dose of 75100 mg daily long-term
regardless of treatment strategy.
A P2Y12 inhibitor should be added to aspirin as soon as
possible and maintained over 12 months, unless there are
contraindications such as excessive risk of bleeding.

Clopidogrel

Ticagrelor

1.Kolh P et al. Eur Heart J August 29 2014; DOI:10.1093/eurheart/ehu278 [Epub ahead of

print]
2.Steg PG et al. Eur Heart J 2012;33:25692619; 3.Hamm CW et al. Eur Heart J
2011;32:2999 3054. 4. Amsterdam EA et al. J Am Coll Cardiol Sept 23, 2014 Epub ahead
of print. DOI:10.1016/j.jack.2014.09.017

Prasugrel*
*Not yet approved and
available in Indonesia

Profile P2Y12 inhibitor

*Prasugrel is not yet approved and available in Indonesia

Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 3054

Metabolism P2Y12 inhibitor

(Pro drug vs active drug)
Active compound
Intermediate metabolite
Pro-drug

Ticagrelor
(Active Drug)
Prasugrel*
(Prodrug)
Clopidogrel
(Prodrug)

No in vivo
biotransformation

CYP-dependent
oxidation
CYP3A4/5
CYP2B6
CYP2C19
CYP2C9
Hydrolysis
CYP2D6
by esterase

Binding
Platelet

P2Y12
CYP-dependent
oxidation
CYP1A2
CYP2B6
CYP2C19

*Prasugrel is not yet approved and available in Indonesia

Figure adapted from Schmig A (2009). CYP, cytochrome P450.
Schmig A. N Engl J Med 2009;361:11081111.

CYP-dependent
oxidation
CYP2C19
CYP3A4/5
CYP2B6

Limitation of clopidogrel
Dual antiplatelet therapy (DAPT) with aspirin & clopidogrel
is the current standard treatment in patients with ACS1
- With or without ST segment elevation1
Poor platelet inhibition response to clopidogrel is seen in
approximately 5% - 40% of patients2
- Contribute to residual high risk of recurrent results
Clopidogrel has slow onset of action1
- Prodrug that requires conversion to active metabolite1
Variable metabolism results in interindividual variability in
inhibition of platelet agregation1

1. Bassand JP . European Heart Journal Supplements 2008; 10 : Supplement D, D3D11;

2. Gurbel PA, Tantry US. Thrombosis Research. 2007;120: 311321

Cumulative Incidence (%)

Ticagrelor
: PLATO
study
(efficacy)
Ticagrelor
: PLATO
study
(efficacy)
13
12
11
10
9
8
7
6
5
4
3
2
1
0

030 Days

012 Months
11.7 Clopidogrel
9.8 Ticagrelor

Clopidogrel
5.4

4.8
Ticagrelor

ARR=0.6%

ARR=1.9%

RRR=12%

RRR=16%

P=0.045

NNT=54*

HR: 0.88 (95% CI, 0.771.00)

P<0.001
HR: 0.84 (95% CI, 0.770.92)

10

12

Months After Randomization

No. at risk
Ticagrelor

9,333

8,628

8,460

8,219

6,743

5,161

4,147

Clopidogrel

9,291

8,521

8,362

8,124

6,650

5,096

4,047

Both groups included aspirin.

*NNT at one year.

Wallentin L, et al. N Engl J Med. 2009;361:10451057.

Ticagrelor : PLATO study (safety)

K-M estimated rate (% per year)

Ticagrelor

Clopidogrel

PLATO bleeding criteria

20

TIMI bleeding criteria

18
16
14
12

HR=1.04
(P=0.43)
11,6

HR=1.05
(P=0.33)

11,2

10

HR=1.03
(P=0.70)

5,8

5,8

HR=1.03
(P=0.57)
HR=0.87
(P=0.6553)
5,3

7,9

11,4 10,9

7,7

5,2

4
2

0
Total Major

Both groups included aspirin

Wallentin L, et al. N Engl J Med. 2009;361:10451057.

Major Fatal/LifeThreatening

Other Major

TIMI Major

TIMI Major+Minor

ONSET Ticagrelor vs high dose clopidogrel

Last
Maintenance
Dose
100
90
80

Loading
Dose
180 mg
600 mg

90 mg bid
75 mg qd

*
*

//

70

IPA %

Ticagrelor (n=54)

Clopidogrel (n=50)

P<0.0001
P<0.005
P<0.05
*

60
50

//

40

30

20
10
0
0

0.5

Onset

Time (Hours)
Adapted from Gurbel PA, et al. Circulation. 2009;120:25772585.

24

//

6 weeks

Maintenance

24

48 72 120 168 240

Offset
Time (Hours)

ACS PERKI GUIDELINE - NSTEACS

ACS PERKI GUIDELINE - STEMI

P2Y12 Di Dalam Addendum 2 FORNAS 2015

Updated Guidelines 2014

STEMI Primary PCI and NSTEACS PCI1

A P2Y12 inhibitor is recommended in addition to ASA, and
maintained over 12 months unless there are contraindications
such as excessive risk of bleeding.

NSTE-ACS
Early invasive or ischemia-guided strategy2
A P2Y12 inhibitor (either clopidogrel or ticagrelor) in addition
to aspirin should be administered for up to 12 months to all
patients without contraindications

33

1. Windecker S et al. European Heart Journal / doi:10.1093/eurheartj/ehu278; 2. Amsterdam EA et al. J

Am Coll Cardiol Sept 23, 2014 Epub ahead of print. DOI: 10.1016/j.jack.2014.09.017

OUR PATIENT:

Pasien klinis perbaikan dengan pemberian anti platelet, anti

iskemia dan anti koagulan

Dilakukan tindakan PCI pada hari ke-3 perawatan dengan

hasil CAD 1 VD dan dipasang 1 stent di LCx

Pasien pulang pada hari ke-5 dalam kondisi baik, dengan

terapi:
Aspirin 1x80 mg
Ticagrelor 2x90 mg
Rosuvastatin 1x20 mg
Ramipril 1x5 mg
Bisoprolol 1x5 mg

34