dr.

Ilham Uddin, SpJP, FIHA

Tempat, tgl. Lahir : Tuban, 21 Desember 1968

Riwayat Pendidikan
• Fakultas Kedokteran Universitas Airlangga, Surabaya, Lulus 1994
• Spesialisasi Jantung dan Pembuluh Darah di Bagian Kardiologi dan
Kedokteran Vaskular FK Universitas Indonesia / Harapan Kita National
Cardiovascular Center, Jakarta, lulus 2006
• Fellow Cardiovascular Intervensi, Semarang, 2012-2014

Riwayat Pekerjaan
1. Kepala Puskesmas Compreng, Tuban 1995-1998
2. Sekretaris Bagian Kardiologi & Kedokteran Vaskular FK UNDIP.RSUP dr
Kariadi 2009-sekarang
ACS : Focus on ST elevation MI
(STEMI)

Ilham Uddin, MD, FIHA

Dept. of Cardiology and Vascular Medicine

Kariadi Hospital – Diponegoro University

 Modified from Libby. Circulation 2001;104:365,
Hamm et al. The Lancet 2001;358:1533 and
Davies. Heart 2000;83:361.

1 2 3 4 5 6

3
 Spectrum of Acute Coronary Syndromes
Presentation Ischemic Discomfort at Rest

No ST-segment ST-segment
Emergency Elevation Elevation
Department

– + + + Cardiac
Markers

In-hospital Unstable Non-Q-wave MI Q-wave MI

6-24 hours Angina (UA) (NSTEMI) (STEMI)

Adapted from Braunwald E, et al. Available at:

http://www.acc.org/clinical/guidelines/unstable/unstable.pdf
Pathophysiology of ST-Elevation
Myocardial Infarction

Generally caused by a Results from stabilization of a

completely occlusive platelet aggregate at site of
thrombus in a coronary artery plaque rupture by fibrin mesh

platelet
RBC
fibrin mesh
GP IIb-IIIa
 Spectrum of ACS Presentations
UA NSTEMI STEMI

Ischemia without Necrosis

Definition Transmural necrosis
necrosis (nontransmural)

Negative Biomarkers Positive biomarkers Positive biomarkers

Diagnosis
ECG ST-segment
No ECG ST-segment elevation
elevation

Immediate
Treatment Invasive or conservative depending on risk
reperfusion

Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209.

Left Coronary Artery (LCA)
Right Coronary Artery (RCA)
 Cardiac Biomarkers in STEMI
Cardiac-specific troponins
are optimum biomarkers
(Level IC)
For STEMI, reperfusion
100 therapy should be initiated as
soon as possible and is not
contingent on a biomarker
Multiples of the URL

assay (Level IC)

50
Cardiac troponin-no reperfusion
20 Cardiac troponin-reperfusion
10 CKMB-no reperfusion
CKMB-reperfusion
5

2
Upper reference limit
1

0 1 2 3 4 5 6 7 8
URL = 99th %tile of
Days After Onset of STEMI Reference Control Group

Alpert et al. J Am Coll Cardiol 2000;36:959.

Wu et al. Clin Chem 1999;45:1104.
9
 Evolution of Acute MI

Dr.Sarma@works
 Evidence of multiple “vulnerable”
plaques in acute coronary syndrome
 STEMI: Brief Physical Exam in the
Emergency Department
 Airway, Breathing, Circulation (ABC)
 Vital signs, general observation
 Presence or absence of jugular venous distension
 Pulmonary auscultation for rales
 Cardiac auscultation for murmurs or gallops
 Presence or absence of stroke
 Presence or absence of pulses
 Presence or absence of systemic hypoperfusion
(cool, clammy, pale/ashen)

Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf.

Accessed November 1, 2005.
 STEMI: Acute Medical Therapy
General treatment  Analgesics
measures  Nitrates
 Oxygen
Infarct size  β-blockers (decrease heart rate)
limitation

Reperfusion  Primary PCI or coronary thrombolysis

(primary PCI preferred after 3 hours)

Antithrombotic  Aspirin (162-325 mg, acute dose) & Clopidogrel

and antiplatelet
therapy  Heparin
 If PCI:
– Clopidogrel
– GP IIb/IIIa inhibitors

Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf.

Accessed November 1, 2005.
 Reperfusion Therapy
Class I Recommendation

All STEMI patients should undergo rapid evaluation

for reperfusion therapy and have a reperfusion
strategy implemented promptly after contact with the
medical system. (Level of Evidence: A)

Medical system goal is to facilitate rapid recognition and

treatment of patients with STEMI such that door-to-needle (or
medical contact–to-needle) time for initiation of fibrinolytic
therapy can be achieved within 30 minutes or that door-to-
balloon (or medical contact–to-balloon) time for PCI can be
kept within 90 minutes.

Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf.

Accessed November 1, 2005.
 Total Ischemic Time Correct focus of
attention for optimal STEMI CARE
Wave front phenomenon of myocardial
infarction propagation
(Reimer et al: Circulation 1977)
Area of necrosis compared with area of risk when artery was
occluded:
At 40 minutes : 45% of myocardium irreversibly
injured.
55% of myocardium at risk was
salvageable.

At 3 hours : 33% salvageable

At 6 hours : 16% salvageable
-----------------------------------------------------------------------------------------------
Benefit of reperfusion is time dependent from the first moment
of occlusion
Denktal et al: JACC: 2011: 4: 599
Selection of Reperfusion Strategy in STEMI
Time since the onset of symptoms

Risk of Mortality from STEMI

Availability of skilled PCI Laboratory

Time required for Transport

Any contraindication to thrombolysis

including bleeding, ICH

Patient preference
ACC/AHA STEMI Guidelines 2013
 Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable

Onset of 9-1-1 EMS on-scene Inter-

symptoms of EMS • Encourage 12-lead ECGs. Hospital
STEMI Dispatch • Consider prehospital fibrinolytic if Transfer
capable and EMS-to-needle within
30 min.
PCI
capable
GOALS
5 8
min. EMS Transport
min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.

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

17
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
• Patients receiving fibrinolysis should be risk-stratified to identify need
for further revascularization with percutaneous coronary intervention
(PCI) or coronary artery bypass graft surgery (CABG).
• All patients should receive late hospital care and secondary
prevention of STEMI.

Noninvasive Risk
Fibrinolysis
Stratification
Not Late
Rescue Ischemia Hospital Care
PCI Capable driven and Secondary
PCI Capable Prevention

PCI or CABG

Primary PCI

18
Medical Therapy for STEMI
Managed by Primary PCI
ED
CCL

Presentation Access—Wire—Balloon
ASA

Anticoagulant UFH (Bival)

Clopidogrel 600
Prasugrel 60, or Ticagrelor 180
P2Y12 inhibitor
Eptifibatide
Abciximab
GP IIb/IIIa

Beta Blocker IV prn Oral within 24h

Statin
Step by Step : PCI
 Reperfusion
The medical system goal is to facilitate rapid recognition

and treatment of patients with STEMI such that door-to-

needle (or medical contact–to-needle) time for initiation

of fibrinolytic therapy can be achieved within 30

minutes or that door-to-balloon (or medical contact–to-

balloon) time for PCI can be kept within 90 minutes.

21
 Reperfusion

Patient Transport Inhospital Reperfusion

Goals
D-N ≤ 30 min
5 min < 30 min
D-B ≤ 90 min
Methods of
Speeding
Media campaign Prehospital Time to
Patient education ECG Reperfusion
MI protocol
Critical pathway
Quality Bolus lytics
Greater use of
9-1-1 improvement Dedicated
Prehospital Rx program PCI team

22
23
Langkah-langkah pemberian fibrolisis

Langkah 1: Nilai waktu dan risiko

• Waktu sejak awitan gejala (<12 jam atau > 12 jam
dengan tanda & gejala iskemik)
• Risiko fibrinolisis & indikasi kontra fibrinolisis
• Waktu yang dibutuhkan untuk pemindahan ke pusat
kesehatan yang mampu melakukan IKP (<120 menit)
Langkah 2: Tentukan pilihan yang lebih baik antara
fibrinolisis atau strategi invasif untuk kasus tersebut
• Bila pasien <3 jam sejak serangan dan IKP dapat
dilakukan tanpa penundaan, tidak ada preferensi untuk
satu strategi tertentu.
Keadaan dimana fibrinolisis lebih baik
• Pasien datang < 3 jam setelah awitan gejala dan terdapat
halangan untuk strategi invasif
• Strategi invasif tidak dapat dilakukan:
* Cath-lab sedang/tidak dapat dipakai
* Kesulitan mendapatkan akses vaskular
* Tidak dapat mencapai laboratorium/pusat kesehatan
yang mampu melakukan IKP dalam waktu <120 menit
• Halangan untuk strategi invasif
* Transportasi bermasalah
* Waktu antara Door-to-balloon dan Door-to-needle > 60 menit
* Waktu antar kontak medis dengan balonisasi atau
door-to-balloon > 90 menit
Keadaan di mana strategi invasif
lebih baik:
• Tersedianya cath-lab dengan dukungan pembedahan
* Waktu antar kontak medis dengan balonisasi atau door-to-
balloon < 90 menit
* Waktu antara Door-to-balloon dan Door-to-needle < 1 jam
• Risiko tinggi STEMI
* Syok kardiogenik
* Kelas Killip ≥ 3
• Indikasi kontra untuk fibrinolisis, termasuk peningkatan
risiko perdarahan dan perdarahan intrakranial
• Pasien datang lebih dari 3 jam setelah awitan gejala
• Diagnosis STEMI masih ragu-ragu
28
 Types of fibrinolytic drugs

Non-fibrin specific Fibrin specific

Tissue plasminogen
Streptokinase Activators (t-PA)
Anistreplase Alteplase
Urokinase Reteplase
Tenecteplase
 Types of fibrinolytic drugs:
Non fibrin-specific agents:

Streptokinase – Anistreplase – Urokinase

binds equally to circulating and non-circulating
plasminogen.
produces breakdown of clot (local fibrinolysis) and
circulating plasminogen & fibrinogen thus cause an
unwanted (systemic fibrinolysis) leading to bleeding.
 Fibrin-specific agents:
Tissue Plasminogen Activators (t - PA)

 Direct action: They activate fibrin-bound

plasminogen rather than free plasminogen in
blood.
 Their action is enhanced by the presence of fibrin.
 It binds to fibrin in a thrombus and converts the
entrapped plasminogen to plasmin followed by
activated local fibrinolysis with limited systemic
fibrinolysis.
Currently available thrombolytic agents

Third-generation thrombolytics
tenecteplase (TNK-tPA)

Second-generation thrombolytics
recombinant tissue plasminogen activator (rt-PA), reteplase
(rPA)

First-generation thrombolytics
streptokinase, anistreplase
 Alteplase (Actilyse)
• The “gold standard”
3 fibrinolytic agent
4 – 14% relative decrease
in 30-day deaths
(absolute reduction
2 from 7.3 to 6.3%) with
1 accelerated regimen in
5 GUSTO I
• But some limitations:
NH2
– IV infusion precludes
1 Finger COOH pre-hospital use
2 Growth Factor
– Even the “accelerated”
3 Kringle 1
dose takes 90 minutes
4 Kringle 2
to administer
5 Protease
34
Fibrinolytic ?... Or..