Acute Coronary Syndromes

Bag / SMF Ilmu Penyakit Dalam FK Universitas Islam Sultan Agung Semarang 2010

MI 1

What is Acute Coronary Syndrome (ACS) ?

Acute Coronary Syndrome is when occlusion of one or more of the coronary arteries occurs, usually following plaque rupture, resulting in decreased oxygen supply to the heart muscle. ACS is the largest cause of death in U.S. Over 1 million people will have Myocardial Infarctions this year; almost half will be fatal. Majority of mortality associated with ST Elevation Myocardial Infarction (STEMI).

Acute Coronary Syndrome

Dimana Rasa Nyeri Dirasakan??

Acute Coronary Syndrome

Ischemic Discomfort Unstable Symptoms
History Physical Exam

No ST-segment elevation

ST-segment elevation

ECG

Unstable angina

Non-Q AMI

Q-Wave AMI

Cardiac marker

CAD Causes
Type Atherosclerosis Comments Most common cause. Risk factors: hypertension, hypercholesterolemia, diabetes mellitus, smoking, family history of atherosclerosis. Coronary artery vasospasm can occur in any population but is most prevalent in Japanese. Vasoconstriction appears to be mediated by histamine, serotonin, catecholamines, and endothelium-derived factors. Because spasm can occur at any time, the chest pain is often not exertion-related. Rare cause of coronary artery disease. Can occur from vegetations in patients with endocarditis. Congenital coronary artery abnormalities are present in 1 to 2% of the population. However, only a small fraction of these abnormalities cause symptomatic ischemia.
6

Spasm

Emboli Congenital

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com

Pembuluh darah yang mengalami aterosklerosis & trombosis

Thrombus Formation and ACS

Plaque Disruption/Fissure/Erosion Thrombus Formation

Old Terminology:
New Terminology:

UA

NQMI

STE-MI ST-Segment Elevation Acute Coronary Syndrome (ACS)

Non-ST-Segment Elevation Acute Coronary Syndrome (ACS)

Expanding Risk Factors

Smoking Hypertension Diabetes Mellitus Dyslipidemia

Low HDL < 40 Elevated LDL / TG

Family Historyevent in first degree relative >55 male/65 female

Age-- > 45 for male/55 for female Chronic Kidney Disease Lack of regular physical activity Obesity Lack of Etoh intake Lack of diet rich in fruit, veggies, fiber

Diagnosis Acute Coroner Syndrome

At least 2 of the following

Ischemic symptoms Diagnostic ECG changes Serum cardiac marker elevations

Unstable Angina - Definition

angina at rest (> 20 minutes) new-onset (< 2 months) exertional angina (at least CCSC III in severity) recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)

Canadian Cardiovascular Society Classification Agency for Health Care Policy Research - 1994

Unstable Angina and Non-QWave Myocardial Infarction

Evaluation and management similar Preliminary diagnosis

Clinical symptoms Risk factors Electrocardiogram Cardiac enzymes

Assess short-term risks

Unstable Angina precipitating factors

Inappropriate tachycardia anemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosis High afterload aortic valve stenosis, LVH High preload high cardiac output, chamber dilatation Inotropic state sympathomimetic drugs, cocaine intoxication

TIMI Risk Score for NonST-Segment Elevation Acute Coronary Syndromes

Past Medical History

Age >65 years >3 Risk factors for CAD

Clinical Presentation
ST-segment depression (>0.5 mm) >2 episodes of chest discomfort in the past 24 hrs

Hypercholesterolemia
HTN TM

Positive biochemical marker for infarctiona

Smoking
Family history of premature CHD 50% stenosis of coronary artery) Use of aspirin within the past 7 days
Using the TIMI Risk Score
One point is assigned for each of the seven medical history and clinical presentation findings. The score (point) total is calculated, and the patient is assigned a risk for experiencing the composite end point of death, myocardial infarction or urgent need for revascularization as follows:

High Risk TIMI risk score 57 points

aTroponin

Medium Risk TIMI risk score 34 points

Low Risk TIMI risk score 02 points

15

I, troponin T, or creatinine kinase MB greater than the MI detection limit.

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com

The TIMI Risk Score and Incidence of Adverse Ischemic Events in Patients with NSTE-ACS
50 Death, MI, or Urgent Revascularization (%)

40.9 26.2

40
30

19.9
20 10 0 0/1 2 3 4 5 Number of Risk Factors 6/7 4.7 8.3 13.2

Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA.. 2000;284:835-842. Copyright 2000, American Medical Association. All rights reserved.

Unstable Angina Therapeutic Goals

Therapeutic Goals Reduce myocardial ischemia Control of symptoms Prevention of MI and death Medical Management Anti-ischemic therapy Anti-thrombotic therapy

Unstable Angina Medical Therapy

Anti-ischemic therapy

nitrates, beta blockers, calcium antagonists

Anti-thrombotic therapy

Anti-platelet therapy aspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitors Anti-coagulant therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog

Myocardial Infarction

Occlusion of coronary artery by thrombus Progression of necrosis with time Diagnosis

Clinical symptoms Electrocardiogram Cardiac enzymes

Differential Diagnosis
Ischemic Heart Disease angina, aortic stenosis Nonischemic Cardiovascular Disease pericarditis, aortic dissection

Gastrointestinal esophageal spasm, gastritis, pancreatitis, cholecystitis

Pulmonary pulmonary embolism, pneumothorax, pleurisy

Acute Inferior Wall MI

http://homepages.enterprise.net/djenkins/ecghome.html

ST-Segment Elevation MI

GUIDELINE PENANGANAN PASIEN ACS NON STENT

BAGAIMANA GUIDELINES MENURUT ESC & ACC-AHA

ACC/AHA ACLS ACS Algorithm 2006

Nyeri dada (kecurigaan ischemia)

Diagnosa, penatalaksanaan dan persiapan/pre hospital oleh EMS : - Monitor, support ABC. Persiapan untuk CPR dan defibrilasi 2 - Berikan oksigen, aspirin, nitroglycerin dan morphine bila dibutuhkan - Jika tersedia, periksa ECG 12 lead, jika terdapat ST-Elevasi : Hubungi rumah sakit yang dituju dengan DX pasien Mulai membuat fibrinolytic checklist - RS yang dituju harus menyaiapkan Mobilize Hospital Resources untuk merespon pasien STEMI

Diagnosa cepat oleh Emergency Departemen (<10min) 3

Penatalaksanaan umum cepat oleh E.D

- Check vital signs, evaluasi saturasi O2 - Morphin IV jika nyeri tidak berkurang dengan - Pasang IV line nitroglycerin - ECG 12 lead - O2 4 L/mnt, pertahankan saturasi O2 > 90% - Anamnese singkat, terarah, pemeriksaan fisik - Nitroglycerin SL atau spray atau IV - Periksa awal level cardiac marker, elektrolit - Aspirin 160 samapai 325 mg (jika tidak Dan faal hemostatis diberikan oleh EMS) - Periksa Rontgen dada (<30 m)

Ulang pemeriksaan ECG 12 lead

5

ST Elevasi atau LBBB baru atau diasumsikan baru; dicurigai kuat ST-Elevasi MI (STEMI)
6

13

Mulai terapi tambahan sesuai indikasi. Jangan menunda reperfusi -Clopidogrel --adrenergic reseptor blockers -Heparin (UFH or LMWH)
11 7

10

ST depresi atau T inverted; dicurigai kuat suatu ischemia Resiko tinggi unstable angina / Non ST Elevation MI (AU/NSTEMI)
Mulai terapi tambahan sesuai indikasi -Clopidogrel -Nitroglycerin - -adrenergic reseptor blockers -Heparin (UFH or LMWH) -Glycoprotein IIb/IIIa inhibitor

Normal atau tidak ada perubahan segmen ST atau gelombang T Resiko rendah atau sedang untuk unstable angina
14

Berlanjut memenuhi kriteria sedang atau tinggi (tabel 3,4)atau troponin positive?
15

Onset gejala < 12 jam

Opname di ruangan dgn monitoring bed Tentukan status resiko

12

Pertimbangkan opname di ED chest paint unit atau monitored bed di ED Lanjutkan dengan : Serial cardiac marker (termasuk troponin) Ulang ECG, monitor segmen ST Pertimbangan stress test
16

Strategi reperfusi: Terapi ditetapkan berdasarkan keadaan pasien dan center criteria Menyadari tujuan terapi reperfusi: Door-to-balloon inflation (PCI) = 90 mnt Door-to-needle (fibrinolysis) = 30 mnt Lanjutkan dengan terapi: ACE inhibitor/angiotensi receptor blocker (ARB) 24 jam dari onset HMG CoA reductase inhibitor (statin therapy)

Pasien High-risk: Refractory ischemic chest pain Recurrent/persistent ST deviation Ventricular tachycardia Hemodynamic tachycardia Signs of pump failure Strategi invasive awal termasuk kateterisasi & revaskularisasi penderita IMA dgn syok dlm 48 jam Lanjutkan pemberian ASA, heparin & terapi lain sesuai indikasi: ACE inhibitor / ARB HMG CoA reductase inhibitor (statin therapy) Tidak pada resiko tinggi: penentuan penggolongan resiko dari cardiology

Berlanjut memenuhi kriteria resiko tinggi atau sedang (tabel 3,4) atau troponin-positive

17

Jika tidak ada ischemia atau infare, maka dapat pulang dengan rencana kontrol

CRUSADE

Kepatuhan pada Guidelines Menurunkan angka Mortality di Rumah Sakit

Increased Adherence to Guidelines Decreases Mortality
7
In-hospital Mortality (%)
Adjusted

6 5 4 3 2 1 0

5,95%

6,33% 5,16% 5,07% 4,97%

Unadjusted

4,63% 4,16% 4,17%

25%

25%50%

50%75%

75%

Hospital Composite Quality Quartiles

CRUSADE is a national quality improvement initiative of the Duke Clinical Research Institute. Partial funding for CRUSADE is provided by the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. CRUSADE Data Q3 2006. Cumulative CRUSADE data through September 2003. Duke Clinical Research Institute. Available at: http://www.crusadeqi.com. Accessed February 13, 2007.

Definite Indications for Thrombolytic Therapy

Consistent Clinical Syndrome

Chest pain, new arrhythmia, unexplained hypotension or pulmonary edema ST elevation 1 mm in 2 contiguous leads or new left bundle-branch block

Diagnostic ECG

Less than 12 hours since onset of pain

Absolute Contraindications for Thrombolytic Therapy

History of hemorrhagic stroke Stroke or CVA within 1 year Allergy to the agent Surgery or trauma in past 2 wks Known intracranial neoplasm Suspected aortic dissection Active internal bleeding (except menstruation)

Relative Contraindications for Thrombolytic Therapy

Active peptic ulcer disease Significant hepatic dysfunction Severe uncontrolled hypertension (> 180/110 mmHg )

History of chronic severe hypertensoin

Current anticoagulant use Recent trauma ( within 2-4 weeks) Pregnancy Allergy or prior exposure to streptokinase

Continuing Therapy

Heparin infusion after thrombolysis (except after streptokinase) Aspirin daily Nitroglycerin for 24- 48 hours

-blocker unless contraindicated Angiotensin-converting enzyme (ACE) inhibitor within first 24 hours

Summary
UA NSTEMI AMI

Simptom

Angineus 20 mnt/>

Berat

> 30 mnt

Sign

+ & > berat

EKG

ST elevasi/depresi T: pos tinggi & simetris /neg dalam CKMB ( - ) Tropinin + / -

ST depresi menetap > dlm & lama T : neg dalam CKMB positif Troponin - / +

Hiperakut T ST elevasi Q patologis CKMB ( + ) Troponin + / -

Marker

Pengobatan Cepat pada SKA

Oksigenisasi 2-3 l/mnt dg kanul Aspirin 160 300 mg dikunyah diberikan pada semua pasien SKA Clopidogrel 300 mg Nitrogliserin (SL) 5 mg, jika sakit dada tetap berlanjut dapat diulang setiap 5 menit sampai 3 kali pemberian tidak boleh diberikan pada pasien dengan hipotensi.