acls, acute coronary syndrome

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ACUTE CORONARY

SYNDROMERadityo Prakoso

Department Cardiology and Vascular Medicine

Faculty of Medicine University of Indonesia/

National Cardiovascular Center Harapan Kita Hospital

Jaarta



Anderson et al. JACC 2007;50:e1-157



Adapted from Aroney C, Boyden AN, Jelinek MV, et al.

Management of unstable angina: guidelines !!!.

Med J Aust !!!"#$%&'uppl(:')*+', -it permission.

Ne! terminology for coronary syndromes



aran utama terapi SKA :

engurangi nekrosis miokard pada pasien yg mengalami inf

encegah MACE ( kematian, IMA non fatal,kebutuhan untuk revaskularisasi segera )

ebrilasi segera bila ter!adi "#

atifkasi risiko : EKG 12 ea!

elompok triase %

Elevasi segmen &'Depresi segmen &'E non diagnostik*normal



R"NGKASAN

PRA R/MA0 'A123

• Diagnosti "K# di luar $% las I

• Fi&rinoliti di luar $% '' las IIa

• $isio ematian (( atau disfungsi Ventriel Kiri ((

diru)u e pusat untu revasularisasi cepat las I * + ,- t.n



/AP4 2MA N'35M2

• #0 II&/IIIa * tam&a.an UFH1 aspirin las IIa• 2nti fator 3a dan 4M5H alternatif UFH• 6roponin positif 7 perlu segera terapi agresif

35RAP2 R5P5R6/'2

• Fi&rinoliti u/ IM21 elevasi %6

las I * + ,- t.n las IIa * ( ,- t.n • 2ngioplasti / stent u/ %K21 syo las I * + ,- t.n • 8ila KI fi&rinoliti1 intervensi las I



'3 depresi dan perubaan gelombang 3

• %6 depresi dianggap &ermana &ila ( 9 mm di &a!a. garis dasar 06 di titi J

• 6iti J didefinisian se&agai a.ir omples :$% dan permulaan segmen %6

Bentuk segmen '3 :

• up-sloping * tida spesifi

• horizontal * le&i. spesifi untu isemia • down-sloping * paling terpercaya untu isemia

Perubaan gelombang 3 pada

isemia urang &egitu spesifi

#elom&ang 6 .iperaut

adang; merupaan satu<satunya

peru&a.an "K# yang terli.at



11

2= Normal "C#

8= >6all 6? or 0eaed 6

!avesC= >In)ury?1 %6 elevation

D= 8ip.asic 6 !aves

"= :1 8ip.asic 6 !avesF= :<a&normal

“EVOLVING ECG”



%erial electrocardiograms

A: 8efore tissue plasminogen activator1

mared %6 elevation V9 to V@1 II1 III1 aVF

B: 6!enty minutes after 602

!it. sudden relief of c.est pain



'table ateros7leroti7 pla8ue'table ateros7leroti7 pla8ue



/nstable pla8ue/nstable pla8ue



Anatomi 1oroner dan 519 # sandapan

• %andapan V9 dan V; meng.adap septal area ventriel iri

• %andapan VA dan VB meng.adap dinding anterior ventriel iri

• %andapan V- dan V@ * ditam&a. I dan av4 meng.adap

dinding lateral ventriel iri

• %andapan II1 III dan avF meng.adap dinding inferior ventriel iri



Acute MI: ECG subsets and

correlated infarct-related artery

Category Anatoy of Occlusion ECG !indings

Proximal LAD Proximal to septal perforator S ele!ation "1-#$ %$ a!L$and fas&i&'lar or ('ndle (ran&) (lo&*

+id LAD Proximal to lar,e dia,onal ('t distal to first septal perforator

S ele!ation "1-#$ %$ a!L

Distal LAD or dia,onal Distal to lar,e dia,onal ordia,onal itself

S ele!ation "1-$ or %$ a!L$"5-#

+oderate to lar,e inferiorposterior$ lateral$ ri,)t!entri&'lar/

Proximal CA or left&ir&'mflex S ele!ation %%$ %%%$ a!$ andan of t)e follo3in,:a. "1$ "4$ " (. "5-#&. S in "1-2

Small inferior Distal CA or left&ir&'mflex (ran&)

S ele!ation %%$ %%%$ a! onl



"C# demonstrates large anterior infarction



A: 0roimal large $C2 occlusion

B: %6 elevation in leads II1 III1 aVF1 V-

1 and V@

!it. precordial %6 depression



A : %mall inferior distal $C2 occlusion

B : "C# c.anges in leads II1 III1 and aVF



Penanganan 1usus

3erapi reperfusi1 dengan sasaran:

• Fi&rinoliti door-to-needle + AE menit• 0rimary 06C2 door-to-dilatation + E menit

3erapi Conun7ti;e * om&inasi dengan o&at fi&rinoliti

• 2spirin• Heparin * .ususnya dengan t02 • %6G0 N%2ID

3erapi 3ambaan Clopidogrel

&locer oral 1 &ila memunginan Nitrogliserin iv * isemi menetap1 ontrol .ipertensif dan udem paru 2C" In.i&itor * IM2 anterior1 4V"F + BE1

gagal )antung tanpa .ipotensi < 6D sistoli ( 9EE mmHg



pi #i$rinoitik

ue %asmino&en A'ti(ator ) t%A *

rikan pada AMI yang luas, datang dini dan kemungkinanplikasi pendarahan kecil

rikan dengan dosis bertahapmg bolus iv

mg*kg 0 !angan 1 - mg, $- menit- mg*kg 0 !angan 1 $ mg, 2- menit

ptokinase

rikan pada pasien IMA yang kemungkinan komplikasiarahan otak tinggi, datang lambat dan infarknya tak luas

!uta unit dalam + !am



Terapi #i$rinoitik

Retepase )r%A*+- 3 4 +- 3 iv bolus selang $-5

Tene'tepase )TNK+t%A*&ingle iv bolus• $- mg 6 7 2- kg• $ mg 6 2-0/- kg• 8- mg 6 /-09- kg• 8 mg 6 9-0:- kg• - mg 6 1 :- kg



0eparin 2V & / 6 0 ( 2H21 ;EE,

Direomendasian untu

• 0asien yang strategi reperfusinya menggunaan 06C2 / C28#• 0asien yang di&eri 6021 %treptoinase1 $eteplase atau

6enecteplase

0er.atian

Kontraindiasi seperti pada terapi fi&rinoliti

<M=0 & 5no>aparin (

AE mg &olus iv1 diiuti 9 mg / g / sc tiap 9; )am

Anti 6a7tor ?a &6ondaparinu>(



Nitrogliserin i; direkomendasikan pada :

0asien IM2 ;B<B )am pasca onset yang disertai ompliasi

• #agal )antung ongestif

• Infar antrior yang luas

• Isemia yang persisten

• Hipertensi

Untu pasien IM2 tanpa .ipotensi1 &radiardia atau taiardia1

Infar $V1 pem&erian nitrogliserin IV dapat diterima tetapi

manfaatnya masi. &elum pasti



AC5 inibitor direomendasian pada

0asien IM2 disertai %6 elevasi ( ; sandapan anterior preordial

0asien 2MI dengan "F + BE

0asien 2MI dengan tanda gagal )antung * disfungsi sistoli

0er.atian

Umumnya 2C" in.i&itor di&erian pada ;B )am pertama1setela. terapi trom&oliti selesai dan teanan dara. sta&il



4#



• Cest pain or se;ere epigastri7 pain, typi7al of

myo7ardial is7emia or M2:

• 'ubsternal 7ompression or 7rusing 7est pain

• Pressure, tigtness, ea;iness, 7ramping,a7ing sensation

• /ne>plained indigestion, bel7ing, epigastri7

pain

• Radiating pain to ne7k, a-, soulders, ba7k or to one or bot arms

• Asso7iated dyspnea, nausea and4or ;omiting,

diaporesis

5M5R95NC@ RM 3R2A95



ifferential iagnosis of Prolonged Cest Pain

AM2Aorti7 disse7tion

Peri7arditis

Atypi7al anginal pain asso7iated -it ypertropi7 7ardiomyopaty5sopageal, oter upper gastrointestinal, or biliary tra7t

disease

Pulmonary disease

0yper;entilation syndrome

Cest -all

Psy7ogeni7

6ibrinolyti7 /se in Myo7ardial 2nfar7tion & A0A !! (



Absolute Contraindi7ations Cautions4Relati;e Contraindi7ations

• 0revious .emorr.agic

stroe at any time

• Isc.emic stroes A mo * ecept A .rs

•

Kno!n intracranialmalignant neoplasm

• 2ctive internal &leeding/ &leeding diast.esis

* not include menses

• %uspected aortic dissection

• Head / facial trauma !it.in A mo

• %evere uncontrolled H6 on presentation

*80 (9E/99E mm Hg

• History of prior CV accident or no!n intra< cere&ral pat.ology not covered in CI

•

Current use of anticoagulants *IN$ ;<AL no!n &leeding diat.esis

• $ecent trauma * ;<B !s 1 .ead trauma

• Noncompressi&le vascular punctures

• $ecent * ;<B !s internal &leeding• For streptoinase prior eposure * !it.in -d<;y or prior allergic r• 0regnancy• 2ctive peptic ulcer • History of c.ronic H6

6ibrinolyti7 /se in Myo7ardial 2nfar7tion & A0A !! (



Rest AnginaD Angina o77urring at rest and

prolonged, usually E ! minutes

Ne-Fonset Angina Ne-Fonset angina of at least CC' Class 222 se;erity

2n7reasing Angina Pre;iously diagnosed angina tat as

be7ome distin7tly more fre8uent,

longer in duration, or lo-er in tresold &i.e., in7reased by E # CC'(

7lass to at least CC' Class 222 se;erity.

/A4N'35M2

30R55 PR2NC2PA< PR5'5N3A32N'



0290 R2'1F65A3/R5' & R2'1 R2'5' =230 N/MB5R (

0istory

Clini7al findings

5C9

Cardia7 markers

Prolonged is7emi7 dis7omfort & E! min (,

ongoing rest pain, a77elerating tempo of is7emia

Pulmonary edema" '% or ne- rales

ne- MR murmur

ypotension, brady7ardia, ta7y7ardia

age E$* years

Rest pain -it transient '3Fsegment 7anges

E !.!* mV" ne- bundleFbran7 blo7k,ne- sustained V3

5le;ated & e.g. 3n3 or 3n2 E!.# ng4m< (

2H21 ;EE9



i&- risk .or pro&ression to M" or !eat-

recurrent ischaemia * dynamic &'0segment change( in particular &'segment depression,or transient &'0segment elevation )early post0infarction unstable angina

elevated troponin levelshaemodynamic instability ;ithin observation perioma!or arrhythmias ( repetitive "', "# )DM

;ith an EC pattern ;hich precludes assessment o&'0segment changes

E&C, <--<



Unsta&le angina



2cute anterolateral myocardial infarction



4ateral myocardial infarction=

%6 segment elevation in leads I and aV4



2cute inferior myocardial infarction



2cute inferoposterior myocardial infarction=

%6 segment elevation in II1 III and aVF

!it. %6 depression in leads V9 and V;



%u&endocardial isc.emia=

2nterolateral %6<segment depression



IMA:

A6%6A P89%S 9AS %+A

P8<=AA6 89

86>%+ 9AD%A9 +86%69A & AR2 %(

=0

A"C#E! G$



A"C#E!-G$

A:Aspirin B: Blood pressure, Body weight C: Cigarette, Cholesterol D: Diabetic, Diet E: Exercise, Education

F: Family screening : od !: !appy

acls, acute coronary syndrome

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