acute coronary syndromes - pspk.fkunissula.ac.id ska.pdf · bag / smf ilmu penyakit dalam fk...
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MI 2
Acute CoronarySyndromes
Acute CoronarySyndromes
®
Bag / SMF Ilmu Penyakit DalamFK Universitas Islam Sultan Agung
Semarang2014
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What is Acute Coronary Syndrome(ACS) ?
Acute Coronary Syndrome is when occlusion ofone or more of the coronary arteries occurs,usually following plaque rupture, resulting indecreased oxygen supply to the heart muscle.ACS is the largest cause of death in U.S. Over 1million people will have Myocardial Infarctionsthis year; almost half will be fatal.Majority of mortality associated with STElevation Myocardial Infarction (STEMI).
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Acute Coronary Syndrome
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Dimana Rasa Nyeri Dirasakan??
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CAD CausesType Comments
Atherosclerosis Most common cause. Risk factors: hypertension,hypercholesterolemia, diabetes mellitus, smoking, family history ofatherosclerosis.
Spasm Coronary artery vasospasm can occur in any population but is mostprevalent in Japanese. Vasoconstriction appears to be mediated byhistamine, serotonin, catecholamines, and endothelium-derivedfactors. Because spasm can occur at any time, the chest pain isoften not exertion-related.
Emboli Rare cause of coronary artery disease. Can occur from vegetationsin patients with endocarditis.
Congenital Congenital coronary artery abnormalities are present in 1 to 2% ofthe population. However, only a small fraction of theseabnormalities cause symptomatic ischemia.
6DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:http://www.accesspharmacy.com
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Pembuluh darah yang mengalami aterosklerosis & trombosis
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Thrombus Formation and ACS
UA NQMI STE-MI
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Non-ST-Segment Elevation AcuteCoronary Syndrome (ACS)
ST-SegmentElevationAcuteCoronarySyndrome(ACS)
OldTerminology:
NewTerminology:
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Expanding Risk FactorsSmokingHypertensionDiabetes MellitusDyslipidemia Low HDL < 40 Elevated LDL / TG
Family History—eventin first degree relative>55 male/65 female
Age-- > 45 for male/55for female
Chronic Kidney Disease Lack of regular physical
activity Obesity Lack of diet rich in
fruit, veggies, fiber
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Chest pain
11
ECG
Troponin rise /fall
Bio-chemistry
Diagnosis
STEMI NSTEMIAdapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366
ST segmentST depressionST elevation
Troponinnormal
UA
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Diagnosis Acute CoronerSyndrome
At least 2 of thefollowing
Ischemic symptomsDiagnostic ECG
changesSerum cardiac
marker elevations
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Unstable Angina -Definition
angina at rest (> 20 minutes)new-onset (< 2 months) exertionalangina (at least CCSC III in severity)recent (< 2 months) acceleration ofangina (increase in severity of at leastone CCSC class to at least CCSC classIII)
Agency for Health Care Policy Research - 1994Canadian Cardiovascular Society Classification
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Unstable Angina andNon-Q-Wave Myocardial
InfarctionEvaluation andmanagement similarPreliminary diagnosis Clinical symptoms Risk factors Electrocardiogram Cardiac enzymes
Assess short-termrisks
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Unstable Anginaprecipitating factors
Inappropriate tachycardia anemia, fever, hypoxia, tachyarrhythmias,
thyrotoxicosisHigh afterload aortic valve stenosis, LVH
High preload high cardiac output, chamber dilatation
Inotropic state sympathomimetic drugs, cocaine intoxication
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GRACE REGISTRYHigher mortality 6months afterdischarge inNSTEMI vs STEMI
NSTEMI
STEMI
UA
NSTEMI
STEMI
UA
Fox KAA et al. BMJ 2006;333:1091-1094
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Risk Stratification is important in NSTE-ACSManagement
TIMI SCORETIMI SCORE GRACE SCOREGRACE SCORE
recommended as thepreferred classification toapply on admission and atdischarge in daily clinical
routine practice
recommended as thepreferred classification toapply on admission and atdischarge in daily clinical
routine practice
Less accurate in predictingevents but its simplicity
makes it useful and widelyaccepted
Less accurate in predictingevents but its simplicity
makes it useful and widelyaccepted
Hamm W et al. European Heart Journal 2007; 28:1598–1660; Hamm CW et al. Eur Heart J2011;32:2999 – 3054
CLINICAL CONDITIONCLINICAL CONDITION1
2 3
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• Relevant rise or fall in troponin• Dynamic ST- or T-wave changes
(symptomatic or silent)• GRACE Score > 140
• Diabetes mellitus• Renal insufficiency(eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF• Early post infarction angina• Prior PCI• Prior CABG• GRACE risk score 109 - 140
HIGH RISKHIGH RISK VERY HIGH RISKVERY HIGH RISK
• Haemodynamic instability orcardiogenic shock
• Recurrent or ongoing chestpain refractory to medicaltreatment
• Life-threatening arrhythmiasor cardiac arrest
• Mechanical complications ofMI
• Acute heart failure• Recurrent dynamic ST-T
wave changes, particularlywith intermittent ST-elevation
Intermediete RISKIntermediete RISK
Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
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TIMI Risk Score for Non–ST-Segment Elevation Acute Coronary Syndromes
Past Medical History Clinical Presentation
Age >65 years ST-segment depression (>0.5 mm)
>3 Risk factors for CAD >2 episodes of chest discomfort in the past 24 hrs
Hypercholesterolemia Positive biochemical marker for infarctiona
HTN
TM
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, myocardialinfarction or urgent need for revascularization as follows:
High Risk Medium Risk Low Risk
TIMI risk score 5–7 points TIMI risk score 3–4 points TIMI risk score 0–2 points
21
aTroponin 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
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GRACE RISK SCOREAge ( Years ) Point< 40 040 – 49 850 – 59 3660 – 69 5570 – 79 73> 80 91
Heart Rate< 70 070 – 89 790 – 109 13110 – 149 23150 – 199 36> 200 46
Systolic BP (mmHg )< 80 6380 – 99 58100 – 119 47120 – 139 37140 – 159 26160 – 199 11> 200 0
Creatinin (mg/dl)0,0 – 0,39 20,4 – 0,79 50,8 – 1,19 81,2 – 1,59 111,6 – 1,99 140,2 – 3,99 23> 4 31Killip class
Class I 0Class II 20Class III 39Class IV 59
Cardiac arrest at admission 43Elevated cardiac marker 15ST segmen deviation 30
Total possible score is 258
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Bleeding risk score – CRUSADE SCORE
Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Very low < 20 ; low (21–30) ; moderate (31– 40);high (41–50); very high (50)
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Unstable AnginaTherapeutic Goals
Therapeutic GoalsReduce myocardial ischemiaControl of symptomsPrevention of MI and death
Medical ManagementAnti-ischemic therapyAnti-thrombotic therapy
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Unstable AnginaMedical 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
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Myocardial Infarction
Occlusion of coronary artery bythrombusProgression of necrosis with timeDiagnosisClinical symptomsElectrocardiogramCardiac enzymes
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Ischemic Heart Disease• angina, aortic stenosis
Nonischemic Cardiovascular Disease• pericarditis, aortic dissection
Gastrointestinal• esophageal spasm, gastritis, pancreatitis,
cholecystitis
Pulmonary• pulmonary embolism, pneumothorax,
pleurisy
Differential DiagnosisDifferential Diagnosis
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Acute Inferior Wall MI
http://homepages.enterprise.net/djenkins/ecghome.html
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ST-Segment Elevation MI
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Definite Indications forThrombolytic TherapyDefinite Indications forThrombolytic TherapyConsistent Clinical Syndrome Chest pain, new arrhythmia,
unexplained hypotension or pulmonaryedema
Diagnostic ECG ST elevation 1 mm in 2 contiguous
leads or new left bundle-branch blockLess than 12 hours since onset of pain
Consistent Clinical Syndrome Chest pain, new arrhythmia,
unexplained hypotension or pulmonaryedema
Diagnostic ECG ST elevation 1 mm in 2 contiguous
leads or new left bundle-branch blockLess than 12 hours since onset of pain
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Continuing TherapyContinuing Therapy
Heparin infusion after thrombolysis(except after streptokinase)Aspirin dailyNitroglycerin for 24- 48 hours-blocker unless contraindicatedAngiotensin-converting enzyme (ACE)inhibitor within first 24 hours
Heparin infusion after thrombolysis(except after streptokinase)Aspirin dailyNitroglycerin for 24- 48 hours-blocker unless contraindicatedAngiotensin-converting enzyme (ACE)inhibitor within first 24 hours
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SummaryUA NSTEMI AMI
Simptom Angineus 20 mnt/> Berat > 30 mnt
Sign + + + & > berat
EKG ST elevasi/depresiT: pos tinggi &
simetris /neg dalam
ST depresimenetap > dlm &
lamaT : neg dalam
Hiperakut TST elevasiQ patologis
Marker CKMB ( - )Tropinin + / -
CKMB positifTroponin - / +
CKMB ( + )Troponin + / -
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Pengobatan Cepat pada SKA
Oksigenisasi 2-3 l/mnt dg kanulAspirin 160 – 300 mg dikunyah diberikan pada semua pasien SKAClopidogrel 300 mgNitrogliserin (SL) 5 mg, jika sakitdada tetap berlanjut dapat diulangsetiap 5 menit sampai 3 kalipemberian ” tidak bolehdiberikan pada pasien denganhipotensi”.
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