Pipin Ardhianto

Cardiovascular Department

Medical Faculty of Diponegoro University

Pathophysiology and ECG ManifestationsOf

Coronary Heart Disease

Definition of Acute Coronary

Syndrome

A syndrome largely due to coronary atheroclerosis

plaque rupture or erosion, which is further subdivided

into presentations with and without ST-segment

elevation on the ECG.

Antman, E M. 2004

Causes of ACS

Atherosclerosis Cause

> 95% ACS because of disruption of plaque

Platelet agregation

Intracoronary thrombus

Non Atherosclerosis Cause

Vasculitis syndrome

Coronary emboli (IE, prosthetic valve)

Congenital anomali of coronary artery

Coronary trauma or aneurysm

Spasm

Increased blood viscosity

Increased myocardial demand

Hurst, 2011

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Heart attack, Stroke etc

“STRESS“ testing only detects THIS

Usually begin in later childhood

Pathophysiology of Atheroscelrotic (1)

Hurst, 2011

Pathophysiology of Atheroscelrotic (2)

Zubrycki, M. J Physiol Pharmacol. 2014

When will the plaque be ruptured?

Vulnerable plaque:

Plaques with large lipid core

Thin fibrous cap covering lipid core

High density of macrophage, matrix metalloproteinase and inflammatory cell

Holroyd, 2003

8Stable VS Unstable Plaque

APPROACH

Identifying those with chest pain suggestive of

IHD/ACS.

Thorough history required:

Character of pain

Onset and duration

Location and radiation

Aggravating and relieving factors

Autonomic symptoms

CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN (ADAPTED FROM ROSEN’S, EMERGENCY MEDICINE)

CHARACTERISTIC SUGGESTIVE OF ANGINA LESS SUGGESTIVE OF

ANGINA

TYPE OF PAIN DULL

PRESSURE/CRUSHING

PAIN

SHARP/STABBING

DURATION 2-5 MIN, <20 MIN SECONDSTO

HOURS/CONTINUOUS

ONSET GRADUAL RAPID

LOCATION/CHEST WALL

TENDERNESS

SUBSTERNAL, NOT

TENDER TO PALP.

LATERAL CHEST

WALL/TENDER TO PALP.

REPRODUCIBALITY WITH

EXERTION/ACTIVITY

WITH

BREATHING/MOVING

AUTONOMIC SYMPTOMS PRESENT USUALLY ABSENT

Wu Et al. J of Am Physycian. 2009

How To Deal With?

ECG Manifestation of ACS

Subendocardial ischemia : ST depression (horizontal/downsloping), T

wave inversion

Transmural ischemia : ST elevation

ECG abnormalities of ischemia

“Diastolic Injury Current Theory” “Systolic Injury Current Theory”

NSTE-ACS/UAP

•ST depression 0,5 mm in 2 contiguous leads

• Inverted symetrical T wave 3 mm in 2 or more concomitant leads

•Suspect UAP if ST segment changes while chest pain & normal while no complaints

•Normal ECG does not exclude the possibility of NSTE-ACS

STE MI

•New or presumably new ST elevation, 2 mm in V1-3 or 1 mm in other leads

•Occurs in 2 concomitant leads

•Pathologic Q wave (0,03 wide, 1 mm deep) in 2 concomitant leads

•New or presumably new LBBB

A = Normal

B = Acute

ST elevation/tall T

C = Hours

ST elevation

R wave, Q wave begins

D = Day 1-2

T wave Biphasic

Deeper Q wave

E = Days later

ST normalizes

T wave inverted

F = Weeks later

ST & T normal

Q wave persists

ECG evolution of Acute STEMI

Pathophysiologic of Heart Disease: Acute

Coronary Syndromes, Lilly, 4th ed, 2007

Atypical ECG Presentation

1. LBBB or Ventricular paced rhythm

Atypical ECG Presentation

2. Isolated posterior myocardial infarction

Infarct in Infero-basal area

Often correspondent to LCx territory

Isolated ST depression in V1 – V3

Use additionl posterior chest lead to confirm posterior infart ( ST elevation > 0.05mm )

Atypical ECG Presentation

3. Left Main Coronary Oclusion

ST segment elevation in lead aVR or V1

St depression in eight or more other leads

Accompanied with hemodynamics compromise

CARDIAC

CATHETHERIZATOIN

PREVENSI KARDIOVASKULAR

A. ASPIRIN dan ANTI KOAGULAN

Aspirin diberikan secara rutin dan terus menerus pada pasien pasca serangan jantung.

Bersama dengan nitrat merupakan obat yang penting bagi kegawat daruratan PJK

Bertujuan sebagai anti beku darah

Dosis : 80 - 320 mg

B=BLOOD PRESSURE & BODY WEIGHT

Target tekanan darah < 140/90 mmHg• mengubah pola hidup• terapi obat

Kelebihan berat badan dan obesitas

• Kelebihan berat badan ( BMI > 25 kg/m2 ), obesitas ( BMI > 30 kg/m2 ) mengurangi berat badan dengan diet yang benardan meningkatkan aktivitas fisik

• Penurunan berat badanmenurunkan tekanan darah, kadarkolesterol, glukosa darah

• Lingkar pinggang : indeks klinis obesitas dan pantauanpenurunan BB Lingkar pinggang pria > 94 cm dan wanita > 80 cm merupakanindikasi penurunan BB

C= CHOLESTEROL and CIGARETES CESSATION

• Target kadar total kolesterol < 190 mg/dL dan kolesterolLDL < 100 mg/dL

• Kadar kolesterol HDL dan trigliserida tidak sebagai target terapi

• HDL < 40 mg/dL, Trigliserida > 180 mg/dL meningkatkanrisiko

• Mengubah pola hidup• terapi obat : HMG Co A reductase inhibitor (statin)

D = DIET and DIABETES

• Memilih makanan sehat1. mengurangi lemak total hingga < 30 % dari total asupan energi,

asam lemak jenuh < 1/3 dari total lemak dan kolesterol < 300 mg

per hari

2. mengganti asam lemak jenuh dengan lemak tidak jenuh dari

sayuran dan makanan laut

3. meningkatkan asupan buah, sereal dan sayuran

4. mengurangi total asupan kalori bila berat badan perlu

diturunkan

5. mengurangi asupan garam dan alkohol bila tekanan darah

tinggi

• Glukosa darahTarget kontrol glukosa darah pada diabetes yakni :

kadar glukosa darah puasa 91 – 120 mg/dL,

post prandial 136 – 160 mg/dL,

HbA1C < 7 % dan menghidari hipoglikemia

E. EDUCATION and EXERCISEEDUCATION

- Pencegahan Primersasaran : kelompok resiko tinggi

tujuan : mencegah/mengurangi kejadian PJK

- Pencegahan SekunderSasaran : kelompok pasien PJK

Tujuan : mencegah komplikasi

- Pencegahan TersierSasaran : kelompok pasien PJK dengan komplikasi

Tujuan : mencegah mortalitas dan morbiditas

EXERCISE

Olahraga aerobik minimal 30 menit yang dilakukan minimal 5 x / minggu

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F = FUNHindari stress berlebihan, perbanyak aktivitas rekreasi yang menyenangkan

G = Genetic conselingTerutama terhadap pasien dengan keluarga penyakit jantung prematur.

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Framingham Heart StudyMurabito et al Circulation 1993; 88: 2548-54

Patients (%)

Women

0

Men

20 40 60

62 %

46 %

First clinical presentation of coronary artery disease is frequently an

acute coronary syndrome. i.e. can be the last …

Clinical presentation of coronary disease

Courtasy of John Deanfield

Take Home Messages

ACS largely due to atherosclerosis plaque rupture or erosion

Atherosclerosis plaque last a lifetime

ECG is the mainstay to determine ACS

Pay attention to normal ECG but relevant symptom or Atypical ECG changes on admission.

Serial ECG may help

Prevention is all the core

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