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Acute Coronary

Syndromes

Bag / SMF Ilmu Penyakit Dalam


FK Universitas Islam Sultan Agung
Semarang
MI 2 2014
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??
CAD Causes
Type Comments
Atherosclerosis Most common cause. Risk factors: hypertension,
hypercholesterolemia, diabetes mellitus, smoking, family history of
atherosclerosis.
Spasm 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.
Emboli Rare cause of coronary artery disease. Can occur from vegetations
in patients with endocarditis.
Congenital Congenital coronary artery abnormalities are present in 1 to 2% of
the population. However, only a small fraction of these
abnormalities cause symptomatic ischemia.

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition:
6
http://www.accesspharmacy.com
Pembuluh darah yang mengalami aterosklerosis & trombosis
Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment


Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
Expanding Risk Factors
Smoking Age-- > 45 for male/55
Hypertension for female
Diabetes Mellitus Chronic Kidney Disease
Dyslipidemia Lack of regular physical
activity
Low HDL < 40
Obesity
Elevated LDL / TG
Lack of diet rich in
Family Historyevent fruit, veggies, fiber
in first degree relative
>55 male/65 female
Chest pain

ST elevation ST depression
ECG ST segment

Bio-chemistry Troponin rise / Troponin


fall normal

Diagnosis

STEMI NSTEMI UA
Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 3054, Davies MJ. Heart 2000;83:361366 11
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-Q-Wave 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
GRACE REGISTRY
STEMI Higher mortality 6
months after
NSTEMI
discharge in
NSTEMI vs STEMI
UA

NSTEMI

STEMI

UA

Fox KAA et al. BMJ 2006;333:1091-1094


Risk Stratification is important in NSTE-ACS
Management

1 CLINICAL CONDITION

2 3
TIMI SCORE GRACE SCORE

Less accurate in predicting recommended as the


events but its simplicity preferred classification to
makes it useful and widely apply on admission and at
accepted discharge in daily clinical
routine practice
Hamm W et al. European Heart Journal 2007; 28:15981660; Hamm CW et al. Eur Heart J
2011;32:2999 3054
HIGH RISK VERY HIGH RISK
Relevant rise or fall in troponin
Dynamic ST- or T-wave changes Haemodynamic instability or
(symptomatic or silent) cardiogenic shock
GRACE Score > 140 Recurrent or ongoing chest
pain refractory to medical
Intermediete RISK treatment
Life-threatening arrhythmias
Diabetes mellitus or cardiac arrest
Renal insufficiency Mechanical complications of
(eGFR <60 mL/min/1.73 m) MI
LVEF < 40% or congestive HF Acute heart failure
Early post infarction angina Recurrent dynamic ST-T
Prior PCI wave changes, particularly
Prior CABG with intermittent ST-
GRACE risk score 109 - 140 elevation
Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
TIMI Risk Score for NonST-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, myocardial
infarction or urgent need for revascularization as follows:
High Risk Medium Risk Low Risk
TIMI risk score 57 points TIMI risk score 34 points TIMI risk score 02 points
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:
21
http://www.accesspharmacy.com
GRACE RISK SCORE
Age ( Years ) Point Heart Rate Creatinin (mg/dl)
< 40 0 < 70 0 0,0 0,39 2
40 49 8 70 89 7 0,4 0,79 5
50 59 36 90 109 13 0,8 1,19 8
60 69 55 110 149 23 1,2 1,59 11
70 79 73 150 199 36 1,6 1,99 14
> 80 91 > 200 46 0,2 3,99 23
Systolic BP (mmHg ) Killip class >4 31
< 80 63 Class I 0
80 99 58 Class II 20
Total possible score is 258
100 119 47 Class III 39
120 139 37 Class IV 59
140 159 26 Cardiac arrest at admission 43
160 199 11 Elevated cardiac marker 15
> 200 0 ST segmen deviation 30
Bleeding risk score CRUSADE SCORE

Very low < 20 ; low (2130) ; moderate (31 40);


high (4150); very high (50)
Hamm CW et al. Eur Heart J 2011;32:2999 3054
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
Definite Indications for
Thrombolytic Therapy
Consistent Clinical Syndrome
Chest pain, new arrhythmia,
unexplained hypotension or pulmonary
edema
Diagnostic ECG
ST elevation 1 mm in 2 contiguous
leads or new left bundle-branch block
Less than 12 hours since onset of pain
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 ST depresi Hiperakut T


T: pos tinggi & menetap > dlm & ST elevasi
simetris /neg dalam lama Q patologis
T : neg dalam

Marker CKMB ( - ) CKMB positif CKMB ( + )


Tropinin + / - Troponin - / + Troponin + / -
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.