ACUTE CORONARY

SYNDROME
PRESENTATOR : dr.MARWAN NASRI
PEMBIMBING : Prof.dr.HARRIS HASAN,SP.PD (K), SP.JP (K)

PROGRAM PENDIDIKAN MAGISTER

KEDOKTERAN JANTUNG DAN PEMBULUH DARAH
FAKULTAS KEDOKTERAN
UNIVERSITAS SUMATERA UTARA

DEFINITION
Acute coronary syndrome (ACS) refers to a
spectrum of clinical presentations ranging from
those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in
nonST segment elevation myocardial infarction
(NSTEMI) or in unstable angina.
It is almost always associated with rupture of an
atherosclerotic plaque and partial or complete
thrombosis of the infarct-related artery.

UNIVERSAL DEFENITION
MYOCARDIAL INFARCTION

UNIVERSAL DEFINITION OF
MYOCARDIAL INFARCTION

Hospitalizations in the U.S. Due to

Acute Coronary Syndromes (ACS)
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI

STEMI

1.24 million

.33 million

Admissions per year

Admissions per year

Heart Disease and Stroke Statistics 2007 Update. Circulation

2007; 115:69-171. *Primary and secondary diagnoses. About
0.57 million NSTEMI and 0.67 million UA.

ATHEROSCLEROSIS
TIMELINE

MECHANISMS OF
CORONARY THROMBOSIS

Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 171

CONSEQUENCES OF
CORONARY THROMBOSIS

Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 173

INITIAL
EVALUATION
AND
MANAGEMEN
T

CHEST PAIN

ECG ASSESSMENT

ECG ASSESSMENT
ECG manifestations of acute myocardial
ischaemia (in absence of LVH and LBBB)

ECG changes associated with prior

myocardial infarction

ACUTE STEMI
EVOLUTION

Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182

BIOMARKER FOR ACS

From: ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations: A
Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents

J Am Coll Cardiol. 2012;60(23):2427-2463. doi:10.1016/j.jacc.2012.08.969

TIMING OF RELEASE OF VARIOUS BIOMARKERS

AFTER ACUTE MYOCARDIAL INFARCTION

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.

BIOMARKER FOR ACS

European Heart Journal (2011) 32,2999 - 3054

TROPONIN KINETICS IN THE INDEX CASES

Mahajan V, Jarolim P. Circulation 2011;124:2350-2354

Copyright American Heart Association, Inc. All rights reserved.

Treatment of Acute
Coronary Syndromes:
STE vs. Non STE

Treatment of Acute Coronary

Syndromes
Anti-ischemic therapies

-blocker
Nitrates
+/- Calcium channel blocker

General measures:

Pain control (morphine)

Supplemental O2 if needed

Antithrombotic therapies
Antiplatelet agents:

Anticoagulants (use one):

Aspirin
Clopidogrel (or prasugrel)
GP IIb/IIIa inhibitor (for selected high
risk patients; may be deferred until PCI)
LMWH (enoxaparin)
Unfractionated intravenous heparin
Fondaparinux
Bivalirudin (should be used in ACS
patient only if undergoing PCI)

Adjunctive therapies:

Statin
Angiotensin converting-enzyme inhibitor

STEMI

REPERFUSI

REPERFUSION THERAPY :
TIME IS MUSCLE

Modified from Gersh BJ, Stone GW, White HD, Homes DR Jr: Pharmacological facilitation of primary percutaneous coronary
intervention for acute myocardial infarction: Is the slope of the curve the shape of the future? JAMA 293:979, 2005.

Recommendation for Reperfusion Therapy

REPERFUSION THERAPY FOR STEMI

From: Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review
of Contemporary Management Options
J Am Coll Cardiol. 2007;50(10):917-929. doi:10.1016/j.jacc.2007.04.084

Figure Legend:
American College of Cardiology/American Heart Association Guidelines for Selecting a Reperfusion Strategy

*Operator experience >75 primary PCI cases per year. Team experience >36
Copyright The American College of Cardiology.
primary PCI cases per year. Applies
fibrin-specific agents. This calculation
All rightsto
reserved.

Date of download:
4/22/2014

Figure 3. A suggested strategy for the management of STEMI. All patients are promptly
evaluated at the earliest point of care and should receive prompt antiplatelet and
antithrombin therapy and proceed either along a pharmacological or mechanical reperfusion
strategy.

Armstrong P et al. Circulation 2003;107:2533-2537

Copyright American Heart Association, Inc. All rights reserved.

Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

REPERFUSION INJURY

Circulation. 2002;105:2332-2336

PRIMARY PCI IN STEMI

Indications for Fibrinolytic Therapy

When There Is a >120-Minute Delay
From FMC to Primary PCI

Indications for Transfer for Angiography

After Fibrinolytic Therapy

*Although individual circumstances will vary, clinical stability is defined by the

absence of low output, hypotension, persistent tachycardia, apparent shock, highgrade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous
recurrent ischemia.

Indications for PCI of an Infarct Artery in

Patients Who Were Managed With Fibrinolytic
Therapy or Who Did Not Receive Reperfusion
Therapy

*Although individual circumstances will vary, clinical stability is defined by the absence of low output,
hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic
supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

Combined reperfusion strategies

in ST-segment elevation MI:
Rationale and current role

doi:10.3949/ccjm.77a.10024

Combined reperfusion Strategies

in st-segment elevation MI:
rationale and current role

PCI VS THROMBOLITIC

UAP/NSTEMI

Braunwald Clinical Classification of UA/NSTEMI

DIAGNOSTIC AND THERAPEUTIC STEPS

NSTE ACS

Step one - Initial

Evaluation
CHEST
PAIN

ECG

WORKING
DIAGNOSIS

INITIAL
TREATMENT

RISK
FACTOR

STEMI
NSTE
MI
ACS
UNLIKELY

Step Two - Diagnosis Validation

And Risk Assesment
After the patient is assigned to the group NSTE-ACS, i.v.
and oral antithrombotic treatments will be started
Routine clinical chemistry, particularly troponins (on
presentation and after 69 h)
Repeat or continuous ST-segment monitoring
Ischaemic risk score assessment (GRACE score).
Echocardiogram
Bleeding risk assessment (CRUSADE score)
Optional: chest X-ray, CT, MRI or nuclear imaging for
differential diagnoses (e.g. aortic dissection, pulmonary
embolism, etc.)

Step Two - Diagnosis Validation

And Risk Assesment

RISK STRATIFICATION

European Heart Journal (2011) 32,2999 - 3054

Thrombolysis In Myocardial Ischemia (TIMI)

risk score for unstable angina or nonST
elevation myocardial infarction (UA/NSTEMI)

A, modified from Antman EM, Cohen M, Bernink PJLM, et al: The TIMI risk score for unstable angina/nonST elevation
MI: A method for prognostication and therapeutic decision-making. JAMA 284:835, 2000. B, data from Cannon CP,
Weintraub WS, Demopoulos LA, et al: Comparison of early invasive and conservative strategies in patients with
unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 344:1879, 2001

GRACE RISK SCORE

Mortality in hospital and at 6 months

Step Three Invasive Strategy

Criteria for high risk with indication for
invasive management

INVASIVE VS CONSERVATIF

Decision-making algorithm for the management of patients with non-ST-elevation acute

coronary syndrome

Bassand J et al. Eur Heart J 2007;28:1598-1660

Decision-making algorithm for the

management of patients with non-STelevation acute coronary syndrome

Step Four
Revascularization Modalities
ANGIOGRAPHY

NO CRITICAL
LESION

MEDICAL
THERAPY

SINGLE-VESSEL
DISEASE

PCI

MULTIVESSEL
DISEASE

PCI/CABG

STEP FIVE: HOSPITAL DISCHARGE

AND POST-DISCHARGE MANAGEMENT
MEASURES CHECKED AT
DISCHARGE

Acute MI: Complications

Recurrent ischemic/reinfarction
Arrhythmias
Myocardial dysfunction
Mechanical complications
Pericarditis
Thromboembolism

Complications of MI
Myocardial Infarction

Ventricular
thrombus
Embolism

Contractility

Cardiogenic
shock
Ischemia

Electrical
instability

Tissue
necrosis

Arrhythmias

Pericardial
inflammation
Pericarditis

Hypotension

Coronary
perfusion
pressure

Papillary
muscle
infarction/
ischemia

Ventricular Ventricular
septal
rupture
defect

Mitral
regurgitation
Congestive
heart failure

Cardiac
tamponade

TERIMA KASIH