Sie sind auf Seite 1von 35

Acute Coronary Syndrome

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
2

Chief Complaint
Chest Pain
Angina Equivalent
Accompanied symptom ?; associated
with cardiac function

Angina Pectoris
A syndrome resulting from myocardial
ischemia
Demand and supply imbalance
Careful history taking; risk factor, activity
/stress-induced pain, location,character of
pain, duration, etc

Spectrum Of ACS

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
7

Physical Examination
Alert-Unconscious
BP: Hypertension-Normal-Hypoptension
HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
RR: Tachypnea-apnea
Cor: Regular-iregular, murmur, gallop
Pulmo: Normal-Rales- wheezing
Ext: cold, pulsation, edema, etc.
8

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
9

UAP/Acute NSTEMI

10

Acute NSTEMI

11

Acute STEMI- Evolution

12

LOKASI ISKEMIA
BERDASARKAN PERUBAHAN DI SANDAPAN EKG
SANDAPAN
II ,III, aVF
V1,V2
V3-V4
V1-V6, I, aVL
I,aVL ,V5,V6
I, V6
V7-V9
V3R, V4R

LOKASI ISKEMIA / INFARK


Inferior
Septal
Anterior
Anterior ekstensif
Lateral
Apikal
Posterior
Ventrikel kanan
13

14

ECG demonstrates large anterior infarction


15

16

17

Inferior STEMI

18

LBBB

19

RBBB

20

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
21

Increased serial cardiac marker


Troponin T/Troponin I
CKMB

22

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
23

Treatment of ACS
Treat the emergency condition;
complication of ACS; asystole, apneu,
syock, acute lung edema, etc
Confirm the diagnosis
Treat the cause
Treat co-morbid
24

DRUGS for AMI


MONACo greets all MI patients
M = Morphine
O = Oxygen
N = Nitrate
A = Aspirin
Co= Clopidogrel

25

The time is muscle

26

Emergency Department
(1)
AMI Protocol
-ECG screening within 10 minutes
-Door-to-drug time < 30 minutes
-Door-to-balloon time inflation < 90
minutes
For all patients with ischemic-type chest
pain, provide supplementary oxygen, IV
access, and continuous ECG monitoring
27

Emergency Department
(2)
Reperfusion therapy for ST-segment
elevation MI (STEMI)
- Rule out contraindications and
assess risk-benefit ratio
-Consider PCI if ineligible for
fibrinolytics
-angiography for cardiogenic shock
(angioplasty or CABG if indicated)
28

Fibrinolytic Use in Myocardial Infarction ( AHA 2004 )


Absolute Contraindications

Cautions/Relative Contraindications

Previous hemorrhagic

Severe uncontrolled HT on presentation

stroke at any time

(BP >180/110 mm Hg)

Ischemic strokes 3 mo
( except 3 hrs )

History of prior CV accident or known intracerebral pathology not covered in CI

Known intracranial
malignant neoplasm

Current use of anticoagulants (INR 2-3);


known bleeding diathesis

Active internal bleeding


/ bleeding diasthesis
( not include menses )

Recent trauma ( 2-4 wks ), head trauma

Noncompressible vascular punctures


Recent ( 2-4 wks ) internal bleeding
Suspected aortic dissection For streptokinase : prior exposure
( within 5d-2y ) or prior allergic rx
Head / facial trauma
Pregnancy
Active peptic ulcer
within 3 mo
History of chronic HT 29

PCI

30

31

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
32

33

34

Thank You

35