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Sindrom Koroner Akut
Departemen Ilmu Penyakit Dalam
FKUI / RSUPN Dr Cipto Mangunkusumo
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Mortality in Acute Coronary Syndrome
Hospital mortality STEMI > NSTEMI
Mortality rate at 6 months STEMI vs NSTEMI
very s m lar 12% vs 13%
Death rate at 4 ears NSTEMI 2 x STEMI
ESC Guideline 2007
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Sindrom Koroner Akut
• Suatu keadaan gawat darurat jantungden an manifestasi klinis erasaan tidak
enak di dada atau gejala-gejala lain sebagai
akibat iskemia miokard
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( SKA )
• Infark miokard akut dengan elevasi segmen ST
e eva on myocar a n arc on
• Infark miokard akut tanpa elevasi segmen ST( Non-ST elevation myocardial infarction /
NSTEMI )
• Angina pektoris tak stabil
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Ischemic Discomfort
Presentation
Acute Coronary Syndrome
Working Dx
ECG ST Elevationo ST Elevation
NSTEMI
Cardiac
Biomarker
UA
Non-ST ACS
Final Dx
NQMI Qw MI
Unstable
Angina
Myocardial Infarction
Q Q
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538;
Davies MJ. Heart 2000; 83:361-366.
Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.
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Patofisiologi SKA
• Disrupsi plak •
• Vasokonstriksi
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Disrupsi Plak
• Infark miokard akut ( IMA ) :- -
- 60 % terjadi pada stenosis < 50 %• s o ter a nya ruptur p a tergantung :
Kerentanan plak , bukan ukuran
( derajat penyempitan plak )
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ACSACS PathophysiologyPathophysiologyPlaque Rupture, Thrombosis, andPlaque Rupture, Thrombosis, and MicroembolizationMicroembolization
Quiescent plaqueQuiescent plaqueProcessPlaque formation
ProcessPlaque formation
ar er Cholesterol
LDL
ar er Cholesterol
LDLLipid coreLipid core
InflammationInflammationC-Reactive Protein
C-Reactive Protein
Vulnerable plaqueVulnerable plaque
Multiple factors
? Infection
Multiple factors
? Infection
Interleukin 6, TNFα,
sCD-40 ligand
Interleukin 6, TNFα,
sCD-40 ligand
Collagen
platelet
TFClottingTFClotting CascadeCascadeInflammationInflammation
Plaque Rupture
? Macrophages
Metalloproteinases
Plaque Rupture
? Macrophages
Metalloproteinases
MDA Modified LDLMDA Modified LDL
Macrophages
Foam CellsMetalloproteinases
PlateletPlatelet--thrombin microthrombin micro--emboliemboliPlaquePlaque ruptureruptureThrombosis
Platelet Activation
Thrombosis
Platelet ActivationD-dimer, Complement,
Fibrinogen, Troponin,
D-dimer, Complement,
Fibrinogen, Troponin,
CRP, CD40LCRP, CD40L
Courtesy of David Kandzari.
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BEKUAN DARAH
NORMAL
RUPTUR/ SOBEK
PENGAPURAN
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-( Vulnerable Plaque )
• >
• Fibrous cap tipis ( kolagen dan sel otot
• Aktivitas sel inflamasi meningkat
( makrofag, limfosit T dan sel mast )
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Pato enesis SKA• Angina pektoris tak stabil
relatif kecil oklusi trombus transien.Trombus labil, oklusi sementara, 10-20 menit
• NSTEMI ( Non ST elevation myocardial infarction )
Kerusakan plak lebih berat oklusi trombus lebih, ,kolateral
•
Disrupsi plak pada daerah lebih besar oklusitrombus fixed dan persisten , > 1 jam nekrosismiokard transmural
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Harus ditegakkan secara cepat dan tepat
berdasarkan 3 kriteria :1. Gejala klinis berupa nyeri dada khas
2. Gambaran elektrokardiogram
3. Evaluasi biokimia enzim jantung
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Nyeri DadaSifat nyeri dada tipikal ( angina ):
• Lokasi : substernal, retrosternal, dan prekordial
• S at nyer : rasa sa t sepert te an, rasa ter a ar,ditindih benda berat, ditusuk, rasa diperas dan
• Penjalaran ke : leher, lengankiri, punggung /
interskapula, mandibula, gigi , lengan kanan• Nyeri membaik atau hilang dengan istirahat atau obat
nitrat
• Faktor pencetus : latihan fisik, stres emosi, udaradingin dan sesudah makan
, , ,
keringat dingin dan lemas
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Patient experiences chest
pain/discomfort
Has the patient been previously prescribed NTG?
No
Is Chest Discomfort/Pain Unimproved or
Worsening
Take ONE NTG Dose Sublingually
Yes
5 Minutes After It Starts ?
Yeso
Is Chest Discomfort/Pain Unimproved or
Worsening
5 Minutes After Taking ONE NTG Dose
Sublingually?
CALL 9-1-1
IMMEDIATELY
Sublingually?
Yes No
otify Physician
Follow 9-1-1 instructions
[Pts may receive instructions to chew ASA (162-325 mg)*
if not contraindicated or may receive ASA* en route to the
For pts with CSA, if sx are
significantly improved after ONE
NTG, repeat NTG every 5 min for a
total of 3 doses and call 9-1-1 if sx
hospital]
have not totally resolved.
*Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated
formulations. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 3. CSA = chronic stable angina.
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ElektrokardiogramEKG 12 sandapan secara serial.
Ciri-ciri gambaran EKG pada SKA:
• Angina Pektoris Tak Stabil :Depresi gelombang ST dengan atau inversigelombang T, kadang-kadang elevasi segmen STsewaktu nyeri, tanpa gel.Q
,
>1 mm pada sandapan ekstremitas
,T dalam
• STEMI : terbentuk el ada EKG serial
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Petanda Biokimia ( Enzim Jantung )
• a u an secara ser a
• Creatinin Kinase ( CK ) MB:
men ng a se e a am, punca : - am,
normal : 2-4 hari•
meningkat setelah 2 jam, puncak : 10-24 jam,
masih da at dideteksi Tn T : 5-14 hari Tn I : 5-10 hari )
• Kenaikan nilai enzim di atas 2 kali nilai batas atas
normal menunjukkan adanya nekrosis jantung (infark miokard )
- , ,
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Definisi Infark Miokard Akut
Nekrosis miokard akut akibat gangguan aliran,
akibat oklusi arteri koronaria karena trombus
atau spasme e at yang er angsung ama.
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Mana ement of STEMIMana ement of STEMI
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Options for Transport of Patients With STEMI
Hospital fibrinolysis:
Door-to-Needle
ithin 30 min.
Not PCIcapable
Onset of
symptoms of
STEMI
9-1-1
EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs.
• Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30
min. PCI
Inter-
Hospital
Transfer
EMS Transport
GOALS
Patient EMS Prehospital fibrinolysis
- -
EMS transport
- -
5
min.8
min.
- -
within 30 min.
- - .
Patient self-transportHospital door-to-balloon
within 90 min.Dispatch
1 min.
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at
http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001. Figure 1.
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Penatalaksanaan
• Tata laksana Pra-Rumah sakit•
- Instalasi Gawat Darurat
- ntensive oronary are nit
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Tata Laksana Pra Rumah Sakit
Prinsip penatalaksanaan :•
• Apakah ada indikasi reperfusi segera
• Teknis tranportasi ke RS yang dirujuk
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TerapiTerapi ReperfusiReperfusi pada pada STEMI (ESC 2008)STEMI (ESC 2008)
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Primar PCI
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
PCI capability should be treated with primaryPCI within 90 min of first medical contact as a
STEMI patients presenting to a hospital without PCI
III
IIaIIaIIa
IIbIIbIIb
IIIIIIIII
III
IIaIIaIIa
IIbIIbIIb
IIIIIIIII
III
IIaIIaIIa
IIbIIbIIb
IIIIIIIII
IIaIIaIIa
IIbIIbIIb
IIIIIIIII
sys ems goa .
STEMI patients presenting to a hospital without PCI
capability, and who cannot be transferred to a PCI
center and undergo PCI within 90 min of first
di l h ld b d i h fib i l iedical contact, should be treated with fibrinolytic
therapy within 30 min of hospital presentation as a
systems goal, unless fibrinolytic therapy isg y py
contraindicated.
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SKA Tan a Kom likasi
• Tentukan tanda vital, monitoring EKG, alatresusitasi rekam EKG 12 sanda an
• Nitrat short acting SL: bila nyeri dada, TD sistolik> 90
• O2 3-5 l/m
• Infus Nacl 0,9 % atau dekstrosa 5 %• Aspirin 160-325 mg oral ( bila tak ada
kontraindikasi )
• op ogre mg. a an pr may mg• Nyeri tak berkurang dengan nitrat : MO 2,5 mg,
mg
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SKA Tanpa Komplikasi
Bila ada indikasi trombolitik/ primary PCI :• ST elevasi >1 mm pada > 2 sandapanekstremitas atau > 2 mm pada > 2 sandapan
prekordial berdampingan
• Usia < 75 tahun
memungkinkan : primary PCI/ trombolitik
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SKA dengan Komplikasi
ema paru :
• O2 6-8 l/m
• trat atau : – ug m
• Furosemid IV : 40-80 mg/ drip.
• MO : 2,5 mg dapat diulang tiap 5 menit sampai
dosis total 20 mg
yo ar ogen , r tm a, ar ac arrest.segera distabilkan indikasi untuk Primary PCI
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Transportasi ke RS yang Dirujuk
• Pasien dengan nyeri dada yang mungkinmenderita SKA harus ditandu den an
posisi yang menyenangkan , dianjurkan
elevasi ke ala 40 dera at dan harusterpasang akses intravena
•
khusus
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Tata Laksana di IGD• Harus segera dievaluasi
• Pemeriksaan klinis dan EKG 12 sandapan
• O2, infus NaCl 0,9 atau dekstrosa 5 %
•
• Obat : - nitrat SL, transdermal/ nitrogliserin IV,
- - + ,
bila alergi/kontraindikasi : beri klopidogrel
atau tiklo idin
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Tata Laksana ICCU
Umum• Pasang infus IV: dekstrosa 5% atau NaCl 0,9%• antau tan a v ta : t ap am sampa sta , t ap am
atau sesuai kebutuhan catat jika frekuensi jantung <60atau >110 kali/ mnt: tekanan darah <90 atau >150
• Aktivitas: istirahat di tempat tidur dengan kursi
commode di samping tempat tidur & mobilisasi sesuai
• Diet: puasa sampai bebas nyeri, kemudian diet cair.Selanjutnya diet jantung (komplek karbohidrat 50-55%
,dari kalori), tmsk makanan tinggi kalium (sayur, buah),magnesium (sayuran hijau, makanan laut) & serat (buah
, ,
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Oksigen nasal 2 l/mnt: dlm 2-3 jam pertama;
rendah (<90%)
a. Morfin 2,5 mg (2-4 mg) IV, dpt diulang
i 5 mn m i i l 20 m b. Pethidin 25-50 mg IV atau
.
d. Nitrat sublingual / patch, intravena bila
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• Terapi reperfusi primay PCI / (trombolitik) streptokinase / tPA:
Tujuan : 1. door to needle time < 30 mnt
2. door to dilatation time < 90 mnt
1. Elevasi ST ≥ 1 mm pada 2 / lebih sandapan ekstremitas berdampingan / ≥ 2 mm pd 2 / lebih sandapan prekordial,
jam, usia < 75 th
2. Blok cabang berkas (BBB) & anamnesis dicurigai infark
Dosis obat-obat trombolitik:
1. Stre tokinase: 1 5 uta UI dlm 1 am
2. Aktivator plasminogen jaringan (tPA): bolus 15 mg,dilanjutkan 0,75 mg/kgBB (maksimal 50 mg) dalam jamertama & 0 5 m /k BB maksimal 35 m dalam 60 mnt
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• Antitrombotik :1. As irin 160-325 m hisa / telan2. Clopidogrel ( Loading dose 300 mg / 4 tab )3. Heparin:Rekomendasi:a. Pasien yg menjalani terapi revaskularisasi per kutan / bedah
b. Diberikan intravena pada terapi reperfusi alteplase.c. Un ractionated he arin UFH IV / low molecular wei ht
heparin (LMWH) SK pada pasien dengan infark miokardnon-ST elevasi
d. UFH SK (mis. 7500 U BID) / LMWH (mis. Enoxaparin 1trombolitik & tidak ada kontraindikasi heparin. Pada pasiendengan risiko tinggi terjadi emboli sistemik ( infark miokardanterior / luas, fibrilasi atrial, riwayat emboli / terdapatrom us ven r e r epar n e erp .
e. Heparin IV pada pasien yang mendapat terapi trombolitik nonselektif ( streptokinase, anisteplase, urokinase ) yang
Heparin diberikan dengan target aPTT 1,5-2,5 kali kontrol
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• Mengatasi rasa takut dan cemas: diazepam 3 x- .
• Obat pelunak tinja: laktulosa (laksadin) 2 x 15
• Terapi tambahan:
• enye at eta: a ta a a ontra n as
• Penghambat ACE terutama pada: infark
m o ar a ut uas anter or, gaga antungtanpa hipotensi, riwayat infark miokard
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Beta-Blockers
Oral beta-blocker therapy should be initiated in the first 24
hours for patients who do not have any of the following: 1)
I IIa IIb IIIhours for patients who do not have any of the following: 1)
signs of heart failure, 2) evidence of a low output state, 3)
increased risk* for cardiogenic shock, or 4) other relative
contraindications to beta blockade (PR interval > 0.24 sec,ontraindications to beta blockade (PR interval 0.24 sec,
2
nd
- or 3
rd
-degree heart block, active asthma, or reactive
airway disease).
It is reasonable to administer an IV beta blocker at the time of
presentation to STEMI patients who are hypertensive and who
do not have any of the following: 1) signs of heart failure, 2)
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
evidence of a low output state, 3) increased risk* for
cardiogenic shock, or 4) other relative contraindications to
beta blockade (PR interval > 0.24 sec, 2
nd
- or 3
rd
-degree heart
bl k ti th ti i di )lock, active asthma, or reactive airway disease).
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AnticoagulantsAnticoagulants
Patients undergoing reperfusion with fibrinolytics
should receive anticoa ulant thera for a minimum of
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
48 hours (Level of Evidence: C) and preferably for the
duration of the index hospitalization, up to 8 days
recommended if anticoagulant therapy is given for more
than 48 hours because of the risk of heparin-induced
.
(Level of Evidence: A)
include:♥ UFH (LOE: C)
♥ Fondaparinux (LOE:B)
A i l
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Anticoagulants
It is reasonable for patients with STEMI who do not
undergo reperfusion therapy to be treated with
I IIaIIb IIIg p py
anticoagulant therapy (non-UFH regimen) for the
duration of the index hospitalization, up to 8 days.
Convenient strategies that can be used includeI IIaIIb IIIConvenient strategies that can be used include
those with LMWH
Level of Evidence: C)
or
fondaparinux Level of Evidence: B) using the same
dosing regimens as for patients who receive
fibrinolytic therapy.
I IIaII III
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Meadows TA, Bhatt DL. Circ Res. 2007;100:1261-1275.
Thi idi
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Thienopyridines
Clopidogrel 75 mg per day orally should be added toI IIa IIb III
aspirin in patients with STEMI regardless of whether
they undergo reperfusion with fibrinolytic therapy or I
I
o no rece ve reper us on erapy.
Treatment with clo ido rel should continue
II IIaIIb III
for at least 14 days.
Thi idi
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Thienopyridines
In patients < 75 years who receive fibrinolyticI IIa IIb IIIerapy or w o o no rece ve reper us on erapy,
is reasonable to administer an oral clopidogrelloading dose of 300 mg . (No data are available to
guide decision making regarding an oral loading
dose in patients ≥ 75 years of age.)
Long-term maintenance therapy (e.g., 1 year) with
clopidogrel (75 mg per day orally) can be useful inI IIaIIb III
pa en s re ar ess o w e er ey un er o
reperfusion with fibrinolytic therapy or do not
receive reperfusion therapy.
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Penyulit dan Penatalaksanaan
• Aritmia dan cardiac arrest•
• Syok kardiogenik
• omp as me an
• Perikarditis
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Aritmia dan Cardiac Arrest
ATRIAL FIBRILASI
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Aritmia dan Cardiac Arrest• Fibrilasi Atrium
Rekomendasi :
Kardioversi elektrik untuk pasien dengan ggn.
Digitalisasi cepat untuk menurunkan respons ventrikel
cepat dan memperbaiki fungsi ventrikel kiriPenyekat beta IV untuk menurunkan respons ventrikel
cepat pada pasien tanpa disfungsi ventrikel kiri secaraklinis, penyakit bronkospasme, atau blok AV
Diltiazem atau verapamil IV untuk menurunkan responsventrikel cepat jika penyekat beta merupakan
Harus diberikan heparin
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• Fibrilasi Ventrikel
Rekomendasi :
s oc uns nc oron ze w
200 J; jika tak berhasil harus diberikan shock u - u s oc .
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Takikardia Ventrikel
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• Takikardia Ventrikel
Rekomendasi:
>
menyebabkan kolaps hemodinamik) harus diterapidengan DC shock unsynchronized menggunakan
energi awal 200 J; jika gagal harus diberikan shock
kedua 200-300 J dan jika perlu shock ketiga 360 J.
VT monomorfik menetap yang diikuti dengan
angina, edema paru, atau hipotensi (TD < 90
mm g arus erap gn s oc sync ron ze
energi awal 100 J. Energi dapat ditingkatkan jika
VT monomorfik yang tidak disertai angina edema paru
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VT monomorfik yang tidak disertai angina, edema paru
a au po ens mm g erap gn sa a sa uregimen berikut :
-. ,
2. Disopiramid: bolus 1-2 mg/kg dalam 5-10 menit.
a. Cara I: diberikan 150 mg infus selama 10 mnt,
dilanjutkan 1 mg/mnt selama 6 jam dilanjutkan pemeliharaan 0,5 mg/mnt
b. Cara II: diberikan 5 mg/kgBB selama 20-60 mnt,
an ut an peme araan mg g a am
jam
.
(anestesi sebelumnya)
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Blok AV Derajat II ( Tipe Wenckebach )
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Blok AV Derajat III
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Rekomendasi atropin:
• s sto ventr e
• Blok AV simtomatik terjadi pada tk. Nodus AVera a ua pe a au era a gn r me escape
komplek sempit)
.50/mnt disertai hipotensi, iskemia aritmia, escape
ventrikel .
Dosis 0,5 mg IV dpt diulang tiap 5 mnt dgn dosis total 2 mg IV Dosis 0,5 mg IV dpt diulang tiap 5 mnt dgn dosis total 2 mg IV
Iso roterenol Isu rel : 0,5Iso roterenol Isu rel : 0,5--4 u /mnt bila tera i atro in a al,4 u /mnt bila tera i atro in a al,sementara menunggu pacu jantung sementara.sementara menunggu pacu jantung sementara.
Rekomendasi Pacu Jantung Sementara
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Rekomendasi Pacu Jantung Sementara
(Transvenous)
• Asistol
• Bradikardia simtomatik (termasuk bradikardia
hipotensi tidak respons dengan atropin)
• BBB bilateral (alternating BBB atau RBBB dgn
a erna ng
• Blok bifaskular baru atau tidak diketahui
lamanya disertai dgn blok AV derajat 1
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Rekomendasi Pacu Jantung Permanen
• B o V era at ua menetap pa a s stem H s-
Purkinje dengan BBB bilateral atau blokantung omp et sete a IM
• Blok AV lanjut (derajat 2 atau 3) transient dandisertai BBB
• Blok AV simtomatik ada berba ai dera at
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Gagal Jantung/Edema Paru Akut
Penatalaksanaan gagal jantung
Diuretik furosemid IV
Nitrogliserin (mengurangi preload &
afterload ): 5 ug/mnt, dosis dinaikkan bertahapsampai tekanan arteri sistolik turun 10-15% tapi
tidak kurang dari 90 mmHg
Penghambat ACE
Digitalisasi terutama bila ada fibrilasi atrial
Penatalaksanaan Edema Paru Akut
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Penatalaksanaan Edema Paru Akut
Terapi O2: diberikan sampai 8 l/mnt, untukmempertahankan PaO2 kalau perlu dengan masker.
Intubasi endotrakeal, suction dan penggunaan
ventilator :
kondisi pasien makin memburuk, timbul sianosis,
makin sesak, takipnea, ronki bertambah, PaO2 tdk
2
konsentrasi dan aliran tinggi, retensi CO2,
,
edema secara adekuat.
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rog ser n su ngua a au :- Peroral 0,4-0,6 mg tiap 5-10 menit.
- a s sto cu up a > mm g,
diberikan mulai dosis 0,3-05 ug/kgBB )
Morfin sulfat : 2,5 mg (2-4 mg) IV,
dapat diulang tiap 5 menit sampai dosis total 20 mg
Diuretik: furosemid 40-80 mg bolus IV,
dapat diulang atau dosis ditingkatkan setelah 4 jam,
atau dilanjutkan dengan drip kontinyu sampai dicapai produksi urin 1 ml/kgBB/jam
Obat untuk menstabilkan keadaan klinis dan
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1. Nitroprusid IV: dimulai dosis 0,1 ug/kgBB/ mnt :
- ika tidak ada res ons an baik den an tera i nitrat
- regurgitasi mitral, regurgitasi aorta, hipertensi berat.
1. Dopamin 2-5 ug/kgBB/mnt atau dobutamin 2-10.
2. Digitalisasi : bila ada fibrilasi atrium atau kardiomegali
3. Intubasi & ventilator pada pasien dengan hipoksia berat,asidosis, atau tidak berhasil dgn terapi oksigen
4. Obat trombolitik atau revaskularisasi (urgent PTCA, CABG)
.
6. Koreksi definitif , misalnya penggantian katup atau repair pada regurgitasi mitral berat bila ada indikasi dan keadaan
n s memung n an.
S ok Kardio enik
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S ok Kardio enik
Penatalaksanaan
2
Norepinefrin IV 8-12 ug/mnt untuk mencapai tekanan arterisistolik ± 80 mmHg
Setelah TD 80 mmHg tercapai diganti dengan dopamin 5-15 ug/kg/mnt
Jika tekanan arteri sistolik menca ai 90 mmH dobutamin IV dapat diberikan bersamaan untuk mengurangi dosisdopamin
tersediaRevaskularisasi arteri koroner segera jika sarana tersedia
Terapi trombolitik jika sarana revaskularisasi tak tersedia
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• Diseksi aorta
• Perikarditis akut
• Penyakit esofagus, saluran cerna bagian atas, atau
sistem bilier
• Penyakit paru:
Penyakit pleura: infeksi, keganasan, atau sistem imun
Emboli paru akut
neumo ora s
• Penyakit dinding dada: tulang, neuropati, herpes
• s ogen
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Komplikasi mekanik
Ruptur septum ventrikel
uptur n ng ventr e
Penatalaksanaan: operatif
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Perikarditis
• Penatalaksanaan
-
terpilih
,
Kortikosteroid
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• Pertahankan preload ventrikel kanan Loading volume (infus NaCl 0,9%)
Hindari penggunaan nitrat dan diuretik
Pertahankan sinkroni AV: Pacu jantung sekuensial AV pada blok jantungderajat tinggi simtomatik yang tidak respons dengan atropin
• Berikan inotropik : dobutamin jika curah jantung gagal meningkatsetelah loading volume.
ventrikel kiri Pompa balon intraaortik
,
Penghambat ACE• Reperfusi
PTCA primer
CABG (pada pasien tertentu dengan penyakit multivessels)
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Trombolitik
. wayat stro emorag ; stro en s a n
atau kejadian serebrovaskular dalam 1 tahuntera r
2. Neoplasma intrakranial
3. Perdarahan internal aktif (kecuali
menstruasi)
4. Curiga diseksi aorta.
Kontraindikasi Relatif Pemberian Trombolitik
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. per ens era yang a er on ro mm g2. Rw. bencana serebrovaskular sebelumnya atau diketahui
kelainan patogenegis intraserebral yang tidak termasuk.
3. Penggunaan antikoagulan terakhir dengan dosis terapi (INR> 2-3) diketahui diatesis perdarahan
. rauma aru a am - mgg , termasu trauma atau ce erakepala atau resusitasi jantung paru (RJP) lama (> 10 menit)atau operasi besar ( 3 minggu ).
. ungs vas u ar yang a apa e an6. Streptokinase/anistreplase; riwayat penggunaan sebelumnya
(khususnya dalam 5 hari- 2 tahun terakhir) atau reaksi alergi
7. Kehamilan8. Ulkus peptikum aktif
9. Riwayat hipertensi berat kronik
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( APTS )
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Sindrom klinis nyeri dada yang sebagian besar
disebabkan oleh lak aterosklerotik dan
diikuti kaskade proses patologis yang
menurunkan aliran darah koroner ditandaidengan peningkatan frekuensi, intensitas atau
lama n eri an ina timbul ada saat
melakukan aktivitas ringan atau istirahat,tan a terbukti adan a nekrosis miokard.
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Rawat di ICCU
asang n us : e strosa atau a
0,9%
Aktivitas: istirahat di tempat tidur dengan
kursi commode disamping tempat tidur dan
mobilisasi sesuai toleransi setelah 12 jam
Diet: uasa sam ai n eri hilan diet cair
dan diet jantung (rendah lemak tinggi serat)
Farmakologis:
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• Oksigen nasal 2 l/m; terutama pada pasiensianosis, distres pernapasan, atau risiko tinggi
• Mengatasi rasa nyeri:
a.Nitrat sublingual atau patch
b.Jika angina tidak membaik setelah pemberiannitrogliserin SL 3 kali berturut-turut atau setelah
erap an s em a e ua ang na eru ang ma adiberikan nitrogliserin drip dan:
• Morfin 2 5 m 2-5 m IV da at diulan tia 5 menit
sampai dosis total 20 mg atau• Petidin 25-50 mg IV atau
• rama o - mg
Aspirin 80-325 mg hisap atau telan, klopidogrel,
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atau kontraindikasi terhadap aspirin
Heparin IV sesuai protokol, target aPTT 1,5-2,5kontrol. Biasanya diberikan 3-5 hari tergantung
respons klinis, atau LMWH.
nitrogliserin SL
Penghambat beta1. Propano o
2. Metoprolol
3. Atenolol
4. EsmololTarget frekuensi jantung 50-60 kali/menit
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• Mengatasi rasa takut dan cemas: diazepam 3 x 2-
• Obat pelunak tinja: lactulose (laksadin) 2x15 cc• Pert m ang an antagon s a s um terutama
diltiazem bila ditemukan:
. pertens : te anan ara s sto >mmHg
. s em a re ra er
3. Variant angina
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uDilakukan pada pasien dengan :
episode iskemia berat > 1 x dan
berkepanjangan (> 20 menit), terutama yang
disertai dengan :
Edema aru akut Regurgitasi mitral baru atau perburukan
po ens
Perubahan ST-T baru
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Mana ement of NSTEMIMana ement of NSTEMI
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Select Mana ement Strate :Select Mana ement Strate :
Initial Conservative StrategyInitial Conservative Strategy
ajor Changes
New Trial Data
Selection of Initial Treatment Strategy: InitialSelection of Initial Treatment Strategy: Initial
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nvas ve ersus onserva ve ra egynvas ve ersus onserva ve ra egyInvasive Recurrent angina/ischemia at rest with low-level activities despite
intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New/presumably new ST-segment depression
High-risk findings from noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Prior CABG
High risk score (e.g., TIMI, GRACE)
Reduced left ventricular function (LVEF < 40%)
Conservative onservative . ., ,
Patient/physician presence in the absence of high-risk features
Algorithm forAlgorithm for
Patients withPatients withDiagnosis of UA/NSTEMI is Likely or
Definite
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UA/NSTEMIUA/NSTEMIManaged byManaged by
ASA (Class I, LOE: A)Clopidogrel if ASA intolerant (Class I,
LOE: A)
A
an n aan n a
InvasiveInvasive Invasive StrategyInit ACT (Class I, LOE: A)
Acce table o tions: enoxa arin or UFH Class I LOE: A
Select Management Strategy
Initial
Conservative
Strategy
B
bivalirudin or fondaparinux (Class I, LOE: B) B1
Prior to Angiography
Init at least one (Class I, LOE: A) or
B2
o ass a, : o e o ow ng:
Clopidogrel
IV GP IIb/IIIa inhibitor
Factors favoring admin of both clopidogrel
Delay to Angiography
High Risk FeaturesEarly recurrent ischemic discomfort
Proceed to Diagnostic Angiography
Anderson JL, et al. J Am Coll Cardiol . 2007;50:e1-e157, Figure 7. ACT = anticoagulation therapy; LOE =
level of evidence.
LongLong--Term Antithrombotic Therapy at Hospital DischargeTerm Antithrombotic Therapy at Hospital Dischargeafter UA/NSTEMIafter UA/NSTEMI
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UA/NSTEMI
Patient Groups at
Discharge
New
Medical Therapy
without Stent
Bare Metal Stent
Group
Drug Eluting
Stent Group
ASA 162 to 325 mg/d for at least 1
month, then 75 to 162 mg/d
indefinitely (Class I, LOE: A)
ASA 75 to 162 mg/d indefinitely
(Class I, LOE: A)
Cl id l 75 /d t l t 1
ASA 162 to 325 mg/d for at
least 3 to 6 months, then 75 to
162 mg/d indefinitely
(Class I, LOE: A)
Clopidogrel 75 mg/d for at least 1
month and up to 1 year
(Class I, LOE:B)
Clopidogrel 75 mg/d at least 1
month (Class I, LOE: A) and up
to 1 year (Class I, LOE: B)
Clopidogrel 75 mg/d for at
least 1 year (Class I, LOE: B)
Add: Warfarin (INR 2 0 to 2 5) Continue with dual antiplatelet
Yes No
Indication for
Anticoagulation?
Add: Warfarin (INR 2.0 to 2.5)
(Class IIb, LOE: B)
Continue with dual antiplatelet
therapy as above
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 11. INR = international normalized ratio; LOE = level of evidence.
Kesimpulan
SKA k k d d j
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• SKA merupakan keadaan gawat darurat jantungyang mencakup : APTS, IMA non ST elevasi (
an e evas
• Prinsip penatalaksanaan SKA : mengembalikan
primer
• SKA erlu enan anan se era mulai di luar RSsampai di RS.
• Terapi IMA dimulai sedini mungkin, reperfusiarus su a ter a sana se e um - am
• Pengenalan SKA dalam keadaan dini merupakan
akan memperbaiki prognosis pasien
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Terima kasih
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