Intervention Procedure in

Acute Coronary Syndrome

Dr. dr. Eka Ginanjar, Sp.PD-KKV, FINASIM, FACP, FICA

Division of Cardiology, Internal Medicine Departement, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Pelayanan Jantung Terpadu (PJT) RS Dr Cipto Mangunkusumo, Jakarta

CURRICULUM VITAE

Dr. dr. Eka Ginanjar, SpPD, K-KV, FINASIM, FACP, FICA Education:

Medical Doctor – FKUI 2003

Spesialis Penyakit Dalam (SpPD) – FKUI/RSCM 2009

Clinical and Interventional Cardiology – National Heart

Institute, Kuala Lumpur Malaysia 2012

Konsultan Kardiovaskular (KKV), FKUI/RSCM 2014

PhD in Medical Science – FKUI 2019

Fellow/membership: Instructor for American Heart Association (AHA) BLS-ACLS

2010

Fellow of Indonesian Society of Internal Medicine (FINASIM)

2012

Fellow of American College of Physician (FACP) 2014

Fellow of International College of Angiology (FICA) 2015

Member of European Society of Cardiology (ESC) 2013

Member of European Association of Percutaneous

Cardiovascular Interventions (EAPCI) 2013

Member of Acute Cardiovascular Care Association (ACCA)

2013

Position: Medical Staff and Lecturer at FKUI/RSCM

Clinical and Interventional Cardiologist at PJT-RSCM

Clinical and Interventional Cardiologist at RS MMC Jakarta

General Secretary of Indonesian Society of

Cardiocereberovascular

HEAD OF INTEGREATED HEART CENTRE (PJT) – RSCM

Secretary General of PAPDI

@Dr_EKG

Interest:Interventional CardiologyPeripheral & Endovascular InterventionEmergency MedicineAcute Cardiovascular CareHeart Failure and Stem CellPublic Health and Health EconomicsHospital Management

CASE

Tn. T 40 yo

Presented with typical chest pain since 4 hours

Referred from RS K

Smoker 1-2 packs per day

Fatigue, BP 120/80 mmHg, HR 60 bpm, RR 20 x/m

WHAT SHOULD WE DO….?

ACS

Coronary

Thrombosis

Myocardial

Ischemia

CAD

Atherosclerosis

Risk Factors

( Dyslipidemia, BP, ,

Insulin Resistance,

Platelets, Fibrinogen, etc)Adapted from

Dzau et al. Am Heart J. 1991;121:1244-1263

Arrhythmia and

Loss of Muscle

Remodeling

Ventricular

Dilatation

Congestive

Heart Failure

End-stage

Heart Disease

Primary prevention

Secondary prevention

Stroke

The Cardiovascular Continuum of Events

Spectrum of Pathology and Clinical IHD

Stable angina NSTEMI STEMI

IHD= Ischaemic heart diseaseNSTEMI= Non ST segment elevation myocardial infarctionSTEMI= ST segment elevation acute myocardial infarctionACS= Acute coronary syndrome

ACS

Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.

Ischemic Heart Disease

SUPPLY vs DEMAND

Initial Assessment for ACS patients

10 minutes10 minutes

No need to wait the result

No need to wait the result

REVASCULARIZATION

RISK Stratification on NSTEMI/UAP

Case 2 Mrs. S 45 YO

Chest pain since 12 hours, on and off

DM

Trop T Negatif

Component Time Delay

Improve Public

Awareness ACS Network

CODE STEMI

In Hospital and EMS

Diagnose capabilities

Importance for Early Reperfusion

Reperfusion is a key strategy in Acute STEMI care

and it time dependent

Shortening the time from symptom to reperfusion

and choosing the optimal reperfusion strategy for

STEMI patients are a great challenges in practice.

The infarction related artery (IRA) must be opened

early, consistently, and thoroughly in order to

effectively restore myocardial perfusion

1. Zhang et al. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2011; 12(8):629-632; 2. Ibanez B et al. Eur Heart J. 2017; 00: 1–66

TIME and Myocardial Salvage

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Recommended /

indicated

Should be

considered

Not

recommended

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Recommended /

indicated

Should be

considered

Not

recommended

A primary PCI strategy is

recommended over fibrinolysis

within indicated Timeframes

1 A

2017

CATHLAB

Percutaneus Coronary

Intervention

CASE 3

Tn. M 54 yo.

Chest pain since 2 hours

History of HT, DM, Smoking

Trop T Negatif

Danchin N. J Am Coll Cardiol Intv. 2009; 2: 901– 908.

The success of reperfusion in STEMI is dependent on

the time of administration

Time delays are central in the decision-making process

Registry data show that the 30-min DTN and 90-min

DTB time goals are extremely difficult to achieve

Analysis of the NRMI (National Registry of Myocardial

Infarction) 3/4 data demonstrated that only 4.2% of

patients undergoing PPCI achieve a DB time 90 min

Time delays are also crucial to determine the best

reperfusion strategy

Mortality benefit with fibrinolytics is

greatest with shortest delay to treatment

1. Boersma E et al. Lancet 1996;348:771–775;

P=0.001 vs

other

timepoints

0 0.5 1.0 40

Odds ratio

≥12–24

≥6–12

≥3–6

≥2–3

≥1–2

0–1

Proportional effect of fibrinolytic therapy on

35-day mortality according to treatment delay1

Benefit shown for treatment delays up to 12 hours

Control/placebo

better

Fibrinolytic

better

Time to

treatment (h)

22 trials were

reported between

1983 and 1993

and indexed in

the MEDLINE

information

system.

Timing and logistical factors influence choice

of reperfusion strategy

1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation2013;127:e362–e425; 3. Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation2004;110:1909–1915; 6. Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142

• PCI vs non-PCI capable hospitals1–3

• Dependence on operator

expertise/volume3

• Availability of a 24/7 service1,3*

• Availability of a pre-hospital system for

diagnosis and treatment3,4,5

*Patients treated during non-working hours (6 PM to 8 AM) have a greater delay to therapy, twice the failure rate of PPCI, and a >2-fold increased 30-day mortality rate3,6

• Patient ability to recognize

symptoms1,2

• Mode of transportation to the

hospital

(self-presentation vs EMS)1,2

• Inter-hospital transfer challenges

(distance, traffic patterns, climatic

conditions etc)2,3

Time to reperfusion Healthcare resource

Contraindications to fibrinolytic therapy1–3

1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042; Accessed November 6, 2017; 2. O’Gara PT et al. Circulation2013;127:e362–e425; 3. Morse MA et al. Drugs 009;69:1945–1966

• Previous intracranial hemorrhage or stroke of

unknown origin at any time

• Ischemic stroke in the preceding 6 months

• Central nervous system damage or neoplasms or

arteriovenous malformation

• Recent major trauma/surgery/head injury (within

the preceding 3 weeks)

• Gastrointestinal bleeding within the past mo

• Known bleeding disorder (excluding menses)

• Aortic dissection

• Non-compressible punctures in the past 24 h (e.g.

liver biopsy, lumbar puncture)

• Ischemic stroke more than 6 months ago

ABSOLUTE

• Transient ischemic attack in the preceding 6

month

• Oral anticoagulant therapy

• Pregnancy or within 1 week postpartum

• Refractory hypertension

• Advanced liver disease

• Infective endocarditis

• Active peptic ulcer

• Prolonged or traumatic resuscitation

RELATIVE

Fibrinolytic Therapy

Drugs Dosage & AdministrationSpecific

Contraindication

Streptokinase 1.5 Million units over 30-60 min i.v. Previous treatment

with streptokinase

or anistreplase

Alteplase 15 mg i.v. bolus

0.75 mg/kg i.v. over 30 min (up to 50 mg)

Then 0.5 mg/kg i.v. over 60 min (up to 35 mg)

Reteplase 10 units + 10 units i.v. bolus given 30 min apart

Tenecteplase

(TNK-tPA)

Single i.v. bolus:

30 mg (6000 IU) if <60 kg

35 mg (7000 IU) if <70 kg

40 mg (8000 IU) if <80 kg

45 mg (9000 IU) if <90 kg

50 mg (10000 IU) if ≥90 kg

It is recommended to reduce to half-dose in

patients ≥75 years old ESC Guideline. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Fibrinolytic Complication and it’s

management Hypotention Allergic reaction Bleeding Arythmia

• Patient position –

supine

• Reduce or stop

streptokinase

drops

• Provide Ringer

Lactate / NaCL

100 ml (10

minutes)

• Stop vasodilator

drug (eg. Nitrate)

• Streptokinase

drop continue if

systolic pressure

> 90 mmHg

Mild allergic

Antihistamin injection

(difenhidramin 10 mg

i.v)

Severe allergic

Dexamethasone

injection 5 mg

Minor Bleeding

Pressure to bleeding

area

Major Bleeding – eg

ICH

Stop streptokinase

and refer patient for

further bleeding

management

• Refer to ACLS

guidelines

• Reperfusion sign

• Premature

Ventricular

Contraction

• Idiophatic

Ventricular Rhytm

Parameter Successful Fibrinolytic Therapy

1. Reduction of chest pain

2. Decrease ST elevation > 50%

3. Arrhythmia reperfusion Reference : iSTEMI Indonesia Video

Early Reperfusion Strategy in STEMI

Rescue PCI

If Failed Thrombolytic

(60 -90 min after start

thrombolytic)

Routine Angiography

± PCISuccessful Thrombolytic

Within 2-24 Hours

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6,

2017.

Symptom

Onset

Primary PCI Fibrinolytic

0 – 3 hours

3 – 12 hours

> 12 hours

Presented to PCI

HospitalWire crossing 60 minutes

Presented to Non

PCI HospitalWire crossing 90 minutes

Maximum

target

time from

diagnosis

Summary

Primary Management in every spectrum of CAD is very important from risk factor management to primary management of acute space.

Risk Stratification is very important step for NSTEMI/UAP

Reperfusion is a key strategy in Acute STEMI care and it time dependent

PPCI is preferred options for reperfusion strategy for STEMI patients

Fibrinolytic therapy is an important reperfusion alternative when onset chest pain < 3 hours or when primary PCI cannot be offered in a timely manner

Important to know capabilities of each hospital before referring STEMI patients to prevent delay

35

YOUR CLINICAL JUDGMENT IS VERY IMPORTANT