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ACUTE CORONARY SYNDROME(ACS)
BENITA PUTRI PERMATA
EPIDEMIOLOGI
> 6.000.000 penduduk Amerika menderita penyakit jantung koroner
Setiap tahun di Amerika Serikat 1.300.000 pasien dirawat di RS dengan UAP / NSTEMI, sedangkan 350.000 pasien Infark miokard dengan STEMI.
Sering pada pria dengan umur antara 45-65 tahun
Tidak ada perbedaan dengan wanita setelah umur 65 tahun.
ThrombusThrombus
PPllaatteelleettss
LumenLumen
Lipid Rich CoreLipid Rich Core
EndotheliumEndothelium
ThickThickFibrous CapFibrous Cap
UnstableUnstableStableStable
ThinThinFibrous CapFibrous Cap
Falk E et al. Falk E et al. Circulation.Circulation. 1995;92:657–671. 1995;92:657–671.
Plak Aterosklerosis
Plaque disruption (plaque cracking, fissuring, rupture – thrombosis start point)
Plaque rupture The main releasing factors
Faktor yang mempengaruhiruptur plak
Disfungsi sel endotel
komponen lipid plak
derajat inflamasi lokal
tonus arteri daerah plak yang ireguler
lokal tekanan shear stress
fungsi trombosit dan sistem koagulasi
Faktor presipitasi
Variasi sirkadian
Tekanan darah
Denyut jantung
Stress emosional
Latihan fisik
DIAGNOSIS
Keluhan : nyeri dada khas angina/infark
Keluhan tambahab : dyspnoe, palpitasi
Perubahan EKGST elevasi
ST depresi/ T inverted
BBB (bundle branch block)
Peningkatan cardiac markerTroponin I/T, CK, CK-MB, CRP, dll
NYERI DADALokasi: substernal, retrosternal, dan prekordial.
Sifat nyeri: rasa sakit, seperti ditekan, rasa terbakar, ditindih benda berat, seperti ditusuk, rasa diperas, dan dipelintir.
Penjalaran ke: biasanya ke lengan kiri, dapat juga ke leher, rahang bawah, gigi, punggung/interskapula, perut, dan dapat juga ke lengan kanan.
Nyeri membaik atau hilang dengan istirahat, atau obat nitrat.
Faktor pencetus: latihan fisik, stres emosi, udara dingin, dan sesudah makan.
Gejala yang menyertai: mual, muntah, sulit bernapas, keringat dingin, lemas dan cemas.
LOCALIZATION OF MI
Anatomic area ECG Leads w/ STE Coronary artery
Septal V1-V2 Proximal LAD
Anterior V3-V4 LAD
Apical V3-V6 Distal LAD,LCx, or RCA
Lateral I, aVL LCx
Inferior II.III.aVF RCA (-85%),LCx (-15%)
RV V1-V2 &V4R Proximal RCA
Posterior ST deppression V1-V3
RCA or LCx
EKG Perubahan Segmen ST
Acute Anterior Myocardial Infarction
Acute Anterolateral Myocardial Infarction
Acute Lateral Myocardial Infarction
Acute Inferoposterior Myocardial Infarction
0.04
CCS functional classification of Angina Pectoris
Kelas 1 : aktivitas fisik biasa/sehari-hari tidak menimbulkan angina, seperti jalan, naik tangga tidak menyebabkan angina. Angina timbul pada keadaan fisik berat, cepat, tergesa-gesa, kegiatan fisik lama dalam pekerjaan atau rekreasi
Kelas 2 : Pembatasan ringan dari kegiatan fisik biasa/sehari-hari. Angina timbul apabila jalan atau naik tangga dengan cepat, naik bukit, naik tangga atau jalan dengan emosi-stress, jalan atau naik tangga sesudah makan, udara dingin
Kelas 3 : Pembatasan bermakna dari aktivitas fisik sehari-hari. Angina sudah timbul pada jalan mendatar jarak dekat atau naik tangga pada kondisi normal
Kelas 4: aktivitas fisik selalu disertai angina. Angina dapat timbul pada keadaan istirahat
Stratifikasi ResikoResiko Rendah:Tidak mempunyai angina sebelumya
Sudah tidak ada serangan angina
Sebelumnya tidak memakai obat antiangina
EKG normal/tidak ada perubahan dari sebelumnya
Enzim jantung tidak meningkat
Usia muda
• Resiko Sedang– Angina baru dan makin berat
– Angina pada waktu istirahat
– Tidak ada perubahan segmen ST
– Enzim jantung tidak meningkat
• Resiko Tinggi– Angina waktu istirahat– Agina berlangsung
lama/angina pasca infark– Sebelumnya sudah mendapat
terapi intensif– Perubahan segmen ST yang
baru– Kenaikan troponin– Keadaan hemodinamik tidak
stabil– Usia lanjut
PENANGANAN
Unstable angina pectoris
Tindakan Umum:Perawatan di Rumah Sakit (sebaiknya di ICCU)
Bed rest
Penenang
Oksigen
Morfin/petidin
UA/NSTEMI (NSTE ACS) Anti-ischemic and other treatment
Nitrates (SL, PO, topical, or IV)
Anginal sx, no in mortality
β – blocker PO; IV if ongoing pain, HTN or HR (w/o s/s CHF)Eg, metoprolol 5mg IV q5 min x 3Then 25-50 mg PO q6hTitrate to HR 50-60
13% in priggression to MI Controindicated if HR <50, SPB <90Moderate or severe CHF,severe bronchospasm
CCB (nondihydropyridines) If cannot tolerate β B bronchospasm
ACEI or ARB Especially if CHF or EF <0,040 and if SBP>100
Morphine Consider if persistent sx or pulmonary edema should not be used to mask persistent CP
Oxygen Use if necessary to keep S2O2>90%
Antiplatelet Therapy
Aspirin162-325 mg x 1Then 75-325 mg/d
50-70% D/MIIf ASA allergy, use clopidogrel instead(and desensitize to ASA)
Clopidogrel (ADP reseptor blocker)300mg x 1 75 mg/d600mgx 1 150 mg/dx7d may
Give in addition to ASA, 20% CVD/MI/stroke but need to wait >5 d ater d/c clopi prior to CABG
Prasugrel (ADO reseptor blocker)180mgx1 10mg/dreversible
More rapid (~30min) and potent plt inhib c/w clopi. 19% CVD/MI/stroke in ACS w/ planned PCI vs clopi, but bleedingParticullary efficacious in DMAvoid if>75 y
Ticagrelor(ADP reseptor blocker)180 mg x 1 90mg bidReversible
More rapid (~30min) and potent plt inhib c/w clopi. 16% CVD/MI/stroke and 22%death c/w planned PCI vs clopi but with non CABG bleeding frequency of dyspnea.
GP IIb/Iia inhibitors (GPI)Abciximab;eptifibatide;tirofiban
Ma be given in addition to oral antiplt Rx(s)No clear benegit for starting GPI prior to PCI and risk of bleeding
Anticoagulant Therapy
UFH60 U/kg IVB (max 4000 U)12 U/kg/h (max 1000 U/H)
24% D/MITitrate to aPTT 1,5-2x
Enoxaparin (low molecular weight heparin)
Consider instead to UFH ~10% D/MIBenefit greatest if conservative strategy. Can perform PCI on enixaparin
Bivalirudin (direct thrombin inhibitor)
Use instead of heparin for pts w? HIT. With invasive strategy, bival alone noninferior to heparin+GPI
Fondaparinux (Xa inhibitor) C/w enox, 17% mortality & 38% bleeding by 30 d, however risk of cath thromb
STEMI
ANTIPLATELET THERAPY
Aspirin 162-325mg 23% in death
ADP receptor blockerClopidogrel 600mg pre-PCI,300mgIf lysis (not if>75 y) 75mg/dPrasugrel & ticagrelor as above
Lysis:clopidogrel 41% in patency, 7% mort
GP IIb/Iia inhibitorAbciximab, tirofiban
Lysis; no indication
Anticoagulant therapy
UFH60 U/Kg IVB12 U/Kg
No demonstrated mortality benefitPatency with fibrin-spesific lysisTitrate to aPTT 1,5-2
Enoxaparin30 mg IVBx1 1 mg/kg SC bid(>75 y: no bolus, o,75 mg/kg SC bid)(CrCl <30 mL/min: 1 mg?kg SC qd)
Lysis 17%D/Miw/ ENOX x 7
Bivalirudin0,75 mg/kg IVB 1,75 mg/kg/hr IV
PCI : death 7 bleeding but acute stent thrombosis c/w heparin+GPI
Fondaparinux Lysis : superior to placebo & to UFH with less bleeding
Immediate adjuntive therapy
Β blockersEg. Metoprolol 25mg POTitrate ti HR 55-60IV only if HTN & no s/s CHF
-20% arrhytmic death or reMI, 30% cardiogenic shock&no overall mortallity when given to Pts inc. those w/mod CHFContraindic. If HR <60 or>110
NitratesSL or IV
?-50% mortallityUse to relief of sx, control of BP or Rx of CHF contraindic in hipovolemia
Oxygen Use if necessary to keep S2O2>90%
Morphine Reliefe pain anxiety, venodilation preload
ACE inhibitorsEg. Captopril 6,25 tidTitrate up as tolerate
`10% mortality greatest benefit in ant MI, EF<40% or prior MIContraindication in severe hypotension or renal failure
ARBs Appear~ACEI
insulin Treat hyperglycemia >180 mg/dl while avoiding hypoglicemia, no clear benefit for intensive control
AntiiskemiaNitrat, beta bloker, Ca antagonis
Antiagregasi trombositAspirin, Clopidogrel, glikoprotein IIB/IIIA inhibitor
AntitrombinUFH, LMWH, Direct thrombin inhibitors
Tindakan revaskularisasi pembuluh koroner
Reperfusi
Memperpendek lama oklusi koroner
Meminimalkan derajat disfungsi dan dilatasi ventrikel
Mencegah STEMI berkembang menjadi pump failure/takiaritmia maligna
Terapi Reperfusi
Sequence of Events from Unstable Atherosclerotic Plaque to Death
Sequence of Events from Unstable Atherosclerotic Plaque to Death
UNSABLE PLAQUEUNSABLE PLAQUE
Coronary occlusion
Infarction
LV Dilatation
Death
Late Reperfusion
LV Remodeling
Electrical InstabilityPump FailurePump Failure
LV Dysfunction
Early Reperfusion
Limit Infarction
X
X
Circulation 1993;88:2426-36 Circulation 1993;88:2426-36
ACS
Coronary Thrombosis
Myocardial Ischemia
CAD
Atherosclerosis
Risk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)
Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
The cardiovascular continuum of events
DYSLIPIDEMIA
Arrhythmia andLoss of Muscle
Remodeling
Ventricular Dilatation
Congestive Heart Failure
End-stage Heart Disease
Atherosclerosis
PROGNOSIS
pola nyeri
Usia
Perubahan segmen ST
Peningkatan troponin T
CRP and other inflammatory markers
DAFTAR PUSTAKAHamm CW, Bertrand M, Braunwald E. Acute coronary syndrome without ST elevation : implementation of new guidelines. Lancet 2001; 358: 1533-8.
Antman EM, Fox KM. Guidelines for the diagnosis and management of unstable angina and non Q wave myocardial infarction. Proposed revisions. Am Heart J 2000; 139:461-75.
Patrono C, Renda G. Platelet activation and inhibition in unstable coronary syndromes. Am J Cardiol 1997; 80(5A): 17E-20E.
Hamm CW, Braunwald E. A Classification of unstable angina revisited. Circulation 2000; 102:118-22.
Lincoff MA. GUSTO IV: Expanding therapeutic options in acute coronary syndrome. Am Heart J 2000; 140: S103-14.
Trisnohadi HB. Angina Pektoris Tak Stabil. Dalam: Sudoyo A, Setiyohadi B, Alwi I, K Simadibrata M, Setiati S, editor. Buku Ajar Ilmu Penyakit Dalam. Jilid III. Edisi IV. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit Dalam FKUI, 2006. hal. 1621-3.
Alwi I. Tatalaksana Infark Miokard Akut Dengan Elevasi ST. Dalam: Sudoyo A, Setiyohadi B, Alwi I, K Simadibrata M, Setiati S, editor. Buku Ajar Ilmu Penyakit Dalam. Jilid III. Edisi IV. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit Dalam FKUI, 2006. hal. 1630-9.
Alwi I, Harun S. Infark Miokard Akut Tanpa Elevasi ST. Dalam: Sudoyo A, Setiyohadi B, Alwi I, K Simadibrata M, Setiati S, editor. Buku Ajar Ilmu Penyakit Dalam. Jilid III. Edisi IV. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit Dalam FKUI, 2006. hal. 1641-7.
Brown CT. Penyakit Aterosklerosis Koroner. Dalam: Price SA, Wilson LM. Patofisiologi. Konsep Klinis Proses-Proses Penyakit. Edisi 6. Volume 1. Jakarta: ECG, 2006. hal. 577-88.
Scottish Intercollegiate Guidelines Network. Acute Coronary Syndromes, a National Clinical Guideline.Myocardial Infarction. Tersedia pada situs: http://www.sign.ac.uk. Diperbaharui pada bulan Februari 2007. Diunduh pada bulan Mei 2010.
Circulation Journal of The American Heart Association. ACC/AHA Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation): Developed in Collaboration with the American College of Emergency Physicians, the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Tersedia pada situs: http://circ.ahajornals.org. Diperbaharui pada tahun 2007. Diunduh pada tanggal 28 Mei 2010.
Circulation Journal of The American Heart Association. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 207 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practical Guidelines. . Tersedia pada situs: http://circ.ahajornals.org. Diperbaharui pada tahun 2007. Diunduh pada tanggal 28 Mei 2010.