PERAWATAN KLIEN DENGAN SKA (ACUTE CORONER SYNDROME)Harmayetty Moenaf

Silent Ischemia/asymptomaticStable AnginaAcute Coronary Syndrome (Non-STEMI/UA and STEMI)ArrhythmiasHeart FailureSudden Death

TYPICAL ANGINA

Retro sternalQuality :Precipitating factor (+) / (-)Radiating to left neck, ear, jaw, back

Usual distribution of pain withmyocardial ischemiaLess common sites of pain withmyocardial ischemiaRight sideEpigastriumJawBack

HEART ATTACT !!!!

Diketahui secara kebetulan (check up)Tidak terdapat keluhanEKG menunjukkan depresi segment STPemeriksaan lain dalam batas normalMekanisma diduga karena

Gejala KlinisNyeri dada saat aktifitas, stressBersifat kronis dan menetap dalam 30 hariNyeri precordial daerah retrosternalSeperti tertekan benda berat atau terasa panasSeperti diremas atau tercekik

Mekanisme terjadinya iskemiaKarena gangguan keseimbangan antarasuplai dan kebutuhan oksigen miokard

Prinsip PengobatanMenjaga agar suplai oksigen selalu seimbang dengan kebutuhan oksigen miokard

MedikamentosaGol. Nitrat : ISDNCalsium antagonis : DiltiazemBeta blocker : BisoprololAnti-trombotik : Aspirin HMG Co A reduktase : Statin

Penanganan faktor-faktor resiko Perlu dipertimbangkan terapi interventionalPercutaneus transluminal coronary angioplasty (PTCA)Coronary bypass surgery (CABG)2. ANGINA PEKTORIS STABIL (STABLE ANGINA)

Penyebab Acute coronary syndrome adanya penyempitan pembuluh darah/plaque/pembuntuan arteri sehingga aliran darah ke jantung terganggu Plaque terbentuk dari kolesterol dan benda lainnyaPembentukan plaque didalam tubuh membutuhkan waktu yang lama

Wright, R. S. et al. J Am Coll Cardiol 2011;57:e215-e367

Acute Coronary Syndromes Algorithm.O'Connor R E et al. Circulation 2010;122:S787-S817Copyright American Heart Association

Prehospital fibrinolytic checklist. O'Connor R E et al. Circulation 2010;122:S787-S817Copyright American Heart Association

Silent Ischemia/asymptomaticStable AnginaAcute Coronary Syndrome (Non-STEMI/UA and STEMI)ArrhythmiasHeart FailureSudden Death

Non -ST ElevationST- ElevationNSTEMIMyocardial InfarctionNQMIUnstable AnginaQwMI

PATHOPHYSIOLOGY

European Heart Journal doi :10.1093.14 June 2007

European Heart Journal (2007) 28,882

AdmissionWorking DiagnosisECGBiochemistryRisk StratificationDiagnosisTreatmentC H E S T P A I N Troponin (+) Troponin 2x (-)High Risk Low RiskSTEMIInvasive Non-InvasiveReperfusionSuspicion of Acute Coronary Syndrome ( ACS )Normal / Undetermined ECGPersistent ST-ElevationST/T-abnormalitiesGuideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14th, 2007NSTEMIUA

Prolonged (>20 min) anginal pain at restNew onset (de novo) severe angina (CCS class III)Recent destabilization of previously stable angina with at least CCS III (crescendo angina) or Post MI angina

Clinical suspicion of ACSThrombolysisPCIHigh riskLow riskStress test,coronary angiography1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.Second troponin measurementPositiveTwice negativeASAPCI, CABG or medical managementdepending upon clinical and angiographic features*Omit clopidogrel if the patient is likely to go to CABG within 5 days

Risk Stratification ACS

FeatureHigh RiskAt least of the following features must be present :HistoryAccelerating tempo of ischemic symptoms in preceding 48 hoursCharacteristic of painProlonged ongoing (> 20 minutes) rest painClinical FindingsPulmonary edema, most likely due to ischaemiaNew or worsening MR murmurS3 or new / worsening ralesHypotension, bradycardia, tachycardiaAge > 75 yearsECGAngina at rest with transient ST-segment changes > 0.05 mVBundle-branch block, new or presume newSustained ventricular tachycardiaCardiac MarkersElevated (eg. TnT or TnI >0.1 ng/mL)

FeatureIntermediate RiskAt least No high-risk feature but must have 1 of the following :HistoryPrior MI, peripheral or cerebrovascular diseases, or CABG, prior Aspirin use.Characteristic of painProlonged ( > 20 min) rest angina, now resolved, with moderate or high likehood of CAD.Rest angina ( < 20 min) or relieved with rest or sub-lingual NTG.Clinical FindingsAge > 70 yearsECGT-wave inversions > 0.2 mVPathological Q-wavesCardiac MarkersSlightly elevated (eg. TnT > 0.01 but < 0.1 ng / mL

FeatureLow RiskAt least No high- or intermediate-risk feature but may have any of the following features :HistoryCharacteristic of painNew-onset or progressive CCS Class-III or IV angina the past 2 weeks without prolonged ( > 20 min) rest pain but with moderate or high likelihood of CAD.Clinical FindingsECGNormal or unchanged ECG during an episode of chest discomfort.Cardiac MarkersNormal

Clinical presentationCor-AngiographyProlonged Chest pain > 2 hoursECG: ST-elevation II,III,AVFArrived at PCI center

Clinical suspicion of ACSThrombolysisPCIHigh riskLow riskStress test,coronary angiography1. Bertrand ME et al. Eur Heart J 2002; 23; 18091840.Second troponin measurementPositiveTwice negativeASAPCI, CABG or medical managementdepending upon clinical and angiographic features*Omit clopidogrel if the patient is likely to go to CABG within 5 days

Therapeutic Approach to STEMI Antman et al. Circulation 2004;110:e82-292

ESC Guidelines 2008

REPERFUSIONCLASS I STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a system goal (Level of Evidence : A)

2. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact, should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a system goal unless fibrinolytic therapy is contraindicated (Level of Evidence : B)

European Heart Journal (2007) 28,882

ALGORTMA SINDROME KORONER AKUT (APTS/NSTEMI)Nyeri dadaReview ECG 12 leadBiomakerSTEMISegera lakukan pemeriksaan fisik < 10 menit : Periksa TTV, evaluasi saturasi O2 Pasang IV line Periksa ECG 12 lead Periksa biomakerRo dada < 30 menit

Segmen ST DepresiGel T inversiECG non diagnostikBiomaker (-)Nyeri dada menetapMRS dg terapi :ClopidogrelNitrogliserinHeparinGlycoprotein Iib/IIIa inhibitorSegera diberikan pengobatan : M orphine IV bila nyeri dada tidak hilang dg nitrogliserin O xygen 4L/menit, pertahankan saturasi O2>90% N itrogliserin A spirin 300 mg (160-325 mg)Segmen ST ElevasiAda perubahan segmen STBiomaker (+)Nyeri dada menetapAPTS/NSTEMIUlangi ECGUlangi biomaker setelah 6-12 jam onset nyeri dadaAPTS/NSTEMI

*******Acute Coronary Syndromes Algorithm.Prehospital fibrinolytic checklist. Adapted from Antman EM, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82-e292, with permission from Lippincott Williams & Wilkins. Copyright 2004, American Heart Association.*****The management of patients with different manifestations of ACS is governed by different sets of guidelines which take into account the exact nature of the eventRecent European Society of Cardiology (ESC) guidelines for the management of unstable angina and NSTEMI are summarized on this slideThese guidelines currently suggest clopidogrel should not be started in patients who might possibly go for CABG; however, data from the CURE trial, published in August 2004, suggests that the benefit of using clopidogrel early in these patients outweighs the risk of increased bleeding1

Reference1. Fox et al. Circulation 2004; 110: 12021208.

********The management of patients with different manifestations of ACS is governed by different sets of guidelines which take into account the exact nature of the eventRecent European Society of Cardiology (ESC) guidelines for the management of unstable angina and NSTEMI are summarized on this slideThese guidelines currently suggest clopidogrel should not be started in patients who might possibly go for CABG; however, data from the CURE trial, published in August 2004, suggests that the benefit of using clopidogrel early in these patients outweighs the risk of increased bleeding1

Reference1. Fox et al. Circulation 2004; 110: 12021208.

***