dr. Beny Hartono, SpJP, FIHA

Assessing Chest pain

• Character• Time of onset, duration, frequency• Changes in tempo• Exacerbating and alleviating factors• Pain during situation associated

with increased myocardial O2 demand ( e.g. exertion, stress )

SINDROM KORONER AKUT•Merujuk pd sekumpulan keluhan dan tanda klinis yang sesuai dengan iskemia miokard akut•Mencakup Infark miokard akut ( dgn elevasi /depresi segmen ST , gelombang-Q dan non gel Q) dan angina tidak stabil ( UAP)

Sindrom Koroner Akut

Tanpa elevasi ST Elevasi ST

Infark Miokard AkutAngina Tdk Stabil NQMI Qw MI

NSTEMI

Kursus SKAk

Immediate Assessment in ED

• Vital signs, including blood pressure• Oxygen saturation• IV access• 12-leads ECG• Brief, targeted history and physical exam (to identify

reperfusion candidates)• Fibrinolytic check list; check contraindications• Obtain initial cardiac markers• Portable Chest X-ray < 30 min.• Assess for the following :

-Heart rate > 100 bpm and SBP < 100 mmHg-Pulmonary edema/rales or-Signs of shock

If any of these conditions is present, consider triage to a facility capable of cardiac catheterization and revascularization

Early Repolarisation !!!

LOKASI ISKEMIA BERDASARKAN PERUBAHAN DI SANDAPAN EKG

SANDAPAN LOKASI ISKEMIA / INFARK• II ,III, aVF Inferior• V1,V2,V3 Anteroseptal•V1-V4 Anterior• V1- V6 Anterior ekstensif• I,aVL ,V5,V6 Lateral• I, V6 Apikal• V7-V9 Posterior• V4R Ventrikel kanan

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

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)

• Prompt aspirin (160-325 mg) for all patients with AMI who are reperfusion candidates.

Emergency Department (3)

• Beta-blockers for all patients without contraindications.

• IV nitroglycerin for initial 24-48 hrs in patients with AMI and CHF, large anterior infarction, persistent ischemia, or hypertension.

Fibrinolytics

• Absolute Contraindications :

-Any prior intracranial hemorrhage (ICH)-Known structural cerebral vascular lesion (eg. AVM)-Known malignant intracranial neoplasma-Ischemic stroke within 3 month EXCEPT acute ischemic stroke within 3 hrs-Suspected aortic dissection-Active bleeding or bleeding diasthesis-Significant closed head trauma or facial trauma within 3 months

Fibrinolytic

• Relative Contraindications :

- Check your handbook !!!

Summary : Guideline 2010

Thank you