rodarohw case-acs dynamics nstemi to stemi management and prognosis

8/9/2019 RoDaroHW Case-ACS Dynamics NSTEMI to STEMI Management and Prognosis

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R.D. Robi

* ACS ProgressionNSTEMI to STEMI


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CounselorDr. H. A. Fauzi Yahya., Sp. JP. (K), FIHA.

by RD. Robin H Wibowo

*

Case Report Presentation


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*

Case Presentation

Case discussion

Conclusion


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* General information

* A male patient, TW, 59 years old

* Retired go ernment employee


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Clinical History

!mo"ing

Dyslipidemia

#eit$er

C$est pain!%& $istory

C$est pain5 Hourbe'ore


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* Physical Examinat()P 5*+cmH %

H(R -*

Kardiomegali -/

!0 normal, !normal, !+ -/ !1 -/2urmur -/Rales -*3* 03+

4dema -/Warm -*3*

&P 00 36 mmHg,regular $eart rateo' 67 bpm,RR 1 8!a% 97


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* a!oratory "in#in

Hb : 11,1 : 36 #a : 139 ?D! :

Tr : 255000 = : 4,0


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*

Ele$tro$ar#io


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*

Rontgen th


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* %iag

*

NSTEMI& 'illip II* T@2@ 36* ?RAC4 059


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*

Treat

* &R, % + liter3menit, Hepcup* Diet antung @ 05 ""al3$ari, protein 0 gr3"g&&3$ari, =H:> 7 :1* Aspilets loading dose 07 mg, dilan ut"an 08B0 mg po*

Clopidogrel loading dose + mg, dilan ut"an 0865 mg po* @!D# 5 mg !> prn* Heparinisasi dengan 4no8aparin 8 ,7 cc sc* Rencana angiografi $oroner #an a# hoc PCI (early)* "urosemi#e *x+, mg i- target !alance ./,,.0,,, cc1*+ 2am* %ia3epam ,.,./ mg* axa#ine ,.,.0/ mg* Ator-astatin ,.,.+, mg* Peri$sa profil lipi#& G%P& G% *4PP& asam urat* Peri$sa E'G serial1*+ 2am atau !ila nyeri #a#a* Rencana echocar#iografi* Ra5at I6C1I7


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Clinical History

Admisson

nd Day

PersistentC$est Pain

+rd DayC$est Pain

Worsened&reat$lessnes

s


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*

Ele$tro$ar#io@

@@

@@@

5

0

05

5

+

+5

+5

e-els

C'M8


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* Acute 48tensi e Anterior !T42@

=illip @@@

PrimaryPCI


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* Angiogra


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Clinical History

Admisson

+rd Day

PrimaryPC@

6t$ DayDisc$arge


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*

Case Presentation

Case discussion

Conclusion


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* O-e

*

* #CCH=, data 'rom 9/ 00 s$owed t$erewas 5 5 !T42@ patients -+5 , 0761 #!T42@patients - + , and 99


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* %efini

2yocardial in'arction -2@ is deFned in pat$ology AC! spectrum -


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* Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$


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Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$


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* #!T42@ is an unstable coronary conditionprone to isc$emic recurrences and ot$ercomplications

* T$e ?RAC4 study s$owed B/0 o' #!T42@patients will $a e recurrent angina wit$ !Tsegment c$anges on $ospitaliJation.



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* Ris$ Stratification for 9A1NS

* @mportant in management* Determines t$e c$oice o' management*

4stimating prognosis* !e eral ris" scores predicting ris" Widely used =illip, T@2@ and ?RAC4 score



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=illip Classi'ication o' A2@=illip Classi'ication o' A2@

Absence o' !+ gallop rales

Class I


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T@2@ 00&

TIMI Risk Score for UA/ ST!MI

% "/MI/Ur#e$ Re&'sc()'ri*' io$ +s TRS

A$ '$ !M, -AMA 2000.284 83

$e oof

A >

' r

50 ST >

e& A !)

M

4arly Ris" !trati'ication4arly Ris" !trati'ication


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T@2@ 06

TIMI Risk Score for ST!MI

Mor ')i ' 30 7 &s ST!MI TRS

Morro: "A, irc()' io$ 2000.102 203

;is oric')A#e 65 4

> 53"M/;T /A$#i

!='S < 100 ;R > 100 ?@i))i II I+

ei# < 6

rese$ ' io$A$ erior ST

B Ti e o R= >

Risk Score C

4arly Ris" !trati'ication4arly Ris" !trati'ication


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o e$7i( of A?ri7#e7 !S F(i7e)i$es 2008, ?lobal Registry o' Acute Coron


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* In-asi-e -ersus conser-ati-e approach

* 2eta/analysis -&a ry et al E signiFcant ris" reduction 'or all caumortality and non/'atal 2@ 'or an early in asi e approac$ at years wit$out an e8cess o' deat$ and non/'atal 2@ at 0 mont$

* 2eta/analysis -% Donog$ue et al E signiFcant reduction in deat$2@, or re$ospitaliJation wit$ AC! 'or in asi e strategy at 0 year

* 2eta/analysis - o8 et al E re ealed a reduction in rates o' deat$and non/'atal 2@ at 5/year 'ollow/up, wit$ t$e most pronounceddi''erence in $ig$ ris" patients -00,0 .

* &a ry AA, =umb$ani D(, Rassi A#, et al. &eneFt o' early in asi e t$erapy in acute coronary syndromes: a meta/analysis o' contemporary randomiJed clinical trials. ( Am Coll Cardiol7E1B:0+09I0+ 5.

* %ODonog$ue 2, &oden W4, &raunwald 4,et al. 4arly in asi e s conser ati e treatment strategies in women and men wit$ unstable angina and non/!T/segment ele ation myocardialin'arction: a meta/analysis. (A2A BE+ :60IB .

* o8 =A, Clayton TC, Damman P, et al. >ong/term outcome o' a routine ersus selecti e in asi e strategy in patients wit$ non/!T/segment ele ation acute coronary syndrome a meta/analysis o' indi idual pati ent data. ( Am Coll Cardiol 0 E55: 1+5I 115.

6ighlight the role of ris$

strati;cation


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* Timing of angiography an# inter-entio

The TIMACS trial* !igniFcant reduction in deat$, 2@, or stro"e at 7 mont$s

in $ig$ ris" #!T42@ patients -?RAC4 score L01 , wit$ early -K 1 $ compared wit$ a delayed strategy.* Howe er, t$ere was not signiFcant di''erence wasobser ed in patients wit$ a low to intermediate ris"proFle -?RAC4 score K01 .

2e$ta !R, ?ranger C&, &oden W4, et al. 4arly ersus delayed in asi e inter ention in acute coronary syndromes. # 4ngl ( 9E+7 : 075I 065


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Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patie


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* STEMI an# NSTEMI& is it #iffe

* 2ortality L !T42@ t$an #!T42@ -6 s.+I5 ,respecti ely , but 7/mont$s mortality rates are erysimilar -0 and 0+ , respecti ely

* Opera registry s$owed comparable result* >ongterm obser ational study 'ound t$at deat$ rates

L#!T42@ t$an wit$ !T42@E 8 at 1 years

e$ RW, !idney !, C$andra 2, et al. Population trends in t$e incidence and outcomes o' acute myocardial in'arction. # 4ng2ed 0 E +7 : 055I 075

2andelJweig >, &attler A, &oy"o ), et al. T$e second 4uro Heart !ur ey on acute coronary syndromes: c$aracteristics,treatment, and outcome o' patients wit$ AC! in 4urope and t$e 2editerranean &asin in 1. 4ur Heart ( 7E 6: B

Ter"elsen C(, >assen ( , #orgaard &>, et al. 2ortality rates in patients wit$ !T/ele ation s.non/!T/ele ation acutem ocardial in'arction: obser ations 'rom an unselected co$ort. 4ur Heart ( 5 7:0BI 7


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?iles, et al. !T42@ and #!T42@ : are t$ey so di''erent %P4RA registry real/world data 'rom t$e 4uropean PubliHealt$ %utcome Researc$ and @ndicators Collection Pro ect. Arc$ @ntern 2ed 0 E06 :BBBIB95


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urman 2@, Dauerman H>, ?oldberg R(, et al. Twenty/two year -0965 to 0996 trends in t$e incidence, in/$ospital anterm case 'atality rates 'rom initial Q/wa e and non/Q/wa e myocardial in'arction: a multi/$ospital, community/wideperspecti e. ( Am Coll Cardiol 0E+6:0560/B

More attentionto NSTEMI


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* Treatm

!c$iele study 'ound 00 N in mortality 30increase in ad$erence to ACC and AHA guidelines

?AP -T$e ?uidelines Applied in Practice study'ound t$at ris" o' deat$ wit$in a year was 5lower a'ter disc$arge i' $ospitals 'ollowed nationalguidelines

!c$iele , 2ene eau #, !eronde 2 , et al. Compliance wit$ guidelines and 0/year mortality in patients wit$ acutmyocardial in'arction: a prospecti e study. 4ur Heart ( 5E 7:B6+/B .


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*

Case Presentation

Case discussion

Conclusion


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* Conc

* We reported a case o' male patient, 2r TW, 59 yo, w$omwas diagnosed as #!T42@ T@2@ ris" 36 grace score 019,=illip @@. During e aluation, $is myocardial in'arction

e ol ed to !T42@. He was treated wit$ primary PC@, wit$good results.

* AC! represent a p$ysiologic continuum spanning o'unstable angina, non/!T ele ation myocardial in'arctionand !T ele ation myocardial in'arction.

* T$e management must begin wit$ ris" strati'ication,'ollowed wit$ t$erapy according to guidelines, and goode aluation during $ospital care and a'ter disc$arge.


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* Ta$e 6ome Messa

?ood prior e aluation ?ood inter ention

!tate o' t$e art monitoring 'ollow up

!a e muscleOs, !a e li es


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Gracias


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rodarohw case-acs dynamics nstemi to stemi management and prognosis

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