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SIDROMA KORONER AKUT

UMAR F SHIBLY

SPESIALIS JANTUNG DAN PEMBULUH DARAH


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UA/NSTEMI 9/00 Atherosclerotic Plaque Stability

Adapted from Weissberg. Atherosclerosis. 1999;147:S3S10

DEMANDSUPPLY


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UA/NSTEMI 9/00Characteristics of the

stable atherosclerotic plaque

Lipid core

Adventitia


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SAKIT DADA

NON JANTUNGJANTUNG

ANGINA

STABIL TAK STABIL

ATIPIKAL

KEDARURATAN


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UA/NSTEMI 9/00FEATURES NOTCHARACTERISTIC

OF MYOCARDIAL ISCHEMIA (CONTD

Pain reproduced with movement or palpationof the chest wall or arms

Very brief episodes of pain that last a fewseconds or less

Pain that radiates into the lower extremities


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EMERGENCY ROOM TRIAGE

Chest pain or severe epigastric pain, typical ofmyocardial ischemia or MI:

Substernal compression or crushing chest pain

Pressure, tightness, heaviness, cramping,

aching sensation Unexplained indigestion, belching, epigastric pain

Radiating pain to neck, jaw, shoulders, back or toone or both arms

Associated dyspnea, nausea and/or vomiting,diaphoresis

IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG


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THREE PRINCIPAL PRESENTATIONS

Rest Angina* Angina occurring at rest andprolonged, usually > 20 minutes

New-onset Angina New-onset angina of at least CCSClass III severity

Increasing Angina Previously diagnosed angina that hasbecome distinctly more frequent,longer in duration, or lower inthreshold (i.e., increased by > 1 CCS)

class to at least CCS Class III severity

BraunwaldCirculation 80:410; 1989

* Pts with NSTEMI usually present with angina at rest.

S S C O


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UA/NSTEMI 9/00RISK STRATIFICATION IN

EMERGENCY DEPARTMENT

Prolonged ischemic discomfort (>20 min), ongoingrest pain, accelerating tempo of ischemia

Pulmonary edema; S3 or new rales

New MR murmurHypotension, bradycardia, tachycardia

Age >75 years

Rest pain with transient ST-segment changes

> 0.05 mV; new bundle-branch block, new

sustained VT

Elevated (e.g. TnT or TnI>0.1 ng/mL)

History

Clinical findings

ECG

Cardiac markers

HIGH RISK-FEATURES (RISK RISES WITH NUMBER)


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ACUTE CORONARY SYNDROME

No ST Elevation ST Elevation

Unstable Angina NQMI QwMIMyocardial Infarction

NSTEMI


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N Engl J Med. 339:436-43, 199

PURSUIT TRIAL: DEATH OR MI

Days

1

0.98

0.96

0.94

0.92

0

0.9

0.88

0.86

0.84

0.82

0.8 30 60 90 120 150 180


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UA/NSTEMI 9/00RECOMMENDATION

Class I

1. Patients with suspected ACS with chestdiscomfort at rest for >20 min, hemodynamic

instability, or recent syncope or presyncopeshould be referred immediately to an ED or aspecialized chest pain unit.

Other patients with a suspected ACS may beseen initially in an ED, a chest pain unit, oran outpatient facility.


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UA/NSTEMI 9/00ANTI - ISCHEMIC Rx

Class I1. Bed rest with continuous ECG monitoring in pts with

ongoing rest pain.

2. NTG, sublingual tablet or spray, followed by IV

administration for ongoing chest pain.3. Supplemental O2 for pts with hypoxemia, cyanosis or

respiratory distress; finger pulse oximetry or arterialblood gas determination to confirm SaO2>90%.

4. Morphine sulfate IV when symptoms are not immediatelyrelieved with NTG or when acute pulmonary congestionand/or severe agitation is present.


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UA/NSTEMI 9/00ANTI - ISCHEMIC Rx (contd)

Class I5. A -blocker with the first dose administered IV if there

is ongoing chest pain, followed by oral administration.

6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or

diltiazem) as initial therapy in pts with continuing orfrequently recurring ischemia when -blocker iscontraindicated.

7. An ACEI when hypertension persists despite treatment

with NTG and a -blocker in pts with LV systolicdysfunction or congestive heart failure and in ACSpatients with diabetes.


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UA/NSTEMI 9/00ANTIPLATELET Rx

Class I1. Administer ASA as soon as possible after

presentation and continue indefinitely.

2. A thienopyridine (clopidogrel or ticlopidine) in pts

unable to take ASA.

3. Add IV UFH or subcutaneous LMWH to antiplatelettherapy with ASA, clopidogrel, or ticlopidine.

4. Add platelet GP IIb/IIIa receptor antagonist in ptswith continuing ischemia or with other high-riskfeatures and in pts in whom early PCI is planned.


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UA/NSTEMI 9/00ANTIPLATELET Rx

Class I

Definite ACS with continuingPossible ACS Likely/Definite ACS Ischemia or Other High-Risk

Features or planned PCI

Aspirin Aspirin Aspirin+ +

Subcutaneous LMWH IV heparin/LMWHor

IV heparin IV platelet GP IIb/IIIa antagoni

+

BIOCHEMICAL CARDIAC MARKERS IN


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UA/NSTEMI 9/00BIOCHEMICAL CARDIAC MARKERS IN

PTS WITH SUSPECTED ACS WITHOUT ST

CK-MB

1. Rapid, cost-

efficient, accurateassays

2. Ability to detectearly reinfarction

Myoglobin

1. High sensitivity

2. Useful in earlydetection of MI

3. Detection ofreperfusion

4. Most useful inruling out MI

Troponins

1. Powerful for stratificatio

2. Greater sensitivity andspecificity than CK-MB

3. Detection of recent MI uto 2 weeks after onset

4. Useful for selection oftherapy

5. Detection of reperfusion

Advantages

COCAINE


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UA/NSTEMI 9/00COCAINE

CLINICAL CHARACTERISTICS

Ischemic chest pain

Usually male < 40 years

Cigarette smokers, but no other risk factors for

atherosclerosis

Associated with all routes of administration

Not dose dependent

Often associated with use of cigarettes and/or

alcohol

Adapted from Pitts et al.Prog. Cardiovasc. Dis. 40:65, 1997

SPECIAL GROUPS


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UA/NSTEMI 9/00SPECIAL GROUPS

COCAINE

1. NTG and oral Ca2+ blocker for pts with STdeviation that accompanies ischemic chest

discomfort.

2. Immediate coronary arteriography in pts with STelevation after NTG and Ca2+ blocker;

thrombolysis if a thrombus is detected.

Class I


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UA/NSTEMI 9/00ED MANAGEMENT OF UA/NSTEMI

No recurrent pain;Neg follow-up studies

Nondiagnostic ECGNormal serum cardiac markers

ObserveFollow-up at 4-8 hours: ECG, cardiac markers

Neg: nonischemicdiscomfort;low-risk UA/NSTEMI

YESNO

ST and/or T wave changesOngoing pain

+ cardiac markersHemodynamic abnormalities

Recurrent ischemic pain or+ UA/NSTEMI follow-up studies

Diagnosis of UA/NSTEMIconfirmed

ADMIT+ UA/NSTEMI confirmed

Outpatient follow-up

Evaluate

forReperfusion

ST ?

Stress study to provokeischemia prior to discharge

or as outpatient


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UA/NSTEMI 9/00POST-HOSPITAL DISCHARGE CARE

A Aspirin and Anticoagulants

B Beta blockers and BloodPressure

C Cholesterol and Cigarettes

D Diet and Diabetes

E Education and Exercise


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UA/NSTEMI 9/00MEDICATIONS AT HOSPITAL DISCHARG

1. Aspirin 75 to 325 mg/d

2. Clopidogrel 75 mg/qd for patients withcontraindication to ASA

3. -Blocker4. Lipid-lowering agent and diet in patients with

LDL cholesterol >130 mg/dL

5. Lipid-lowering agent if LDL cholesterol level after

diet is > 100 mg/dL6. ACEI for patients with CHF, LV dysfunction

(EF


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1. Smoking cessation and achievement or maintenancof optimal weight, daily exercise, and diet.

2. HMG-CoA reductase inhibitor for LDL cholesterol

> 130 mg/dL.

3. Lipid-lowering agent if LDL cholesterol after diet is> 100 mg/dL.

4. Hypertension control to a BP < 130/85 mm Hg.

5. Tight control of hyperglycemia in diabetics.6. Consider referral of smokers to a smoking

cessation program.

INSTRUCTIONS AT HOSPITAL DISCHARGRISK FACTOR MODIFICATION

Class I


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