Dr.

Herawati Isnanijah, SpJP, FIHA

Mengapa SKA harus SEGERA ditangani?

 Mortalitas dan morbiditas tinggi , 40 % kematian

terjadi sebelum sampai di rumah sakit (HARUS
SEGERA MENDAPAT PENANGANAN DINI YG
TEPAT)
 Di USA, Setidaknya 250.000 kematian akibat infark
miokard terjadi dalam 1 jam setelah onset gejala dan
sebelum terapi dimulai
 Dalam 2 minggu setelah diagnosa, Infark miokard
terjadi pada 12% pasien dengan U.A.
 Dalam SATU tahun hampir setengah kematian terjadi
pada 4 minggu pertama setelah diagnosa.
 Faktor Risiko PJK

1. Merokok, berapapun jumlahnya

2. Kadar kolesterol total dan LDL yg tinggi
3. Hipertensi
4. Diabetes mellitus
5. Riwayat Keluarga terkena PJK usia dini
(pria:<55 thn, wanita:<65 thn)
 SINDROMA KORONER AKUT
 Pada ruptured atheromatous plaque menyebabkan
aktivasi, adesi & aggregasi platelet, sehingga
menginduksi oklusi arteri parsial / total

Sindroma Koroner Akut

Tanpa elevasi ST Elevasi ST

UAP / Non STEMI
(STEMI)
 Treatment Delayed is Treatment Denied

Symptom Call to PreHospital ED Cath Lab

Recognition Medical System

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

Early Recognition of ACS
Symptoms, ECG and biomarkers
Deteksi awal
 Pemeriksaan awal pada Sindrom Koroner Akut

Masuk RS SAKIT DADA

Diagnosis Curiga Sindroma Koroner Akut

Kerja
Elevasi ST ST/T- Normal atau
ECG menetap abnormalities Tdk dpt ditentukan ECG

Bio-
chemistry Troponin
Troponin 2 x negatif
(+)
Stratifikasi Risiko tinggi Risiko rendah
risiko
Diagnosis STEMI NSTEMI Angina Pektoris tidak
stabil
Pengobatan Reperfusi
Fibrinolitik / PCI Invasive Non-Invasive

ESC 2007
 Tanda dan Gejala
• Sakit dada ( sakit, nyeri, rasa tertimpa beban, rasa
terbakar) dibelakang tulang dada, lamanya 10 menit atau
lebih. Sering terasa seperti menekan, “constricting” atau
“crushing”.
• Bisa menjalar ke punggung, bahu, rahang atau lengan.
Disertai rasa lemah, keringat dingin, rasa cemas dan
bahkan bisa pingsan.
• Diikuti sesak, pusing, mual, atau berkeringat
• Time of onset !!!!!
 Pemeriksaan awal pada Sindrom Koroner Akut

Masuk RS SAKIT DADA

Diagnosis Curiga Sindrom Koroner Akut

Kerja
Elevasi ST ST/T- Normal atau
ECG
menetap abnormalities Tdk dpt ditentukan ECG

Bio-
Troponin Troponin
chemistry 2 kali negatif
(+)
Stratifikasi Risiko tinggi Risiko rendah
risiko
Diagnosis STEMI NSTEMI Angina tidak stabil

Pengobatan Reperfusi Invasive Non-Invasive

ESC 2007
 Pemeriksaan awal pada Sindrom Koroner Akut

Masuk RS SAKIT DADA

Diagnosis Curiga Sindrom Koroner Akut

kerja
Elevasi ST ST/T- Normal atau
ECG menetap abnormalities Tdk dpt ditentukan ECG

Bio-
Troponin (+) Troponin
chemistry
2 kali negatif
Stratifikasi Risiko tinggi Risiko rendah
risiko
STEMI NSTEMI Angina tidak stabil
Diagnosis

Pengobatan Reperfusi Invasive Non-Invasive

ESC 2007
Rekaman EKG harus secepatnya
dilakukan dan diinterpretasi
saat pasien tiba di IGD

“Standar waktu 10 menit”

 ELEKTROKARDIOGRAM
EKG 12 Sandapan Pertama

Dalam 10 menit !!
Membuat dan menganalisa EKG
Tentukan:
Irama
Elevasi SEGMENT ST ?
Depresi SEGMENT ST ?
LEFT BUNDLE BRANCH BLOCK (BARU )?
Gelombang Q ?
NON DIAGNOSTIK atau EKG normal
EVOLUSI EKG
PADA
STEMI
LOKASI ISKEMIA
BERDASARKAN PERUBAHAN DI SANDAPAN EKG

SADAPAN LOKASI ISKEMIA / INFARK

• II ,III, aVF Inferior
• V1,V2,V3 Anteroseptal
•V1-V4 Anterior
• V1- V6 Ekstensif Anterior
• I,aVL ,V5,V6 Anterolateral
• I, V6 Apikal
• V7-V9 Posterior
• V3R,V4R Ventrikel kanan
 Pemeriksaan awal pada Sindrom Koroner Akut

Masuk RS SAKIT DADA

Diagnosis kerja Curiga Sindrom Koroner Akut

Elevasi ST ST/T- Normal atau

ECG
menetap abnormalities Tdk dpt ditentukan ECG
Bio-
chemistry Troponin Troponin
(+) 2 kali negatif
Stratifikasi Risiko tinggi Risiko rendah
risiko
STEMI NSTEMI Angina tidak stabil
Diagnosis
Pengobatan Reperfusi Invasive Non-Invasive

ESC 2007
 ENZIM JANTUNG SEBAGAI
PENANDA IMA

• Creatine Kinase-Myocardial band (CK-MB)

• Troponin I dan Troponin T
• Creatine Kinase (CK)
• Aspartate amino transferase (AST)
• Lactate dehydrogenase (LDH)
• Myoglobin
KRITERIA ENZIM UNTUK DIAGNOSIS IMA
 Jika hanya ada 1 sampel CKMB , maka setidaknya
nilainya dua kali lipat nilai normal
 Serial enzim dilakukan dengan jarak pengambilan 4
jam
 Perbandingan CKMB2/CKMB1 > 1,5 meningkatkan
sensitiviti diagnosis IMA pada 6 jam pertama
 Chest X-Ray
• Hanya sebagai alat bantu
• Tidak menentukan pada fase awal
• Hasil memerlukan waktu dan tidak
mempengaruhi diagnosis ACS !!!
 Pemeriksaan awal pada Sindrom Koroner Akut

Masuk RS SAKIT DADA

Diagnosis kerja Curiga Sindrom Koroner Akut

Elevasi ST ST/T- Normal atau

ECG
menetap abnormalities Tdk dpt ditentukan ECG

Biochemistri Troponin (+) Troponin

2 kali negatif
Stratifikasi Risiko tinggi Risiko rendah
risiko
STEMI NSTEMI Angina tidak stabil
DIAGNOSIS

Pengobatan Reperfusi Invasive Non-Invasive

ESC 2007
Management of ACS

Focused on

Early Management
and Emergency Setting
 Treatment Delay Guidelines for Urgent Reperfusion

Following first medical contact, a diagnosis should be made quickly and reperfusion
initiated if necessary - either primary PCI, or fibrinolysis if PCI is not readily available.

Symptom 1st Medical

Diagnosis
Onset Contact (FMC)

≤10 min
Primary
Patient Delay ≤60 min if FMC at PCI-capable facility PCI

≤90 min if FMC not at PCI-capable facility and Primary

transfer to PCI-capable hospital is required PCI

Angiography
≤30 min if PCI not Fibrinolysis
available ≤120 min within 3-24 hrs

PCI = percutaneous coronary intervention.

Adapted from Steg G, et al. Eur Heart J. 2012;33:2569-2619.
The focus is now on systems improvement for
reperfusion in patients with STEMI
Antman EM. J Am Coll Cardiol 2008;52:1216–21
 Options for Transportation of STEMI Pts. and Initial
Reperfusion Treatment Goals

Antman EM. J Am Coll Cardiol 2008;52:1216–21

 JAKARTA CCU NETWORK SYSTEM
PASIEN DENGAN NYERI
Puskesmas, RSUD, RS swasta, klinik
Rekam EKG 12 lead
Ambulans, koordinasi
Pemda DKI Jakarta
RS RUJUKAN YG MEMILIKI
FASILITAS PCI (PCI CENTER)
Presented at EuroPCR 2015, Paris.
119
Transmisi EKG
(Heart Line):
- Direct line: 5682424
- Fax: 29414874
- heartlinepjnhk@gmail.com
- (BBM): PIN:284BB6B1
- WA: 081934178177
e
Dharma S, et al. Open Heart 2015.
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
 Immediate Assessment in ED

• 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
TERAPI PADA SINDROMA KORONER AKUT
PERAWATAN DI RUMAH SAKIT
1. Pain killer (morfin) M
2. Suplemen O2 O
3. Terapi anti iskemia
Nitrat N
Beta Bloker A
CCB
4. Antiplatelet dan antikoagulan C
Aspirin 160 mg, Clopidogrel 300 mg, Ticlopidine O
Heparin atau Low Molecular Weight Heparin
Hirudin
Tranquilizer
5. a. STEMI : tentukan segera pilihan revaskularisasi
( Fibrinolitik Vs PCI)
b. Non STEMI : segera lakukan stratifikasi risiko
1. Morfin: PAIN KILLER
• 2.5mg-5 mg IV pelan
• Hati –hati pada : inferior MCI,asthma , bradikardia
2. Oksigen
• Pemberian O2 diberikan pada pasien dengan
desaturasi O2 (SaO2 <90%)
• O2 mungkin membatasi injury miokard atau bahkan
mengurangi elevasi ST
• Pemberian O2 rutin > 6 jam pertama pd kasus
tanpa komplikasi
3. Anti iskemi
•NITRAT
•B bloker (jika tidak ada kontraindikasi)
•Antagonis kalsium (untuk kasus UAP/NSTEMI)
 ANTIPLATELET
4. Acetyl Salicyilic Acid (Aspilets )
• Dosis 80 – 325 mg P.O.
• MANFAAT : menurunkan angka reinfark 50% dalam 30
hari ; 20% penurunan mortalitias dlm 2 tahun
5. Clopidogrel
• penambahan 300 MG CLOPIDOGREL akan
mengurangi kardiovaskuler event sebesar 13%
• Pasien yg alergi aspirin dp diberikan clopidogrel
• Clopidogrel 1x 75 mg +aspirin pd pasien STEMI yg
dilakukan reperfusion dg fibrinolytic atau bagi yg tidak
dilakukan terapi reperfusion
6. Ticagrelor
7. Gp IIb / IIIa inhibitor
 STEMI
Revaskularisasi
Apa pilihan kita?

 FIBRINOLITIK
 VS
 PCI
 Role EM physician

 Evaluasi yg komprehensive & rencana evaluasi

yg efisien untuk :
 prompt triage
 diagnosis
 initial treatment
 Clinical Findings of AHF

Hypotension
Cool extremities
Low Narrow pulse pressure
Perfusion Sleepiness, obtundation
Elevated BUN, creatinine
Hyponatremia
Orthopnea
Paroxysmal Nocturnal Dyspnea
Neck vein distention
Congestion
Ascites, edema
Hepatojugular Reflux
Rales
Terima kasih
Fibrinolitik lebih dianjurkan jika:
( 3 Point)
1. Presentasi STEMI akut ≤ 3 jam
2. Jika presentasi STEMI > 3 jam namun tindakan
PCI tidak bisa dikerjakan atau terlambat
dikerjakan;
1. Waktu antara pasien tiba sampai dengan
inflasi balon >90 menit
3. Tidak ada kontraindikasi fibrinolitik

 Catatan:
 Fibrinolitik harus dikerjakan dalam waktu < 30
menit (Door to Needle time < 30 menit)
 PCI primer lebih dianjurkan jika:
( 5 Point )
1. Presentasi ≥3 jam
2. Presentasi < 3 jam namun terdapat
kontraindikasi fibrinolitik
3. Tersedia fasilitas PCI dan waktu kontak antara
pasien tiba sampai dengan inflasi balon <90
menit
4. STEMI akut dengan risiko tinggi ( gagal
jantung Killip ≥3 dan syok kardiogenikl)
5. Diagnosis STEMI masih diragukan
 Rangkuman
MONACO
Anti iskemik
UAP & NSTEMI : Heparinisasi
STEMI : revaskularisasi
 Treatment Delay Guidelines for Urgent Reperfusion

Following first medical contact, a diagnosis should be made quickly and reperfusion
initiated if necessary — either primary PCI, or fibrinolysis if PCI is not readily available.

Symptom 1st Medical

Contact (FMC) Diagnosis
Onset
≤10 min

Primary
≤60 min if FMC at PCI-capable facility
PCI
Patient Delay

≤90 min if FMC not at PCI-capable facility and transfer to PCI- Primary
capable hospital is required
PCI

≤30 min if PCI not

available ≤120 min Fibrinolysis Angiography within 3-24 hrs

PCI = percutaneous coronary intervention.

Adapted from Steg G, et al. Eur Heart J. 2012;33:2569-2619.
 Chest discomfort suggestive of ischemia

EMS assesment and care and hospital preparation

•Monitor support ABCs. be prepared to provide CPR & defibrilation
•administer oxygen, aspirin, nitroglycerin, and morphine if needed
•if available, obtain 12 lead ECG; if ST elevation
•notify receiving hospital with transmission and interpretation
•begin fibrinolitic check list
•Notified hospital should mobilize hospital resources to respond to STEMI

Immediate ED assesment (<10 mnt) Immediate ED general treatment

• Check vital sign; evaluate oxigen saturation

• Obtain/Review 12 lead ECG
• Start Oxygen at 4 L/min; maintain
• Perform brief targeted history, physical
• Aspirin 160 to 325 mg (if not given by EMS)
• review complete fibrinolytic checklist; check
• Nitroglycerin Sublingual, spray or IV
• Obtain initial cardiac marker levels, initial
• morphine IV if pain not relieved by
coagulation studies
• obtain portable chest Xray(<30 min)

Review initial 12-lead ECG

ST elevation or new or
presumably new LBBB;
strongly suspicious for injury
ST elevation MI (STEMI)
Start Adjunctive treatment as
indicated (see text for
contraindications)
Do Not Delay Reperfusion
• b-adrenergic receptor blockers
• Clopidogrel
• heparin (UFH or LWMH)
Observe with Continous Monitoring
ST depression or dynamic T wave
inversion; strongly suspicious for Normal or non diagnostic
ischemia High Risk Unstable changes in ST segmen or T wave
angina/ Non-ST-Elevation MI intermediate/ low risk UA
(UA/NSTEMI)
Start Adjunctive treatment as
indicated (see text for
contraindications) Developed high or intermediate
• Nitroglycerin
criteria
• b-adrenergic receptor blockers OR
• Clopidogrel Troponin-positive ?
• heparin (UFH or LWMH)
• Glycoprotein IIb/IIIa inhibitor
Kontraindikasi beta bloker
1) signs of HF
2) evidence of a low-output state
3) PR interval greater than 0.24 s
4) Second or third degree heart block
5) Active asthma
6) Reactive airway disease
 Goals
 Rapidly reverse acute hemodynamic abnormalities
 Rapidly relieve symptoms and improve respiratory
status
 Initiate treatment t hat will slow disease progression
and improve long-term survival
 Apply treatment cost effectively