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PENYAKIT JANTUNG KORONER

Dr.Muhammad Aminuddin Lab/Smf Kardiologi RSUD Dr Soetomo FK Unair Surabaya

PENYAKIT JANTUNG KORONER


Sebab : Proses aterosklerosis pada p.d . koroner Terjadi penyempitan lebih 60 % Gejala Nyeri dada Angina pectoris

FAKTOR RISIKO PKV


1. Tidak bisa dirubah : Sex Usia Riwayat keluarga 2. Bisa dirubah : Dislipidemia Merokok DM Hipertensi LVH Kurang olah raga Obesitas Stress, kepribadian

Nyeri Angina yang Khas - sifat retro sternal - seperti ditekan, diregang, diremas dan terbakar - menjalar ke leher kiri,rahang dan telinga kiri

Secara klinis manifestasi pjk


Asimtomatik orang tua, DM Angina pectoris stabil Angina pectoris tidak Stabil Angina Variant/Prinzmetal Iskhemia myocard tenang Aritmia Gagal jantung Infark myocard Akut Mati Mendadak

INFARK MYOCARD AKUT

Pathophysiology of MI
1. Acute thrombosis 2. Rupture of unstable plaque 3. Vasospasm 4. Embolism 5. Non-thrombotic MI (e.g. related to shock or arrhythmia)

General Guidelines to Differentiate Chest Paint of Myocardial Infarction, Unstable and Chronic Stable Angina
Chest Pains Severity Duration Frequency Timing Myocardial infarction Very severe > 30 minutes Persistent pain At rest Unstable Angina Moderate severe 15 - 30 minutes Increasing frequency Usually no Chronic Stable Angina Mild < 15 minutes Stable, less frequent yes Less than MI

At rest or with exertion With exertion

Relief With No Nitroglycerine Other symptoms

anxiety, diaphoresis, Less than MI dyspnea, nausea

Clinical History :
Characteristics of Chest Paint In MI : Severe chest pain at rest for usually > 30 minutes Same character and location as previous anginal pain but more severe in intensity Not relieved by nitroglycerine Three Anginal Equivalent : (Symptoms Due to CAD Other Than Chest Pain) 1. Dyspnea 2. Cardiac arrythmia 3. Exhaustion Subsets of Patients With Painless MI :

1. Elderly patients (most common presenting symptom is dyspnea and not chest paint) 2. Diabetic patients 3. Patients with central nervous system disease (e.g. post-stroke patient)

Physical Examination :
1. General appearance : Apprehensive, anxious, diaphoretic or dyspneic Cold, clammy extremities 2. Vital signs : In large infacts, patients may be hypotensive, tachycardic, or tachypneic. James Reflex : Hypertension and tachycardia folowing anterior wall MI. Bezold - Jarisch Reflex : Hypertension and bradycardia following interior wall MI. 3. Cardiac examination : Apex beat may be difficult to palpate Check for signs of congestive heart failure : - Neck vein engorgement - Soft S1 - Bibasal rales - Murmur of mitral regurgitation - S3 gallop Differential Diagnosis : - Acute MI - Acute aortic dissection - Acute pericarditis - Costochondritis - Pulmonary embolism - Esophageal spasm - Acute Gastritis - Ruptured viscus

Criteria for Diagnosis


Two Out of 3 of the Following Establishes the Diagnosis : Modified WHO Criteria 1. Prolonged chest discomfort or chest pain 2. ECG evidence of myocardial infarction or ischemia a. ST elevation with development of Q waves - accompanied with either (1) chest discomfort or (3) elevated CK-MB to establish diagnosis of Q wave MI b. ST elevation without development of Q waves - must be accompanied by (3) CK-MB elevation to establish diagnosis of non - Q MI c. ST depression and/or T wave changes - must be accompanied by (3) CK-MB elevation to establish diagnosis of non-Q MI 3. At least a 2 fold rise in CK-MB

ECG Criteria for Myocardial Infarction :


1. ST elevation : > 2 mm in 2 or more chest leads or > 1 mm in 2 or more limb leads 2. Q wave > 0.04 sec (1 small square)

ECG Change in Acute Myocardial Infarction : Leads with ST elevation Location of MI


1. V1 - V2 2. V1 - V3 3. V1 - V6 4. Mirror Image of V1 & V2 5. I, AVL, V5, V6 6. II, III, AVF 7. II, III, AVF & V5, V6 8. II, III, AVF & V3R, V4R 9. Almost all leads Septal wall MI Antero - septal wall MI Antero - lateral wall MI Pasterior LV wall MI Lateral wall MI Inferior wall MI Inferior-lateral wall MI Inferior wall MI with Right ventricular MI Massive MI, Global MI, or Diffuse MI

A. Normal

B. Acute (<24 hours)

C. Recent D. Late E. Old (1-3 days) (3 days-6wks) (> 6 weeks)

II

III

aVR

aVL

aVF

V1-2 V3-4

V5-6
A B C D E

A. Normal

B. Acute (<24 hours)

C. Recent D. Late E. Old (1-3 days) (3 days-6wks) (> 6 weeks)

II

III

aVR

aVL

aVF

V1-2 V3-4 V5-6


A B C D E

Timing of Myocardial Infarction (MI)


Interpretation Q ST T Wave Wave Elevation (-) (-/+) (++) (-/+) (++) (++) peaked (-/+) inverted Approx. Timing of MI 0 - 6 hours 6 - 24 hours 24 - 72 hours

Hyperacute Acute Recent MI

Undetermined age of M
Old MI

(++)

(-)

inverted

72 hours - 6 weeks

(++)

(-)

upright

> 6 weeks

Molecular Markers in the Diagnosis of Acute Myocardial Infarction


Detection Peak Duration Most Common Sampling Schedule

Troponin T Sn = 94% Sp = 60%


Troponin I Sn = 95% Sp = 90% CK - MB

3-12 hours
3-12 hours 6-12 hours 24 hours 36 hours

24 hours

10-14 days
5-10 days

Once at least 12 hours after chest pain


Once at least 12 hours after chest pain Every 12 hours x 3; start at 6 hours after chest pain Once at least 1-2 days after chest pain Once at least 1-2 days after chest pain

24 hours

1 day

3 days

SGOT LDH

2 days 3 days

4 days 10 days

Complications of MI :
Cardiac arrhythmias and sudden death (usually within 24 hours of MI) Congestive heart failure or ventricular dysfunction Cardiogenic shock Deep venous thrombosis and pulmonary embolism Pericarditis (Dresslers syndrome) Rupture of papillary muscle Rupture of ventricular septum Rupture of cardiac wall Systemic arterial embolism Ventricular aneurysm

Three Factors Affecting Prognosis following Myocardial Infarction :


Left ventricular function Extent of coronary artery involvement Presence of ventricular ectopy

Killips Classification of AMI with Expected Hospital Mortality Rate


Killips Classification of AMI Class I : No signs of pulmonary or venous congestion Expected Hospital Mortality 0-5%

Class II : Moderate heart failure or presence of bibasal rales, S3 gallop, tachypnea, or signs of right heart failure including venous (JVP) and hepatic congestion Calss III : Severe heart failure, rales >50% of the lung fields or pulmonary edema
Class IV : Shock with systolic pressure <90 mmHg and evidence of peripheral vasoconstriction, peripheral cyanosis, mental confusion & oliguria

10 - 20 %

35 - 45%
85 - 95%

Forrester Classification Based on Hemodynamic Parameters


Forrester Pulmonary Class Capillary Wedge Pressure (in mm Hg) Cardiac Index (in L/min/m2) Expected Hospital Mortality

I
II

< 18 (good)
> 18 (bad)

> 2.2 (good)


> 2.2 (good)

3%
9%

III
IV

< 18 (good)
> 18 (bad)

<2.2 (bad)
<2.2 (bad)

23 %
51 %

Four Main Objectives in the Treatment of MI :


1. Restore coronary flow as early as possible e.g Thrombolytics 2. Preserve ischemic or jeopardized myocardium e.g Beta-blockers Nitrates Aspirin, Heparin Free radical scavenger 3. Treat cardiac complications e.g. Ace-inhibitors, diuretics for heart failure; Anti-arrhythmics for arrhythmias 4. Treat co-existing diseases, prevent death e.g. Antibiotics for pneumonia

Relative Contraindications to Thrombolytic Therapy in MI :


1. Known bleeding diasthesis (severe thrombocytopenia, coagulopathies) or current use of anticoagulants 2. Previous streptokinase treatment given for the past 6 to 9 months (in which case, give TPA) 3. BP > 180/100 on at least 2 readings 4. Active peptic ulcer disease 5. History of thrombotic cerebrovascular accident 6. Prolonged CPR of > 10 minutes or traumatic CPR 7. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic condition 8. Pregnancy

Patients with ischemic-type chest pain Assess initial 12 lead ECG ST elevation or new/ presumed new LBBB ECG suggests ischemia (ST depression, T wave inversion) Normal or nondiagnostic ECG Further evaluation in ER or monitored bed Yes Admit, start anti-ischemic tx Reperfusion tx if ST elevation develops Evidence of ischemia / MI No Discharge

Management of AMI

Assess thrombolysis contraindications Start anti-ischemic tx Start reperfusion tx Goal: <3-6 hours for Streptokinase / rt-PA or 1 PTCA
Routine labs : CBC, Lipid profile, electrolytes