Pendahuluan

Pedoman penatalaksanaan klinis merekomendasikan penanganan invasif dini bagi pasien non-ST-elevation acute coronary syndrome (NSTE ACS). Bagaimanapun juga, angiografi merupakan prosedur diagnostik yang tidak memberikan keuntungan apabila pasien tidak dilakukan prosedur revaskularsasi. Beberapa penelitian juga menunjukkan banyak pasien yang menjalani angiografi tidak melanjutkannya ke revaskularisasi dini, dan menadapatkan terapi medikamentosa, tapi efek jangka panjang penanganan secara konservastif belum sepenuhnya diketahui.

Definisi
Definisi Acute Coronary Syndrome (ACS) Sindrom koroner akut adala keadaan gawat darurat jantung dengan manifestasi klinis berupa perasaan tidak enak di dada atau gejala-gejala lain sebagai akibat iskemia miokardium. ACS Coronary Heart Disease (CHD)

 Typical anginaAll three of the following

Substernal chest discomfort Onset with exertion or emotional stress Relief with rest or nitroglycerin

Atypical angina
Meets 2 of the above characteristics

Noncardiac chest pain

Meets 1 of the typical angina characteristics
Modified from Diamond GA. A clinically relevant classification of chest

CCS Classification
Classification System of Angina Pectoris
Class 1 Activities Triggering Chest Pain Angina only during strenuous or prolonged physical activity

2
3

Slight limitation, with angina only during vigorous physical activity

Symptoms with everyday living activities, i.e., moderate limitation

Inability to perform any activity without angina or angina at rest, i.e., severe
limitation

Adapted from Braunwald E, Antman EM, Beasley JW, et al: ACC/AHA Guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the management of

UAP NSTEACS ACS NSTEMI

STEACS

STEMI

 Unstable Angina Non-STSegment Elevation MI (NSTEMI)

Similar pathophysiology

Similar presentation and early management rules

STEMI requires evaluation for acute reperfusion intervention

ST-Segment Elevation MI (STEMI)

2. Epidemiologi
CHD adalah penyebab kematian nomor 1 di dunia. 450,000 kematian di U.S di tahun 2009 Setiap tahun ada 1,200,000 kasus baru atau rekurrent penyakit jantung koroner 38% dari mereka mati mendadak.

Patofisiologi SKA
aterosklerosis sel busa bercak perlemakan (10-20 tahun) plak aterosklerotik (40 -50 tahun)

injury dinding pembuluh

agregasi platelet pelepasan isi granuler agregasi platelet lebih lanjut, vasokonstriksi

pembentukan trombus

infark miokardium/angina

Different stages of atherosclerotic plaque development

Characteristics of the stable atherosclerotic plaque

Fibrous cap (VSMCs and matrix)
Endothelial cells Lipid core Intimal VSMCs (repair phenotype)

Adventitia Medial VSMCs (contractile phenotype)

Weissberg, 1999

Plaque disruption
(plaque cracking, fissuring, rupture thrombosis start point)

1 3

Manifestasi Klinis
Palpitations Substernal pain (pressure, squeezing, or a burning sensation) and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm Exertional dyspnea that resolves with pain or rest Diaphoresis from sympathetic discharge Nausea from vagal stimulation Decreased exercise tolerance Hypotension Hypertension Pulmonary edema (sign of LHF) Jugular venous distention (sign of RHF) Cool, clammy skin and diaphoresis in patients with cardiogenic shock

Faktor Resiko
MODIFIABLE RISK FACTOR
Diabetes mellitus

UNMODIFIABLE RISK FACTOR

Increasing age Age-- > 45 for male/55 for female Male sex

Dyslipidaemia
Active and passive cigarette smoking Hypertension High-fat diet Physical inactivity Obesity/insulin resistance

Family history of premature CHD Event in first degree relative >55 male/65 female

Diagnosis
Acute Coronary Syndrome
Chest pain typically to angina/infarction

Tromb osis
No ST Elevation

ECG Cardiac Enzyme Final Diagnosis

ST Elevation Non-STEACS

Non-STEACS

UAP

NSTEMI

Unstable Angina

NQwMI

Myocardial Infarction

Qw MI

Circulation 2001;104:365; Lancet 2001; 358:1533-1538; J Am Coll Cardiol. 2007

Diagnosis of Angina
Diagnosis: Anamnesis Pemeriksaan fisik 10 men EKG it Biormarker Non-invasive Stress Test Coronary angiography Imaging (rarely done)

Anamnesis
Aid in diagnosis and rule out other causes
1. 2. 3. 4. 5. 6. Onset Location and radiation of pain Duration Characteristic and quality of discomfort Palliative/Provocative factors Symptoms associated with discomfort Cardiac risk factors Past medical history -

especially cardiac

Reperfusion questions
1. Timing of presentation 2. ECG c/w STEMI 3. Contraindication to fibrinolysis 4. Degree of STEMI risk

7. 8.

Pemeriksaan Fisik
1. ABC 2. Vital signs, general observation 3. Presence or absence of jugular venous distension (JVD) 4. Pulmonary auscultation for rales 5. Cardiac auscultation for murmurs and gallops 6. Presence or absence of stroke 7. Presence or absence of pulses 8. Presence or absence of systemic hypoperfusion (cool, clammy, pale, ashen)

EKG
ST Elevation atau LBBB baru STEMI
ST Depression or dynamic T wave inversions

NSTEMI
Non-specific ECG

Unstable Angina

Normal or non-diagnostic EKG

ST Depression or Dynamic T wave Inversions

ST-Segment Elevation MI

New LBBB

LBBB criteria: - Wide QRS complex (> 0,12 ms/ 3mm) in V5-V6, I, aVL - Broad on top/ notched - Leads that overlying RV show deep S waves (V1-V4)

Prinsip ACS
1. If the initial ECG is not diagnostic of STEMI, serial ECGs (every 15-30 min) or continuous ST-segment monitoring should be performed in the patient who remains symptomatic or if there is high clinical suspicion for STEMI. 2. Show 12-lead ECG results to emergency physician within 10 minutes of ED arrival in all patients with chest discomfort (or anginal equivalent) or other symptoms of STEMI. 3. In patients with inferior STEMI, ECG leads should also be obtained to screen for right ventricular infarction.

4. Lab exams should be performed as part of the management of STEMI patients, but should not delay the implementation of reperfusion therapy. Result of the lab exams should be ready in 60 min Serum cardiac biomarker CBC Activated partial thromboplastin time (aPTT) Electrolytes and magnesium Blood urea nitrogen (BUN) and Creatinine Glucose Complete lipid profile

5. Cardiac-specific troponins should be used as the optimum biomarkers for the evaluation of patients with STEMI who have coexistent skeletal muscle injury. 6. For patients with ST elevation on the 12-lead ECG and symptoms of STEMI, reperfusion therapy should be initiated as soon as possible and is not contingent on a biomarker assay.

OVERALL MORTALITY THROUGH 1 YEAR

Chen et al., JACC 2008; 369-78

Chen et al., JACC 2008; 369-78