Angina Pectoris :

Focus on ACS
Adi Purnawarman MD,FIHA
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Unsyiah / Zainoel Abidin Hospital Banda Aceh

Pendahuluan
70 Juta orang US(1 dari 4) Penyakit Kardiovaskuler Penyebab terbesar penyebab kematian (38%) 1,2 Juta Kasus baru & Serangan berulang/Thn
65 Juta Hipertensi

4,9 juta Penyakit jantung Kongestif

13 juta Penyakit Arteri Koroner

5,4 Juta Stroke

2020 25 Juta krn PJ & akibat PJK

AHA. Heart disease and stroke statistics; 2012 update. Dallas, TX

Indonesia ?
Studi Kohort 13 tahun (3 kecamatan Mampang), Jak Sel)
30.00%

50 20.00% 40 10.00% 30
20 0.00% 10 0

Penyebab Kematian ** Angka Kematian Penyakit Kardiovaskuler * 1975 1981

1986

1995

PJK

2004 Pyk Lain

Stroke Paru & Kanker Asma

Kusmana D and Team : Jakarta Cardiovasculer Study; The city that promotes Indonesia Healthy Heart , Report I; 2006 * Kusmana D : Pengaruh tidak/stop merokok disertai olah raga teratur dan/atau pengaruh kerja fisik terhadap daya survival penduduk di Jakarta ; penelitian kohort selama 13 tahun. Disertasi, program studi Ilmu kedokteran S3 FK UI, Jakarta, 2002**

Profil Kesehatan NAD Berdasarkan Riset Kesehatan Dasar 2007

53,3% 48,2% 12,8% 16,6% 14,1% 18,5% 1,7% 1,1%

7,2%
0,8%

11,6% 0,5%

Riset Kesehatan Dasar Prov NAD, 2007

Penyakit Kardiovaskular di Aceh

Delima, Mihardja L, Siswoyo H. Prevalensi dan faktor determinan penyakit jantung di Indonesia. Bul Penelit Kesehat 2009; 37 (3): 142-59.

Sindroma Koroner Akut (SKA)

Sekumpulan gejala klinis yang biasanya disebabkan oleh trombosis / aterosklerotik pada pembuluh koroner sehingga menyebabkan sumbatan sebagian atau seluruh lumen pembuluh tersebut Subset-nya :
Angina Tidak Stabil Non STEMI Infark STEMI

Cumulative 6-month mortality from ischemic heart disease

25 Deaths / 100 pts / month 20 15 10 5 0 0 1 2 3 4 5 Months after hospital admission 6 Acute MI Unstable angina Stable angina N = 21,761; 1985-1992 Diagnosis on adm to hosp

Duke Cardiovascular Database

Tanda-Tanda Serangan Jantung Akut Angina klasik :

Sifat nyeri Rasa sakit, seperti ditekan, rasa terbakar,
ditindih benda berat, seperti ditusuk, rasa diperas dan dipelintir Lokalisasi Dada kiri (Substernal prekordial) dan ulu hati ( epigastrium) Penjalaran Leher, lengan kiri, rahang (mandibula), gigi, punggung ke Exercise, stres emosi, udara dingin dan sesudah Faktor makan pencetus Mual, muntah, sulit bernafas, keringat dingin Gejala dan lemas. Nyeri membaik atau hilang dengan penyerta istirahat

Tanda-tanda Serangan jantung

Angina Equivalent
: Tidak ada nyeri / rasa tidak enak di dada yang khas, namun pasien menunjukkan gejala gagal jantung mendadak (sesak napas), atau aritmia ventrikular (palpitasi, presinkop, sinkop)

Dibelakang tulang dada

Dibelakang tulang dada menjalar ke leher

Dari dada menjalar ke bahu dan lengan

Dari dada menjalar ke rahang

Didada bawah di ulu hati (sering ditafsirkan sebagai penyakit maag)

Didareah punnggung di antara kedua belikat

Differential Diagnosis Chest Pain

Cardiac
ACS : Infarct,angina MVP Aortic Stenosis Hypertrophic cardiomyopathy Pericarditis

Gastrointestinal
Reflux esofagus Ruptur esofagus Gall bladder disease Peptic Ulcer Pancreatitis

Lungs
Lung Emboli Pnemonia Pneumothorax Pleuritis

Vascular
Aortic dissection/aneurysma

Others
Musculoskeletal Herpes zoster

Faktor Resiko untuk PJK

Hiperkoagubilitas Hemosisteinemia Jenis Kelamin Gaya Hidup (merokok dll) Hiperlipidemia

Hipertensi
Infeksi? Diabetes

Umur
Genetik Aterosklerosis

Obesitas

Manifestasi Aterotrombosis

Pengenalan dini, Kenali Faktor Resiko !!!

Sequence of Events in Ischemic Heart Disease

Angina Silent Ischemia

MI

Arrythmias Lost of muscle

Remodeling

CAD

Progresif dilatation

Endothelial dysfunction Risk Factor

Heart Failure Death

Atherosclerosis Timeline
Foam cells Fatty streaks Intermediate lesion Atheroma Fibrous plaque Complicated lesion rupture

Endothelial Dysfunction
From First Decade From 3rd decade From 4th decade Smooth muscle and collagen Thrombosis hematoma

Growth mainly by lipid accumulation

ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007

Prognosis with Troponin

8
Mortality at 42 Days

7,5 % 6,0 % 3,7 %

7 6 5 4 3 2 1 0

3,4 % 1,0 %
831

1,7 %
174 148 134 50 67
9,0

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 Cardiac troponin I (ng/ml)

ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007

ACC/AHA 2002 Guidelines Update UA & NSTEMI

Rekomendasi Class I
Diduga ACS Didiagnosa ACS
ACS dengan ischemia atau terlihat resiko tinggi atau direncanakan untuk PCI

Aspirin

Aspirin

+
SC LMWH or IV heparin

Aspirin + IV heparin/SC LMWH 2011-2012 + IV GP IIb/IIIa antagonist

+ Clopidogrel
*During

+ Clopidogrel

2012

hospital care Clopidogrel should be administered to hospitalized patients who are unable to take ASA because of hypersensitivity or major GI intolerance Class IIa: enoxaparin preferred over unfractionated heparin, unless CABG is planned within 24 hours 1. Braunwald E et al. American College of Cardiology (ACC) and the American Heart Association (AHA) Guidelines, USA: ACC/AHA; 2002.

Current Medical Management of Unstable Angina & NSTEMI

Acute Therapy
Morphin, O2, Bed Rest, ECG,Monitoring Nitroglycerin Antiplatelet Therapy Beta Blockers Ace-Inhibitor/ARB Anticoagulant Therapy

Maintenace Therapy
Antiplatelet Therapy Beta Blockers Calcium Chanel Blockers Lipid Lowering Agent Ace-Inhibitors/ARB

Definition of Myocardial Infarction

Third universal definition of myocardial infarction (ESC 2012)
Rise/fall of cardiac biomarker (specifically troponin) with at least one of:
Symptoms of ischemia New or presumed new ST-T change or LBBB in ECG Development of Q pathological waves in ECG Imaging evidence of new regional wall motion abnormality Intracoronary thrombus by angiography or autopsy

Cardiac death with symptoms of ischemia with new ECG changes BUT death occuring before cardiac value are released

Definition of STEMI
Third universal definition of myocardial infarction (ESC 2012)
New ST elevation at J-point in at least two contiguous leads with the cut-points > 0.1mV

Except V2-V3 (male, >40 years old) >0.2mV Except V2-V3 (male, <40 years old) >0.25mV Except V2-V3 (female) 0.15mV Except V7-V9 & V3R-V4R 0.05mV

ST Elevation

Evolution of ST Elevation

Management of Patients with ST Elevation

ST elevation Aspirin Beta-blocker

12 h

> 12 h

Eligible for fibrinolytic therapy

Fibrinolytic therapy contraindicated

Not a candidate For reperfusion therapy

Persistent symptoms ?

Fibrinolytic therapy

Primary PTCA or CABG

No

Yes Consider Reperfusion Therapy

Other medical therapy: ACE inhibitors ? Nitrates Anticoagulants

Modified from Antman EM. Atlas of Heart Disease, VIII; 1996

28

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis: Door-to-Needle within 30 min.

Not PCI capable

Onset of symptoms of STEMI 9-1-1 EMS Dispatch

EMS on-scene
Encourage 12-lead ECGs. Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.

InterHospital Transfer

PCI capable

GOALS
5 min. Patient

8 min.
EMS

EMS Transport
Prehospital fibrinolysis EMS transport EMS-to-needle EMS-to-balloon within 90 min. within 30 min. Patient self-transport Hospital door-to-balloon within 90 min.

Dispatch 1 min.

Golden Hour = first 60 min.

Total ischemic time: within 120 min.

29

TROMBOLITIK
Indikasi, Kontra Indikasi, Prosedur

Kontra Indikasi Trombolitik

(absolut)

Riw Stroke hemoragik (waktu tak terbatas) Riw stroke lain / cerebrovaskular event dalam 6 bulan

Keganasan intrakranial atau kerusakan saraf pusat

Trauma kepala dalam 3 minggu terakhir

Perdarahan internal aktif (tidak termasuk mens)

Diketahui adanya gangguan pembekuan darah curiga diseksi aorta

Kontra Indikasi Trombolitik

(relatif)

Hipertensi berat 180/110 mmHg, atau kronis & uncontrolled Dalam antikoagulan INR > 2 - 3 Trauma kepala, CPR > 10 mnt, operasi besar ( dalam 3 minggu terakhir ) TIA (dalam 6 bulan terakhir) Riw pemberian Streptokinase antara 5 hari - 2 tahun Kehamilan atau 1 mgg post partum Ulkus peptikum aktif Infektif Endokarditis Penyakit hati stadium lanjut

Komplikasi / Efek samping Trombolitik

Perdarahan ringan berat ( hematom ringan s/d stroke hemoragik ) Aritmia ringan berat ( Ekstra sistol jarang s/d VT VF )

Harus dijelaskan pada pasien & keluarga !!

Persiapan Thrombolitik

1 3 5

1. Penjelasan terinci : tujuan , manfaat & kemungkinan efek samping obat 2. Monitor ECG 3. Defibrilator 4. Obat-obatan emergensi / resusitasi 5. Syringe Pump 100 ml 1,5 juta UI streptokinase (1 amp) dlm 100 ml Nacl 0,9% atau D5%

Primary PCI

ACS risk criteria

Low Risk ACS
No intermediate or high risk factors <10 minutes rest pain

Intermediate Risk ACS

Moderate to high likelihood of CAD

Non-diagnositic ECG
Non-elevated cardiac markers Age < 70 years

>10 minutes rest pain, now resolved

T-wave inversion > 2mm Slightly elevated cardiac markers

High Risk ACS

Elevated cardiac markers New or presumed new ST depression Recurrent ischemia despite therapy Recurrent ischemia with heart failure High risk findings on non-invasive stress test Depressed systolic left ventricular function Hemodynamic instability Sustained Ventricular tachycardia PCI with 6 months Prior Bypass surgery

Low risk

Intermediate

risk

High risk

Chest Pain center

Conservative therapy

Invasive therapy

Treatment Delayed is Treatment Denied

Nurses Mini Course

Symptom Recognition

Call to Medical System

PreHospital

ED

Cath Lab

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

39

Summary
ACS includes UA, NSTEMI & STEMI

Management guideline focus Immediate assessment/intervention (MONACO+BAH) Risk stratification (UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMI
Aggressive attention to secondary prevention initiatives for ACS patients Beta blocker, ASA, ACE-I, Statin

Terimeng Gaseh Beh.....