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Clinical Practice of Acute

Coronary Syndrome

Bagaimana dengan
Tenaga Kesehatan?

Pathogenesis of atherosclerosis

Peter Libby,2012

Peter Libby,2012

Risk factor

Smoker

Hypertension

DM

Dislipidemia

Family history

Other risk factors( homocysteine, CRP, LpPLA2,


Lp(a)
Kim Fox et al,2006

Angina pectoris

Kim Fox et al,2006

CCS Classification

Kim Fox et al,2006

Angina

Stable

Unstable

Pierre Bassand et al,2007

Spectrum of Acute Coronary Syndrome

Marco Roffi et al,2015

Criteria for Acute Myocardial Infarction

Thygesen et al, 2012

STEMI
( ST Elevation Myocardial lnfarction)

Thygesen et al, 2012

ECG Evolution...!!!

Timing of Release Cardiac Biomarker

Cardiac biomarker should be examined 6 hours after


first onset of Acute Coronary Syndrome
Amit Kumar,2009

Marco Roffi et al,2015

Differential Diagnosis

Marco Roffi et al,2015

Treatment
Early reperfusion (PCI or Thrombolysis)
Oxygen
Loading dual antiplatelet
Statin high intensity
Morphin sulfat
Nitrat ( if no contraindication)
Beta-blocker ( if no contraindication)
Anticoagulant(Heparin,LMWH,Fondaparinux)
Venodilator ( ACE inhibitor)
Gabriel steg et al,2012

Thygesen et al, 2012

Prehospital & hospital reperfusion strategy

Thygesen et al, 2012

Thygesen et al, 2012

Thombolysis

Fibrinolytic therapy is recommended within 12 h of symptom


onset in patients without contraindications if primary PCI cannot
be performed by an experienced team within 120 min of FMC.

In patients presenting early (<2 h after symptom onset) with a


large infarct and low bleeding risk, fibrinolysis should be
considered if time from FMC to balloon inflation is >90 min.

If possible, fibrinolysis should start in the prehospital setting.

Rescue PCI is indicated immediately when fibrinolysis has


failed (<50% ST-segment resolution at 60 min).

Angiography with a view to revascularization (of the infarctrelated artery) is indicated after successful fibrinolysis.
Thygesen et al, 2012

Boland et al,2003

Doses of Fibrinolytic Agents

Thygesen et al, 2012

Thrombolysis contraindication
Absolute

Relative

Transient ischaemic attack in the preceding 6 months

Previous intracranial haemorrhage or stroke of unknown origin at any time

Oral anticoagulant therapy

Ischaemic stroke in the preceding 6 months

Pregnancy or within 1 week postpartum

Central nervous system damage or neoplasms or atrioventricular malformation

Recent major trauma/surgery/head injury (within the preceding 3 weeks)

Refractory hypertension (systolic blood pressure >180 mmHg and/or diastolic


blood pressure >110 mmHg)

Gastrointestinal bleeding within the past month

Advanced liver disease

Known bleeding disorder (excluding menses)

Infective endocarditis

Aortic dissection

Active peptic ulcer

Non-compressible punctures in the past 24 h (e.g. liver biopsy, lumbar puncture)

Prolonged or traumatic resuscitation

Thygesen et al, 2012

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Rescue PCI

Risk Stratification

Cardiac Complication of
STEMI
Mechanical
Valve
regurgitation
VSR
Freewall
ruptured

Arrhythmia

AF
VT/VF
SVT
SA/AV block

Pump Failure
Cardiogenic
shock

Thygesen et al, 2012

Long-term therapies for ST-segment elevation


myocardial infarction ( Secondary Prevention )

Lifestyle interventions and risk factor control

Smoking cessation

Diet and weight control

Physical activity

Blood pressure control

Psychosocial factor interventions

Van Der Werf et al,


2008

Long-term therapies for STEMI(Secondary Prevention )

Van Der Werf et al,


2008

Van Der Werf et al,


2008

NSTEACS(NSTEMI/UAP)

Thygesen et al, 2012

Marco Roffi et al,2015

Treatment

Oxygen

Loading dual antiplatelet

Statin high intensity

Morphin sulfat

Nitrat ( if no contraindication)

Beta-blocker ( if no contraindication)

Anticoagulant(Heparin,LMWH,Fondaparinux)

Venodilator ( ACE inhibitor)


Marco Roffi et al,2015

Risk Stratification
Grace Score

TIMI Score

Thank You