Pulmonary Trunk Left Main Coronary Artery First Septal Perforator Right Coronary Arte RCA) ~ : «__ Left Circumflex Artery (LCX) First Right Ventricular Diagonal Marginal branch Left Anterior Rescencing Posterior Artery (LAD) Descending Artery (PDA) Posterolateral Branch of LCXMultiples of the URL 100 +— Cardiac troponin Days after onset of AMI Upper reference limitAlgorithm for the Evaluation and Management of Patients Having an Chest Pain I Evaluate for Angina’ i q 4 Chest pain suggestive of ACS Non cardiac chest pain Chronic Stable Angina Treatmentas indicated Protocclfor No ST Elevation ST Elevation by alternative clagnosis Chronic Stable Angina jl | ¥ + Evaluate for Non dlagnosic ECS ‘STT changes reperiusion therapy Normal ital biomerkers On going pain ve Biomarkers Hemodynamic instability (Observe: Follow-up at 4-8 hours; + ECG, card.ac biomarkers Aan to hospital SSApa SIEM I Ant-ischemia therapy { 1 t No recurent pain, Recurrent ischemic pain, Negative follow-up studies Dizonosis of ACS canfirmed + Stress study for pravocsble ischemia Considr evaluation of LY function if ischemia present (Test may be performed either prior to discharge or as outpatient) + + Negative Pbtential diagnosis, Positive Non-carciac chest pain Diagnosis of ACS confirmed2.ECG 3. Troponin ‘oiemis — [ noneriae ua Pec.) neta sro |When blood flow to the heart is decreased = becavse of Boca corer) oars cham me Me esalnoor sf tectron l cotrnne wetioe } | ischemia will progress to injury and nacrosis of ; cardiac issue, 5 a : lechemia > ‘The irverted T wave ‘ is caused by atered : repolarization. Injury SST segment alevation Is a sign of myocardial q Infarction ‘Abnormal Q waves result from the absence ‘of depolarization current ‘rom dead tissue and the Dresence of opposing Currents from other areas - of the heartPersangkaan SKA Nonkardiak Angina stabil Kemungkinan SKA Definitif SKA (kronik) a Tanpaclevasi. _Flevasisegmen ST eke: i ‘ (STEMI EKG: normal atau nondiagnostik segmen ST atau LBBB baru *Marka jantung awal: normal ' Observasi 12 jam sejak awitan angina *Perubahan ST dan/atau gelombangT * Angina berlanjut * Marka jantung positif * Hemodinamik abnormal “Angina tidakberulang —_* Angina berulang, atau * EKG: Perubahan ST Evaluasi unk * Marka jantung: normal dan/atau gelombangT terapi reperfusi * Marka jantung: positif Definitif SKA NEGATIF POSITIF oe jagnosis: bukan SKA atau Diagnosis: definitif atau > Terapi NSTEMI risiko rendah SKA sangat mungkin SKA Pemantauan rawat jalanPelepasan awal myoglobin atau isoform CK-MB Troponin jantung setelah infark miokard “klasik” (CK-MB setelah infark miokard Troponin jantung setelah “mikroinfark” 0 1 2 3 4 5 6 7 8 Hari setelah awitan infark miokard akut Waktu timbulnya berbagai jenis marka jantungNormal Hyperacute ‘ST-elevation Q-wave ‘ST-elevation T-wave T-Wave 0-12-hours developing with T-wave recovery minutes-hours. over Inversion weeks-months 1-12-hours 2-5 days