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• Menjelaskan
– Epidemiologi
– Etiologi dan Faktor Risiko S
– Patofisiologi K
– Klasifikasi
– Gambaran Klinis
A
– Penatalaksaan
– Komplikasi dan Prognosis
Penyakit Kardiovaskuler :
Masalah Yang Berakibat Fatal
Kondisi Ibu Hamil dan
Persalinan
Lain-lain &
defisiensi Peny.Infeksi &
nutrisi parasit
Kecelakaan
Kanker
Peny.Respirasi
Non infeksi 30%
Infeksi Respirasi
Penyebab kematian
Kardiovaskular nomor I di dunia dan
Indonesia
MCI
MATI
STROKE
Platelets
2 •Activation
Plaque
rupture
Activated
platelets
3 •Aggregation
TxA2
ADP Fibrinogen
ASA, Clopidogrel
GP IIb/IIIa Inhibitors
ECG
Diagnosis
STEMI NSTEMI UA
Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366 12
Sindroma Koroner Akut
Ischemic Discomfort History
Unstable Symptoms Physical Exam
No ST-segment ST-segment
ECG
elevation (NTEMI) elevation ( STEMI )
5/98 MedSlides.com 13
AWAS !!!!
SERANGAN JANTUNG !!!
SAKIT DADA
Unstable Angina - Definition
• Inappropriate tachycardia
– anemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosis
• High afterload
– aortic valve stenosis, LVH
• High preload
– high cardiac output, chamber dilatation
• Inotropic state
– sympathomimetic drugs, cocaine intoxication
Unstable Angina prognostic indicators
Low Risk
• new-onset exertional angina
• minor chest pain during exercise
• pain relieved promptly by nitroglycerine
Management
• can be managed safely as an outpatient (assuming
close follow-up and rapid investigation)
Unstable Angina Risk Stratification
Intermediate Risk
• prolonged chest pain
• diagnosis of rule-out MI
Management
• observe in the ER or Chest Pain Unit
• monitor clinical status and ECG
• obtain cardiac enzymes (troponin T or I) every 8 to
12 hours
Unstable Angina Risk Stratification
High Risk
• recurrent chest pain
• ST-segment change
• hemodynamic compromise
• elevation in cardiac enzymes
Management
• monitor in the Coronary Care Unit
Risk Stratification by ECG
Therapeutic Goals
• Reduce myocardial ischemia
• Control of symptoms
• Prevention of MI and death
Medical Management
• Anti-ischemic therapy
• Anti-thrombotic therapy
Unstable Angina Medical Therapy
• Anti-ischemic therapy
– nitrates, beta blockers, calcium antagonists
• Anti-thrombotic therapy
– Anti-platelet therapy
• aspirin, ticlopidine, clopidogrel,
GP IIb/IIIa inhibitors
– Anti-coagulant therapy
• heparin, low molecular weight heparin (LMWH),
warfarin, hirudin, hirulog
Unstable Angina Anti-ischemic Therapy
• restrict activities
• morphine
• oxygen
• nitroglycerine
– pain relief, prevent silent ischemia, control hypertension,
improve ventricular dysfunction
– nitrate free period recommended after the first 24-48 hours
Unstable Angina Anti-ischemic Therapy
• beta-blockers
– lowering angina threshold
– prevent ischemia and death after MI
– particularly useful during high sympathetic tone
• calcium antagonists
– particularly the rate-limiting agents
– nifedipine is not recommended without concomitant ß-
blockade
Unstable Angina Anti-thrombotic Therapy
• Thienopyridines
– ticlopidine (Ticlid; Hoffmann-La Roche)
– clopidogrel (Plavix; Bristol-Myers Squibb)
• GP IIb/IIIa inhibitors
– abciximab (monoclonal antibody)
– eptifibatide (peptidic inhibitor)
– lamifiban and tirofiban (non-peptides)
1. Circulation 1994;89:81-88
2. JAMA 1996;276:811-815
Unstable Angina
Anti-coagulant Therapy
• Low-molecular-weight heparin
advantages over heparin:
– better bio-availability
– higher ratio (3:1) of anti-Xa to anti-IIa activity
– longer anti-Xa activity, avoid rebound
– induces less platelet activation
– ease of use (subcutaneous - qd or bid)
– no need for monitoring
N ST E M I
(Non ST Segment Elevation Mycardial Infarction)
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge Management
Diagnosis of Acute STEMI
History
• Tachycardia or bradycardia
• Extrasystoles
• S3 or S4, mitral regurgitation murmur
• Lung rales
• Hypertension or hypotension
• Pallor, distress
Diagnosis of Acute MI
Electrocardiogram
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge Management
Acute MI - Risk Stratification
ECG Classification - GUSTO I Outcome
40%
30%
20%
10%
0
20
20 30
30 40
40 50
50 60
60 70
70
Ejection
Ejection Fraction (%)
(%)
GISSI-1 (%)
Killip Definition Incidence Control Lytic
Class Mortality Mortality
I No CHF 71 7.3 5.9
II S3 gallop or 23 19.9 16.1
basilar rales
III Pulmonary edema 4 39.0 33.0
(rales >1/2 up)
IV Cardiogenic shock 2 70.1 69.9
Management of Acute MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge Management
PENANGANAN STEMI
PENANGANAN DI RUMAH
ACS DI RUMAH SAKIT
SAKIT
TUJUAN UTAMA
STRATEGI PENGOBATAN
45 % – 75 %
Pasien dilakukan penanganan secara NON STENT / Non PCI
Myocardial Reperfusion
The Original Paradigm
Re-establish Infarct
Limit Infarct Size Mortality
Vessel Patency
STEMI Management
STEMI Diagnosis
Preferably
Preferably PCI possible < 120 min?
<< 60
60 min
min
Immediate
Immediate transfer
transfer to
to
PCI
PCI center
center
Primary-PCI Yes
Yes No
No
Preferably
Preferably ≤
≤ 90
90 min
min
(≤
(≤ 60
60 min
min in
in early
early
Preferably
Preferably
Rescue-PCI presenters)
presenters)
≤≤ 30
30 min
min
Immediately
Immediately Immediate
Immediate transfer
transfer to
to
No PCI
PCI center
center
No Succesful Immediate
fibrinolysis ? fibrinolysis ?
Yes
Yes
Preferably
Preferably 3-24
3-24 h
h
Coronary angiography Steg G et al. Eur Heart J. 2012;33:2569-619
Primary PCI
Treatment of
choice for Acute MI
- PLATELET ADHESION
ANTIPLATELET
- PLATELET AGGREGATION
- THROMBOSIS THROMBOLYTIC
Acute MI Management
Pharmacologic Therapy on Hospital Discharge
0.0
0.0 0.5
0.5 1.0
1.0 1.5
1.5 2.0
2.0
Lytic
Lytic better
better Lytic
Lytic worse
worse
Thrombolysis for Acute MI
Time to Therapy and Mortality Reduction
Pooled Analysis of Randomized Trials
Absolute Mortality Reduction per 1000 Patients
40
30
20
10
0
0 6 12 18 24
Time from Symptom Onset to Randomization (h)
Fibrinolytic Therapy Trialists. Lancet 1994;343:311.
Aspirin in Acute MI
ISIS-2
35 Day Mortality (%)
20
15
13.2
10 10.7 10.4
8
5
4300 4295 4300 4292
0
Placebo ASA SK SK + ASA
Post
AIRE Ramipril 2,006
MI
TRACE Trandolapril 1,749
0 1 2
Rx Better Control Better
Hennekens et al. NEJM 1996;335:1660.
Adjunctive Therapy for Acute MI
Calcium Channel Antagonists
Agent N Odds Ratio & 95% CI Ca+2Ant Control
0 1 2
Less Mortality More Mortality
Held et al, in Topol: Text Int Cardiol 2nd Ed 1993, p.52.
Management of Acute MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge Management
Complications of Acute MI
Diagnosis
Risk Stratification
Acute Therapy
Reperfusion
Adjunctive
Complications
Pre-Discharge Management
Acute
MI
Pre-Discharge Management
• Risk stratification
• Pharmacologic therapy
GUIDELINE PENANGANAN PASIEN
ACS NON STENT
_ C o
on a
M
ACC/AHA ACLS ACS Algorithm
2006
1
Nyeri dada (kecurigaan ischemia)
2
Diagnosa, penatalaksanaan dan persiapan/pre hospital oleh EMS :
- Monitor, support ABC. Persiapan untuk CPR dan defibrilasi
- Berikan oksigen, aspirin, nitroglycerin dan morphine bila dibutuhkan
- Jika tersedia, periksa ECG 12 lead, jika terdapat ST-Elevasi :
• Hubungi rumah sakit yang dituju dengan DX pasien
• Mulai membuat fibrinolytic checklist
- RS yang dituju harus menyaiapkan “Mobilize Hospital Resources” untuk
merespon pasien STEMI
Diagnosa cepat oleh Emergency Departemen Penatalaksanaan umum cepat oleh E.D
(<10min)
- Check vital signs, evaluasi saturasi O2 - Morphin IV jika nyeri tidak berkurang dengan
- Pasang IV line nitroglycerin
- ECG 12 lead - O2 4 L/mnt, pertahankan saturasi O2 > 90%
- Anamnese singkat, terarah, pemeriksaan fisik - Nitroglycerin SL atau spray atau IV
- Periksa awal level cardiac marker, elektrolit - Aspirin 160 samapai 325 mg (jika tidak
Dan faal hemostatis diberikan oleh EMS)
- Periksa Rontgen dada (<30 m)
4
13
5
9
ST Elevasi atau LBBB baru atau ST depresi atau T inverted; dicurigai kuat Normal atau tidak ada perubahan
diasumsikan baru; dicurigai kuat ST- suatu ischemia segmen ST atau gelombang T
Elevasi MI (STEMI) Resiko tinggi unstable angina / Non ST Resiko rendah atau sedang untuk
Elevation MI (AU/NSTEMI) unstable angina
6
10 14
Mulai terapi tambahan sesuai indikasi.
Jangan menunda reperfusi Mulai terapi tambahan sesuai indikasi Berlanjut memenuhi kriteria sedang
atau tinggi (tabel 3,4)atau troponin
-Clopidogrel -Clopidogrel
positive?
--adrenergic reseptor blockers -Nitroglycerin
-Heparin (UFH or LMWH) --adrenergic reseptor blockers
-Heparin (UFH or LMWH) 15
-Glycoprotein IIb/IIIa inhibitor
Pertimbangkan opname di ED chest
paint unit atau “monitored bed” di ED
Lanjutkan dengan :
11
Serial cardiac marker (termasuk
7 troponin)
Opname di ruangan dgn “monitoring bed Ulang ECG, monitor segmen ST
Onset gejala < 12 jam ” Pertimbangan stress test
Tentukan status resiko
8
12
Strategi reperfusi:
16
Terapi ditetapkan berdasarkan Pasien High-risk:
keadaan pasien dan center criteria Refractory ischemic chest pain Berlanjut memenuhi kriteria
Menyadari tujuan terapi reperfusi: Recurrent/persistent ST deviation resiko tinggi atau sedang (tabel
Door-to-balloon inflation (PCI) = 90 Ventricular tachycardia 3,4)
mnt Hemodynamic tachycardia atau
Door-to-needle (fibrinolysis) = 30 mnt Signs of pump failure troponin-positive
Lanjutkan dengan terapi: Strategi invasive awal termasuk
ACE inhibitor/angiotensi receptor kateterisasi & revaskularisasi penderita
blocker (ARB) 24 jam dari onset IMA dgn syok dlm 48 jam 17
HMG CoA reductase inhibitor (statin Lanjutkan pemberian ASA, heparin &
therapy) terapi lain sesuai indikasi: Jika tidak ada ischemia atau
ACE inhibitor / ARB infare, maka dapat pulang dengan
HMG CoA reductase inhibitor (statin rencana kontrol
therapy)
Tidak pada resiko tinggi: penentuan
penggolongan resiko dari cardiology
ACC/AHA 2007 Guidelines Update
untuk UA / NSTEMI
Rekomendasi untuk Antiplatelet dan Anticoagulant 1
09/27/19
ESC Guidelines 2007
• ASA ( Klas 1 A )
– Direkomendasikan pada semua pasien NSTE-ACS bila tidak ada
kontra indikasi, dengan initial LD 160-325 (non enteric) dan dosis
pemeliharaan 75 – 100 mg untuk jangka panjang
• CLOPIDOGREL ( Klas 1A )
– Untuk semua pasien ACS, SEGERA berikan Clopidogrel 300mg LD,
dilanjutkan dengan 75mg/ hari, Clopidogrel harus dilanjutkan hingga
12 bulan, kecuali ada resiko tinggi perdarahan.