Acute Coronary Syndrome

dr. Mohammad Harris Gailani, SpJP

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 Acute Coronary Syndrome
• Major health problem
• High mortality and morbidity

20% Similar with the

other country
1.1 M 72% patient
experienced ACS
Mortality in Incidence in
European USA
(2016) (2016)

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

ACS in Indonesia
Patients Patients
686 patients 18,446 patients

194 patients 5,507 patients

Unclassified ACS Unclassified ACS

Unclassified ACS: Unclassified ACS:

iSTEMI registry. 2019

 Atheroschlerosis

1. Normal artery
2. Lesion initiation
3. Fibrofatty stage
4. Fibrous cap
5. Rupture of fibrous cap
6. Collagen accumulation
7. Mural thrombus

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ACS Diagnosis

10 minutes

No need to
wait the result

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart
 Angina pada SKA
• Angina tipikal persisten lebih dari 20 menit
• Angina de novo CCS kelas III
• Angina kresendo CCS kelas III
• Angina pasca infark
• Rasa tidak nyaman di daerah
substernal
• Dipacu oleh stress atau aktivitas
• Berkurang dengan istirahat atau
pemberian nitrat
Juzar DA, et al. Pedoman Tataalaksana SKA. PERKI. 2018
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STEMI
ECG

Penilaian ST elevasi dilakukan pada J point dan

ditemukan pada 2 sadapan yang bersebelahan.
The J point : THE JUNCTION between the termination of the
QRS complex and the beginning of the ST segment.

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It’s not always about thrombus !

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INITIAL TREATMENT
2018

M
Morphine • Can be repeated per 10 – 30 min, for
sulfate iv patient who not responsive
1-5 mg

O O2 • when SaO2 < 90% or PaO < 60

N NTG / ISDN • If ongoing chest pain by the time admitted at ER

A ASPIRIN
Loading
Ticagrelor
or
• 180 mg loading dose + 90 mg BID
• 300 mg loading dose + 75 mg OD if ticagrelor is
not available or contraindicated
160 – 320mg clopidogrel*

Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

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 Terapi Inisial
UGD
1. Tirah baring

Guideline ESC 2017:

2. Suplemen
oksigen
 Co-Therapy Anti Platelet/DAPT
3. Aspirin 4. Penghambat reseptor ADP/
P2Y12 inhbitor
• 150-300 mg diberikan • bersama aspirin sesegera
segera pada semua pasien mungkin dan dipertahankan
yang tidak diketahui selama 12 bulan kecuali ada
intoleransinya terhadap indikasi kontra
aspirin (SL) • CPG lebih dipilih untuk
• Dosis pemeliharaan 75-150 fibrinolysis (300mg loading)
mg setiap harinya untuk
jangka panjang, tanpa
memandang strategi
pengobatan yang diberikan
 RELIEVE SYMPTOMS
5. Nitrogliserin (NTG)
6. Morfin sulfat
spray/tablet sublingual

Jika nyeri dada tidak hilang dengan satu kali pemberian, 1-5 mg intravena, dapat diulang setiap 5-30 menit, bagi
dapat diulang setiap lima menit sampai maksimal tiga pasien yang tidak responsif dengan terapi tiga dosis
kali. NTG sublingual

Nitrogliserin intravena diberikan pada pasien yang

tidak responsif dengan terapi sublingual, dalam
keadaan tidak tersedia NTG, isosorbid dinitrat (ISDN)
dapat dipakai sebagai pengganti

Nitrat tidak diberikan pada pasien dengan TDS <90

mmHg atau >30 mmHg di bawah nilai awal, bradikardia
berat (<50 kali permenit), takikardia tanpa gejala gagal
jantung, atau infark ventrikel kanan

Nitrat tidak boleh diberikan pada pasien yang telah

mengkonsumsi inhibitor fosfodiesterase: sidenafil
dalam 24 jam, tadalafil dalam 48 jam.
STEMI

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Maximum
target times
according to
reperfusion
strategy
selection in
patients
presenting
via EMS or
in a non-
PCI center 19
PPCI Recommendation

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

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Importance of time to reperfusion in
STEMI patients

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Estimation of risk for intracranial
hemorrhage (ICH) with fibrinolysis
Risk Factors

1.Age ≥ 75
2.Black
3.Female gender
4.Previous stroke history
5.SBP ≥ 160 mmHg
6.Low BW (Men ≤ 80, Women ≤ 65
Kg)
7.INR > 4 or PT > 24
8.TPA use (vs other thrombolytic
agents)

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Fibrinolytic Agents for STEMI

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NSTE-ACS

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 General Approaches in ACS-NSTEMI
Patients

Bueno H and Vranckx P.

The Acute Cardiovascular
care Association Clinical
Decision-Making Toolkit.
European Society of
Cardiology. 2018. 1-208.
Ischemic Risk

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Risk Stratification: GRACE Score
Points for Each Predictive Factor
SBP, Score
Killip Class Score Mm Hg
< 80 63
I 0 80 – 99 58
II 21 100 - 119 47
III 43 120 - 139 37
IV 64 140 - 159 26 High risk: Score >140
160 - 199 11
> 200 0 In-hospital death: >3%
Heart Rate,
Score
Beats/min
Age Score
< 70 0 < 40 0
70-89 7 40 - 49 18
90-109 13 50 - 59 36 Intermediate risk: 109 – 140
110 - 149
150 - 199
23
36
60 - 69
70 – 79
55
73
In-hospital death: 1-3 %
> 200 46 80 91

Predictive Factor Score Creatinine, (µmol/L) Score

0 - 34 2 Low risk: Score ≤ 108

35 – 70 5
• Cardiac arrest at • 43 71 – 105 8
In-hospital death: <1%
admission 106 – 140 11
• Elevated cardiac markers • 15 141 – 176 14
• ST Segment deviation • 30 177 – 353 23
≥ 354 31

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart
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 Risk Criteria Mandating Invasive Strategy
in NSTE-ACS
• Hemodynamic instability or cardiogenic shock • Relevant rise or fall in troponin
VERY HIGH

• Dynamic ST- or T-wave changes

HIGH RISK
• Recurrent or ongoing chest pain refractory to
medical treatment (symptomatic or silent)
RISK

• Life-threatening arrhythmias or cardiac arrest • GRACE Score > 140

• Mechanical complications of MI
• Acute heart failure
• Recurrent dynamic ST-T wave changes,
particularly with intermittent ST-elevation
INTERMEDIATE

• Diabetes mellitus • Any characteristics not mentioned above

• Renal insufficiency

LOW RISK
(eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF
• Early post infarction angina
• Prior PCI
• Prior CABG
• GRACE risk score 109 - 140

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

Aggressive approach recommended in HIGH
RISK-NSTE-ACS Patient

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

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MI
COMPLICATION
THANK YOU

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