Angina Pectoris :Focus on ACS
Adi Purnawarman MD,FIAdi Purnawarman MD,FIHAHADepartment 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
• 2020 25 Juta † krn PJ & ± ½ akibat PJK
4,9 juta Penyakit jantung
Kongestif
AHA. Heart disease and stroke statistics; ”2012 update. Dallas, TX
Indonesia ?
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
7,2%
1,1%0,8% 11,6%1,7%
16,6%12,8%
53,3%
48,2%
0,5%
14,1% 18,5%
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
0 1 2 3 4 5 6
5
10
0
15
20
25
Months after hospital admission
Dea
ths
/ 100
pts
/ m
onth
Acute MIUnstable anginaStable angina
Duke Cardiovascular Database
N = 21,761; 1985-1992Diagnosis on adm to hosp
Tanda-Tanda Serangan Jantung Akut
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 ke
Leher, lengan kiri, rahang (mandibula), gigi, punggung
Faktor pencetus
Exercise, stres emosi, udara dingin dan sesudah makan
Gejala penyerta
Mual, muntah, sulit bernafas, keringat dingin dan lemas. Nyeri membaik atau hilang dengan istirahat
Angina klasik :
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 cardio- myopathy• Pericarditis
Lungs • Lung Emboli• Pnemonia• Pneumothorax• Pleuritis
Gastrointestinal•Reflux esofagus•Ruptur esofagus
•Gall bladder disease•Peptic Ulcer•Pancreatitis
Vascular•Aortic dissection/aneurysma
Others•Musculoskeletal
•Herpes zoster
GenetikObesitas
Diabetes
Hemosisteinemia
Hiperkoagubilitas
Aterosklerosis
Gaya Hidup (merokok dll)
Hiperlipidemia
Hipertensi
Infeksi?Umur
Jenis Kelamin
Manifestasi Aterotrombosis
Faktor Resiko untuk PJK
Pengenalan dini, Kenali Faktor Resiko !!!
Sequence of Events in IschemicSequence of Events in IschemicHeart DiseaseHeart Disease
Risk Factor
Endothelial dysfunction
CAD
Ischemia
• Angina• Silent
MI
• Arrythmias• Lost of muscle
Remodeling
Progresif dilatation
Heart FailureDeath
Foamcells
Fattystreaks
Intermediatelesion
Atheroma Fibrousplaque
Complicatedlesion rupture
From First Decade From 3rd decade From 3rd decade From 4th decade From 4th decade
Atherosclerosis Timeline
Growth mainly by lipid accumulation Smooth muscle and
collagen
Thrombosis hematoma
Endothelial Dysfunction
ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007
Prognosis with Troponin
1,01,7
3,4 3,7
6,0
7,5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9,0
Cardiac troponin I (ng/ml)
Mor
talit
y at
42
Day
s
831 174 148 134 50 67
%%
%%
%
%
ACC/AHA :Guidelines Management patient with UAP,NSTEMI. 2007
ACS dengan ischemia atau terlihat resiko tinggi
atau direncanakan untuk PCI
Aspirin†
+ IV heparin/SC LMWH‡
+IV GP IIb/IIIa antagonist
Diduga ACS
Aspirin†
Didiagnosa ACS
Aspirin†
+ SC LMWH
or IV heparin
ACC/AHA 2002 Guidelines Update UA & NSTEMI
+ Clopidogrel + Clopidogrel*During 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
Rekomendasi Class I
1. Braunwald E et al. American College of Cardiology (ACC) and the American Heart Association (AHA) Guidelines, USA: ACC/AHA; 2002.
2011-2012
2012
Current Medical Management of Unstable
Angina & NSTEMI
• Morphin, O2, Bed Rest, ECG,Monitoring
• Nitroglycerin• Antiplatelet Therapy• Beta Blockers• Ace-Inhibitor/ARB• Anticoagulant Therapy
• Antiplatelet Therapy• Beta Blockers• Calcium Chanel Blockers• Lipid Lowering Agent• Ace-Inhibitors/ARB
Acute Therapy Maintenace Therapy
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
28
ST elevation
12 h
AspirinBeta-blocker
Eligible forfibrinolytic therapy
> 12 h
Fibrinolytic therapycontraindicated
Not a candidate For reperfusion
therapy
Persistent symptoms ?
Fibrinolytic therapyPrimary
PTCA or CABGOther medical therapy:
ACE inhibitors? Nitrates
Anticoagulants
ConsiderReperfusion
Therapy
No Yes
Modified from Antman EM. Atlas of Heart Disease, VIII; 1996
29
Options for Transport of Patients With Options for Transport of Patients With STEMI and Initial Reperfusion TreatmentSTEMI and Initial Reperfusion Treatment
EMS Transport
Onset of symptoms of
STEMI
9-1-1EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30 min.
GOALS
PCIcapable
Not PCIcapable
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
EMS Triage Plan
Inter-HospitalTransfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.
EMS transportEMS-to-balloon within 90 min.
Patient self-transport Hospital door-to-balloon
within 90 min.Dispatch
1 min.
5 min.
8 min.
TROMBOLITIKTROMBOLITIK
Indikasi, Kontra Indikasi,Indikasi, Kontra Indikasi, ProsedurProsedur
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
• 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
Kontra Indikasi Trombolitik (relatif)
Komplikasi / Efek samping Komplikasi / Efek samping TrombolitikTrombolitik
• 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. Penjelasan terinci : tujuan , manfaat & kemungkinan efek samping obat
2. Monitor ECG3. Defibrilator4. Obat-obatan
emergensi / resusitasi
5. Syringe Pump 100 ml 1,5 juta UI streptokinase (1 amp) dlm 100 ml Nacl 0,9% atau D5%
21
4
3
5
Primary PCI
ACS risk criteria
Low Risk ACS
No intermediate or high risk factors
<10 minutes rest pain
Non-diagnositic ECG
Non-elevated cardiac markers
Age < 70 years
Intermediate Risk ACS
Moderate to high likelihood of CAD
>10 minutes rest pain, now resolved
T-wave inversion > 2mm
Slightly elevated cardiac markers
High Risk ACS
Elevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress
testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery
Low risk
High risk
Conservative Conservative therapytherapy
Invasive Invasive therapytherapy
Chest Pain Chest Pain centercenter
Intermediate risk
Nurses Mini Course
39
Symptom Recognition
Call to Medical System
ED Cath LabPreHospital
Delay in Initiation of Reperfusion Therapy
Increasing Loss of Myocytes
Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied
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.....