What’s the Updated Guidelines for

ACS Management?
A Cardiologist perspective

Isman Firdaus, MD
FIHA, FAPSIC, FAsCC, FESC, FSCAI

National Cardiovascular Center, Harapan Kita Hospital

Departement of Cardiology and Vascular Medicine, University
of Indonesia
 Spectrum of Pathology and Clinical IHD

Stable angina NSTEMI STEMI

IHD= Ischaemic heart disease ACS

NSTEMI= Non ST segment elevation myocardial infarction
STEMI= ST segment elevation acute myocardial infarction
ACS= Acute coronary syndrome

Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.

Apa Saja Akibat dari Pembentukan Trombus?
Sebuah trombus dapat menghambat aliran darah sepenuhnya
maupun sebagian, menyebabkan iskemia atau infark.

Not for distribution in the United States, Japan, or France. © 2013 Medtronic, Inc. All rights reserved. UC201403028ML 10/13
• Sebuah sumbatan di arteri
dapat menghalangi oksigen
menuju jaringan distal
miokardium, hal ini disebut
iskemia

• Iskemia dapat teratasi jika aliran

darah dikembalikan, tetapi jika
iskemia tidak ditangani secara
tepat, dapat menyebabkan
kerusakan maupun kematian Kematian otot jantung
jaringan (infark) di bawah aliran
yang tersumbat

http://www.nlm.nih.gov/medlineplus/ency/article/001124.htm. Accessed 9/20/12.

Image: NIH
3
 PLATELET Plays Important Role in
Thrombus Formation

Schafer AL. Am j Med.1996;101(2):199-209

 Jakarta Acute Coronary Syndrome
Registry (JAC Registry)
• Single center registry
• National referral hospital
• 24/7 PCI capable hospital
• Interventional cardiologist and staff capable of
arriving at the laboratory within 30 minute
• 9000 cathlab procedures
• 700 PPCI procedures
 Percentage of patient diagnosed with ACS admitted to
emergency room

11000
10188
10000 9634
8306 8661
9000 8060 8007
8000
7000
Patient

6000
5000
2332
4000 1678 1882 3402
1499 (30,4%) 2832
3000 (20,2%) (23,5%) (35%)
(18,6%) 28%
2000
1000
0
2005 2006 2007 2008 2009 2010
Year
Total patient admitted to ER Number of ACS patient

Source: Jakarta Acute Coronary Syndrome Registry data base 2012, Emergency Unit NCCHK
 ACS registry’s patient distribution
Consecutive ACS
N=2797

STEMI NSTEMI UAP

N= 869 (31,1%) N= 789 (28,2%) N= 1139 (40,7%)

No reperfusion Fibrinolytic Primary PCI

N= 510 (59%) N= 96 (11%) N= 263 (30%)

Source: JAC registry data base 2010, NCCHK

(Dharma S, et al. Neth Heart J 2012;20: 254-259)

 STEMI: description data (N=869)
Variabel Description
Location of STEMI, n (%)
Anterior 530 (61,0)
Non anterior 339 (39,0)
Killip class, n(%)
I 598 (68,8)
II 223 (25,7)
III 25 (2,9)
IV 18 (2,1)
Onset time, n(%)
< 12 hour 422 (49)
> 12 hour 442 (51)

Door to needle (min) 39 (5 – 333)

Door to balloon (min) 91 (16-681)

Continous data were presented as median;minimal-maximal

(Dharma S, Firdaus I, et al. Neth Heart J 2012;20: 254-259)
 Acute reperfusion therapy in STEMI
2500
PCI
2000

1500

N
1000

500 PPCI

0
2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Source: Jakarta Acute Coronary Syndrome Registry data base 2012, Emergency Unit NCCHK
 In-hospital mortality
P<0.001
P<0.03
13,3

Percentage
(%) 6,2
5,3

PPCI Fibrinolytic No reperfusion

(Dharma S, et al. Neth Heart J 2012;20: 254-259)

Cath lab in ED pictures
Alarm center ED pictures with internet service ECG
transmission
Common cause of time delay in Jakarta

Source: www.google.co.id
JAKARTA ACUTE CARDIOVASCULAR CARE
NETWORK SYSTEM

A PATIENT WITH CHEST PAIN

General Physician/ Hospital Call Ambulance

Heartline Hotline
Ambulance

REPERFUSION
 Global STEMI & NCC-HK Meeting
April 2014

Preliminary Survey- Jakarta

Jakarta ACS Registry Area: 740.3 km2 /Population: 11 million (15.000/km2)
(2008-2010)

24 hours Call center –

NCC Harapan Kita 2008
Estimated AMI in Jakarta
24,453 caseWestper-year
Low reperfusion rate: 41%

Jakarta
Late presenter (> 12 hours) : 53.1%
Population: 2,260,825
Area: 127.11 km2
• AMI Incidence Rate 222.3/100.000 per-year
Inter-hospital Referral: 61% = 2.260.825/100.000 x 222,3 = 5026
•Approximately 5026 AMI case per-year
Ref: Singapore Myocardial Infarction Registry Report No.2,
Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259) Trends in Acute Myocardial Infarction in Singapore 2007-2012
EMS / SPGDT
 NATIONAL HEALTH COVERAGE REIMBURSEMENT
REIMBURSEMENT DEPEND ON CASE SEVERITY AND HOSPITAL LEVEL OF
SERVICES

Primary PCI Fibrinolytics

Primary PCI National Type B Fibrinolysis National
Type B Type C Type D
Reimbursement Cardio- Reimbursement Cardio-
(Procedure & vascular
Private Private Private Private
(Procedure & vascular
Hospital Hospital Hospital Hospital
Admission) Center Hospitalization) Center

Minimum 3,414 2,555 Minimum 414

Reimbursement 829 USD 481 USD 249 USD
USD USD Reimbursement USD

Maximum 7,343 3,476 Maximum 1,629 1,025 644

Reimbursement Reimbursement
493 USD
USD USD USD USD USD

PCI: Percutaneous Coronary Intervention

Streptokinase (drug only): 280 USD; Alteplase (drug only): 560 USD

Permenkes 59/2014 on the Healthcare Standard Tariff, Universal Health Coverage/National Health Insurance (JKN)
Indonesia Case Based Groups (INA-CBGs), Social Security Management Agency (BPJS)
 UNIVERSAL HEALTH COVERAGE IN INDONESIA
Number of Cases and Cost of Catastrophic Diseases:
Inpatient January-June 2014 (6 months)
Case Number Cost (USD) Disease

232,010 134,821,667 Cardiac

172,303 55,600,810 Stroke

Catastrophic 138,779 55,600,810 Kidney

Inpatient
70,584 23,232,524 Diabetes
735,827 case
56,033 23,192,193 Cancer

53,948 12,951,916 Thalassemia

Main NCD 12,170 5,277,811 Hemophilia18
6 billion USD/year
Initial Assessment Suspected ACS
 2018

LMD - Layanan Medis Darurat

KMP – Kontak Medis Pertama
IKP – Intervensi Koroner Perkutan KMP : Fasilitas IKP

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

TIME and Myocardial Salvage

TIME IS MUSCLE
 Timing and logistical factors influence choice of
reperfusion strategy

Time to reperfusion Healthcare resource

• Patient ability to recognize • PCI vs non-PCI capable hospitals1–3

symptoms1,2 • Dependence on operator
• Mode of transportation to the expertise/volume3
hospital • Availability of a 24/7 service1,3*
(self-presentation vs EMS)1,2 • Availability of a pre-hospital
• Inter-hospital transfer challenges system for diagnosis and
(distance, traffic patterns, treatment3,4,5
climatic conditions etc)2,3

• 1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3.
Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation 2004;110:1909–1915; 6. Henriques JPS et
al. J Am Coll Cardiol 2003;41:2138–2142
 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
160 – 320mg clopidogrel* contraindicated

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

24
 Adjunctive treatment in Primary PCI and
Fibrinolytic Therapy
2018
Primary PCI Fibrinolytic

Antiplatelet • Ticagrelor 180 mg + 90 mg BID • Clopidogrel*

• Clopidogrel 600 mg + 75 mg * If patient undergoing PCI
OD if ticagrelor is not available after fibrinolytic may
or contraindicated considered to switch to
ticagrelor
Anticoagulant • UFH if patient can not • Enoxaparin sc
received bivalirudin or • UFH iv
enoxaparin • Fondaparinux bolus + sc for
• Enoxaparin 24 hours - streptokinase
GPIIbIIIa Only for no reflow or thrombotic
complication

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

25
 NSTEACS : Pathophysiology

NSTE-ACS patients have varying degrees of coronary obstruction,

undergo more heterogeneous management, and have worse long-term
outcomes
Chang H, et al. Circ Cardiovasc Imaging2012;5:536-546.
 NSTEACS Management strategy
2018
Step 1. initial evaluation

Step 2. Diagnosis validation, risk assessment and

rhythm monitoring

Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge

and post-discharge management

Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018 27

1. ESC Guidelines NSTEACS 2015 ; 2. Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018
Initial Treatment in NSTEACS
Discharge Treatment in NSTEACS
P2Y12 inhibitors

Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054

PLATO: Primary Efficacy Endpoint
(Composite of CV Death, MI, or Stroke)

0–12 Months
13
12 11.7 Clopidogrel
Cumulative Incidence (%)

11
10 9.8 Ticagrelor
9
8
7
6
5 ARR=1.9%
4 RRR=16%
3 NNT=54*
2 P<0.001
1 HR: 0.84 (95% CI, 0.77–0.92)
0
0 2 4 6 8 10 12
No. at risk
Months After Randomization
Ticagrelor 9,333 8,628 8,460 8,219 6,743 5,161 4,147
Clopidogrel 9,291 8,521 8,362 8,124 6,650 5,096 4,047
Both groups included aspirin.
*NNT at one year.

Wallentin L, et al. N Engl J Med. 2009;361:1045–1057.

Summary
• Acute Coronary Syndrome: major cause of mortality
• STEMI – Reperfusion strategy ; NSTEACS – risk
stratification
• High mortality of ACS patient treated non invasively vs
invasive strategy
• Platelet plays important role in thrombus formation
• Dual antiplatelet treatment as standard care of ACS
treatment has proven to improve patient CV outcomes
• Ticagrelor is preferred P2Y12 inhibitor in STEMI Primary
PCI and NSTEACS management