Tata Laksana Dini Acute

Coronary Syndrome di
Layanan Pratama
Inisialisasi Dini Acute Coronary Syndrome
• Typical Angina
• Likelyhood or Probability
• EKG ,,, ECG
• Differensiasi ACS
• Stratifikasi Resiko
Typical Angina
Kecendrungan
EKG
 ECG in NSTEACS1,2
▪ Normal ECG in more than 1/3 of patients
▪ Abnormalities
• ST Depression
• Transient ST Elevation
• T-Wave changes

Flattening of Horizontal
ST Segment ST Segment

Making T wave Downsloping

more obvious ST segment

References: 1. Roffi M et al. Eur Heart J 2016;37(3):267-315; 2. Channer K, Morris F. BMJ 2002;324:1023–6
Tatalaksana awal Angina Pectoris
Angina Pectoris
• O2 ( bila SpO2 < 90% )
• Nitrat ( ISDN 5 mg SL , bisa di ulang tiap 15 menit )
• Loading anti platelet
• A. Asam Asetosalisilat ( Aspilet ) 320 mg
• B. Clopidogrel 300 mg
• Segera tentukan Angina typical atau bukan? ACS atau bukan ? STEMI atau
NSTE - ACS
 Acute Coronary Syndrome (ACS)1

Acute thrombosis induced by a ruptured or eroded

atherosclerotic coronary plaque, with or without concomitant
vasoconstriction, causing a sudden and critical reduction in
blood flow

Reference: 1. Bentzon JF et al. Circ Res. 2014;114:1852-1866

 Spectrum of ACS1

Admission Chest Pain

ST
ST
depression ST segment
ECG elevation

Diagnosis

Bio-chemistry Troponin Troponin

rise/fall normal

STEMI NSTEMI UA

12

Reference: 1. Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054

 Risk Stratification: GRACE Score1

Points for Each Predictive Factor

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

• Cardiac • 43
Creatinine, Score Low risk: Score ≤ 108
(µmol/L)
arrest at • 15 In-hospital death: <1%
admission • 30 0 - 34 2
• Elevated 35 – 70 5
cardiac 71 – 105 8
106 – 140 11
13

markers
• ST Segment 141 – 176 14
deviation 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 J. 2011
 Risk Criteria Mandating Invasive Strategy
in NSTE-ACS1
• Hemodynamic instability or cardiogenic • Relevant rise or fall in troponin

VERY HIGH RISK

shock • Dynamic ST- or T-wave changes

HIGH RISK
• Recurrent or ongoing chest pain (symptomatic or silent)
refractory to medical treatment • GRACE Score > 140
• Life-threatening arrhythmias or cardiac
arrest
• 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

Reference: 1. Roffi M et al. Eur Heart J 2016;37(3):267-315

 NSTEACS Treatment Strategy and Timing According
to Risk Stratification1

Reference: 1. Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

ACS
• Semua ACS harus di rujuk ke RS dengan Fasilitas Tatalaksana Jantung minimal
dengan Fasilitas ICU
• STEMI direkomendasikan dirujuk ke Primary PCI Capable Hospital
• NSTE ACS Very High Risk direkomendasikan ke Primary PCI Capable Hospital
Primary PCI Capable Hospital
• Primary PCI adalah tindakan intervensi coroner perkutan dengan tujuan
revaskularisasi pada kasus sumbatan akut
• Dilakukan pada golden periode ( ideal < 6 jam atau lebih baik lagi < 3 jam
sebelum onset ), ingat “ Time is muscle “
• Primary PCI Capable hospital berarti RS yang memiliki kemampuan megerjakan
Primary PCI pada fase golden periode < 90 menit
TIME is Muscle
Reperfusion Guideline