Tata laksana Sindroma Koroner Akut

Cholid Tri Tjahjono

Lab Kardiologi dan Kedokteran Vaskular Fakultas Kedokteran Univ ersitas Brawijaya

Definisi Sindroma Koroner Akut

Acute coronary syndrome (ACS) describes the continuum

of myocardial ischemia that ranges from unstable angina at one end of the spectrum to nonST segment elevation myocardial infarction (MI) at the other end. Unstable angina is distinguished from stable angina by the new onset or worsening of symptoms in the previous 60 days or by the development of post-MI angina 24 hours or more after the onset of MI. When the clinical picture of unstable angina is accompanied by elevated markers of myocardial injury, such as troponins or cardiac isoenzymes, nonST segment elevation MI is diagnosed. The distinction between nonST segment elevation MI and MI with ST segment elevation is clinically important because acute recanalization therapy is critical for improving the outcome in ST elevation MI but is less urgent in nonST segment elevation MI.

Definition
Myocardial infarction (MI) is myocardial necrosis

caused by ischemia. Practically, MI can be diagnosed and evaluated by clinical, electrocardiographic, biochemical, radiologic, and pathologic methods.

SINDROMA KORONER AKUT spektrum sindrom klinis yang mencakup angina tak stabil sampai ke non ST elevasi MI dan ST elevasi MI

ACUTE CORONARY SYNDROME

No ST Elevation

ST Elevation

NSTEMI

Unstable Angina

NQMI QwMI Myocardial Infarction

Mengapa SKA harus SEGERA ditangani?

Mortalitas dan morbiditas tinggi , 40 %
kematian terjadi sebelum sampai di rumah sakit

( HARUS SEGERA DIRUJUK!!)

Setidaknya 250.000 kematian sehubungan

infark miokard terjadi dalam 1 jam setelah onset gejala dan sebelum terapi dimulai (USA) Dalam 2 minggu setelah diagnosa, Infark miokard terjadi pada 12% pasien dengan U.A. Dalam SATU tahun hampir setengah kematian terjadi pada 4 minggu pertama setelah diagnosa.

Angina Stabil Angina Tidak stabil Infark Miokard Akut Kematian Gagal Jantung

Atherogenesis and Atherothrombosis:

A Progressive Process
Atherosclerotic Plaque Plaque Rupture/ Fissure & Thrombosis

Normal

Fatty Streak

Fibrous Plaque

Myocardial Infarction Ischemic Stroke Critical Leg Ischemia

Clinically Silent

Angina Transient Ischemic Attack Claudication/PAD

Cardiovascular Death

Increasing Age
3

Different Stage of Atherosclerosis Development

Pathway to Thrombosis

Faktor risiko Penyakit Jantung Koroner

Merokok,berapapun jumlahnya Kadar kolesterol total dan LDL yg

tinggi Hipertensi Diabetes mellitus Usia lanjut

Faktor risiko ini sifatnya independen dan aditif, semakin
banyak memiliki Faktor risiko semakin besar risiko menderita PJK

 Faktor predisposisi

faktor yang memperbesar risiko PJK akibat faktor risiko yang kausal 1.Obesitas (BMI >25 Kg/m2) 2.Obesitas abdominal (lingkar pinggang >94cm(pria)>80cm(wanita); waist-hip ratio>0,9(pria) dan >0,8 (wanita) 3.Sedentary 4.Riwayat keluarga terkena PJK usia muda (pria:<55 thn, wanita:<65 thn) 5.Etnik tertentu 6.Psikososial
Pedoman tata laksana SKA dengan ST elevasi , PERKI 2004

Faktor risiko kondisional:

Berhubungan dengan peningkatan risiko PJK 1.Kadar trigliserida yang tinggi 2.Homosistein serum yang tinggi 3.Lp(a) yang tinggi 4.Faktor protrombotik (mis;fibrinogen) 5.Penanda inflamasi (mis CRP)

Pedoman tata laksana SKA dengan ST elevasi , PERKI 2004

KELUHAN UTAMA: Sakit dada atau nyeri ulu hati yang berat, asalnya nontraumatik, dengan ciri-ciri tipikal iskemia miokard atau infark:
Dada bgn tengah/substernal rasa tertekan atau sakit seperti diremas Rasa sesak, berat/tertimpa beban , mencengkeram, terbakar,sakit Penjalaran ke leher, rahang, bahu, punggung atau 1 atau ke 2 lengan Disertai sesak Disertai mual dan/atau muntah Disertai berkeringat

Sakit perut yg tdk dpt dijelaskan, sendawa, nyeri ulu hati

Start ECG

KEADAAN YANG DAPAT MENIMBULKAN SAKIT DADA

Kardiak :
SKA: Infark,angina MVP (mitral valve

Gastrointestinal :

prolaps) Stenosis Aorta Kardiomiopati hipertropi Perikarditis

Reflux esofagus Ruptur esofagus Penyakit kel empedu Ulkus peptikum Pankreatitis
Vaskuler

Paru :

Diseksi Aorta /aneurisma

Lain-lain:

Emboli Paru Pneumonia Pneumothorax Pleuritis

Musculoskeletal Herpes zoster

ACC/AHA Guideline of STEMI 2004

NYERI KARDIAK :

Tidak berhubungan dengan gerakan respirasi dan batuk Tidak berhubungan dengan posisi dan gerakan tubuh Tidak berhubungan dengan kondisi lain seperti herpes zoster, trauma, dll

ANGINA PEKTORIS

Sifat & kualitas Lokasi Penjalaran Durasi Gejala dan tanda klinis yang menyertainya

Angina Pektoris Stabil ( Stable Angina Pectoris)

ANGINA PEKTORIS STABIL, ditandai nyeri dada

atau rasa tidak enak sewaktu adanya beban (aktivitas, beban mental) dimana kebutuhan miokardium tidak dapat dipenuhi dengan suplai yang cukup. Angina Stabil dapat diprediksi dan dapat hilang atau berkurang dengan istirahat dan nitrogliserin.

Angina Pektoris Tak Stabil (Unstable angina )

3 Penampilan klinis tersering: Angina saat istirahat, terus menerus 20 menit atau lebih Angina pertama kali setidaknya CCS kelas III dari Canadian Cardio-vascular Society Classification (CCSC) Angina yang meningkat, angina makin lama makin sering,makin lama atau makin mudah tercetus.

Anatomi Koroner dan EKG 12 sandapan

Sandapan V1 dan V2 menghadap septal area ventrikel kiri Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap dinding lateral ventrikel kiri Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri

Mid LAD occlusion after the first septal perforator (arrow)

ECG : large anterior MI

Occlusion of diagonal branch ( arrow )

ST elevation in I and aVL

ECG demonstrates large anterior infarction

Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6 with precordial ST depression

Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Early repolarization

Left ventricular aneurysm

Unstable angina

Subendocardial ischemia. Anterolateral ST-segment depression

Acute anteroseptal myocardial infarction. Hyperacute T-wave changes are noted

Acute anterolateral myocardial infarction

High lateral infarction

Lateral myocardial infarction

Inferior myocardial infarction

Inferior myocardial infarction. Inferior Q waves with T-wave inversions

Acute inferoposterior myocardial infarction

Right bundle branch block

RBBB + Anterior Infarction

Left bundle branch block

Pemeriksaan awal pada Sindrom Koroner Akut Masuk RS

Diagnosis Kerja ECG Biochemistry Stratifikasi risiko Pengobatan Pencegahan sekunder SAKIT DADA Curiga Sindrom Koroner Akut Elevasi ST menetap Troponin (CKMB) Tanpa Elevasi ST menetap Troponin Normal atau Tdk dpt ditentukan ECG Troponin 2 X negative
Mungkin bukan SKA

Risiko tinggi Risiko rendah

Psn Nyeri Dada Rwyat nyeri dada khas

SINDROMA KORONER AKUT

Aspirin 160 / 320mg mg dikunyah dan Nitrat s.l.

* EKG 12 sandapan Petanda biokimia

EKG Non diagnostik Petanda biokimia (-) Nyeri dada (-) Perubahan ST/T Petanda biokimia (+) Nyeri dada menetap

Elevasi seg ST

EKG tdk berubah Petanda(-) Nyeri dada(-) Pulang

Risiko rendah Risko tinggi Periksa di Periksa Rawat jalan segera

Observasi EKG serial Ulang petanda 6-12 jam stlh onset nyeri dada*
Perubahan seg ST Petanda (+) Nyeri dada menetap

Evaluasi utk reperfusi

Rawat Terapi Nitrat ASA Clopidogrel UFH/LMWH (+/- Antagonis Receptor GPIIb/IIIa

APTS/NSTEMI

Pasien dengan tanda dan gejala klinis SKA

EKG 12 sadapan

ST Elevasi = STEMI
> 0.1 mV pd > 2 sadapan ekstrimitas yang bersebelahan dan/atau > 0,2 mV pd > 2 sadapan prekordial yang bersebelahan atau LBBB baru (yang dianggap baru)

EKG Abnormal lainnya (Bukan ST elevasi) atau EKG normal

High Risk (Risiko Tinggi) -Perubahan EKG yang dinamis meliputi ST depresi - hemodinamik -irama yang tidak stabil (aritmia malignan) - diabetes melitus = Non STEMI, jika nilai troponin positif (T atau I) Low Risk (Risiko rendah) Tidak ada tanda-tanda high risk = UAP , jika nilai troponin negatif

ALGORITMA DIAGNOSIS SKA ACC/AHA

EKG
Atasi Nyeri : Nitrogliserin 0,4 mg (max 1,2 mg) SL bila TD > 90 mmHg + morfin (dapat di ulang) 3-6 mg sampai nyeri teratasi

Pengobatan antipletelet : 160-325 mg tablet asam asetilsalisilat dikunyah + clopidogrel 300 mg PO

STEMI

NSTEMI-UAP

Early invasive strategy UFH (target aPTT 50-70 det) Gp IIbIIIa inhibitor utk pasien risiko tinggi

Konsevatif atau delayed invasive strategy UFH atau LMWH (enoxaparin) Pertimbangkan tirofiban atau eptifibated

Primary PCI, bila :

PCI dpt dilakukan < 90 mnt (pd pasien dgn onset < 3 jam PCI harus dpt dilakukan <60 mnt) Terdapat kontraindikasi trombolitik Onset > 3 jam Syok kardiogenik atau gagal jantung kiri akut Terapi adjuvan : UFH, pertimbangkan GPIIbIIIa inhibitor.

Lebih memilih Fibrinolitik bila: Tdk ada kontra indikasi dan PCI menunggu > 90 menit Onset gejala < 3 jam dan PCI menunggu > 60 menit Terapi adjuvan : UFH,LMWH pada pasien < 75 tahun

Algoritma tatalaksana awal Sindroma Koroner Akut

SAKIT DADA ISKEMIK

Nilai dan tatalaksana segera (<10 menit) Monitor EKG Akses IV Saturasi O2 EKG 12 Sadapan Riwayat Penyakit Kontra indikasi trombolitik Foto Rho Thorax

Pengobatan segera: O2 4 L/menit Aspirin 160-325 mg Nitrogliserin SL atau spray Morphin IV (bila sakit dada tidak hilang dgn nitrogliserin) Ingat : MONA

EKG serial untuk Indikasi terapi trombolitik

NILAI EKG awal 12 sadapan

Elevasi ST atau BBB Baru Pertimbangkan pemberian: Penyekat beta IV Nitrogliserin IV Heparin IV Penghambat ACE (sesuai indikasi tanpa menunda trmbolitik)

Depresi ST atau inversi T :iskemia Pertimbngkan : Heparin IV Nitrogliserin IV Penyekat beta IV Ya

Tidak ada ST & gelombang T Kriteria ATS ?

Tdk > 12 jam

Waktu sejak sakit dada ?

< 12 jam Pilih Cara Reperfusi

Nilai status klinis

Terapi trombolitik : pilih jenis Tak ada kontra indikasi Atau alternatif ekuivalen PTCA primer

Pasien risiko tinggi Gejala menetap Iskemia berulang Penurunan fungsi ventrikel kiri Perubahan EKG luas Baru mengalami IMA, PTCA, CABG

Pertimbangkan : Unit ED sakit dada Serum serial EKG serial Echo/radionuklir

Klinis stabil

PTCA: waktu tiba-lab:< 60 mnt

Kateterisasi jantung: Anatomi tepat untuk revaskularisasi ? Ya Revaskularisasi PTCA CABG

Tdk

Ya

Adakah iskemia/ Infark > 8-12 jam ? Tdk

ICCU : Terapi sesuai indikasi Serum serial EKG serial Echo/radionuklir

Boleh Rawat jalan & kontrol teratur

SAKIT DADA ISKEMIK

Nilai dan tatalaksana segera (<10 menit) Monitor EKG Akses IV Saturasi O2 EKG 12 Sadapan Riwayat Penyakit Kontra indikasi trombolitik Foto Rho Thorax

Pengobatan segera: O2 4 L/menit Aspirin 160-325 mg Nitrogliserin SL atau spray Morphin IV (bila sakit dada tidak hilang dgn nitrogliserin) Ingat : MONA

EKG serial untuk Indikasi terapi trombolitik

NILAI EKG awal 12 sadapan

Elevasi ST atau BBB Baru

Depresi ST atau inversi T :

Tidak ada perubahan ST &T

Pertimbangkan pemberian: Penyekat beta IV Nitrogliserin IV Heparin IV Penghambat ACE (sesuai indikasi tanpa menunda trmbolitik)

Pertimbangkan : Heparin IV Nitrogliserin IV Penyekat beta IV Ya

Kriteria ATS ?

Tdk

> 12 jam Waktu sejak sakit dada ? < 12 jam

Nilai status klinis Pertimbangkan : Unit ED sakit dada Serum serial EKG serial Echo/radionuklir Pasien risiko tinggi Gejala menetap Iskemia berulang Penurunan fungsi ventrikel kiri Perubahan EKG luas Baru mengalami IMA, PTCA, CABG Klinis stabil

Pilih Cara Reperfusi

Terapi trombolitik : pilih jenis Tak ada kontra indikasi

Atau alternatif ekuivalen

PTCA primer

Kateterisasi jantung: Anatomi tepat untuk revaskularisasi ? Ya

Ya
Tdk Adakah iskemia/ Infark > 8-12 jam ?

Tdk ICCU : Terapi sesuai indikasi Serum serial EKG serial Echo/radionuklir

PTCA: waktu tiba-lab:< 60 mnt Revaskularisasi PTCA CABG Boleh Rawat jalan & kontrol teratur

TERAPI PADA SINDROMA KORONER AKUT PERAWATAN DI RUMAH SAKIT 1.Pain killer (morfin) 2.Suplemen O2 M 3.Terapi anti iskemia O Nitrat Beta Bloker N CCB A 4.Antiplatelet dan antikoagulan Aspirin,Ticlopidine, Clopidogrel Heparin atau Low Molecular Weight Heparin Tranquilizer 5.Fibrinolisis ( pada infark miokard dengan elevasi ST) 6. Revaskularisasi koroner Tata laksana pasca perawatan di rumah sakit

KEUNGGULAN DARI LMWH

Mengurangi ikatan pada protein pengikat heparin

Efek yang dapat diprediksi lebih baik

Tidak memerlukan pengukuran APTT Pemakaian subkutan,menghindari kesulitan dalam

pemakaian secara IV Berkaitan dengan kejadian perdarahan yang kecil, namun bukan perdarahan besar Stimulasi trombosit kurang dari UFH dan jarang menimbulkan HIT (Heparin induced thrombocytopenia) Penghematan biaya perawatan (dari studi ESSENCE)

TEHNIK INJEKSI enoxaparin SUBKUTAN

DOSIS YANG DIREKOMENDASIKAN

UFH

Initial I.V BOLUS 60 UI/Kg max 4000 UI Infus :12-15 UI/kg BB/jam max 1000 UI/jam Monitor APTT : 3, 6, 12, 24 jam setelah mulai

terapi Target APTT 50-70 msec (1,5 -2 x kontrol)

LMWH Enoxaparine Nadroparine Fondaparinux

1mg/kg, SC , bid 0,1 ml/10 kg , SC , bid 1X2.5 mg/hari

TERAPI FIBRINOLITIK

Fibrinolitik : Indikasi

Sakit dada khas IMA 12 jam EKG : 1 mm elevasi seg ST pada 2 sandapan yg

bersebelahan 2mm elevasi seg ST pada 2 sandapan prekordial Bundle branch block yg baru Syok kardiogenik pd IMA ( bila kateterisasi dan revaskularisasi tdk dapat dilakukan ) Fibrinolitik door to needle time < 30 menit !! PCI pada IMA lebih unggul bila dpt dilakukan dlm 90 30 menit

Fibrinolitik : indikasi kontra Absolut

Riwayat stroke hemoragik,kapanpun terjadinya Riwayat stroke iskemik dalam 3 bulan kecuali stroke

iskemik dengan onset < 3 jam Neoplasma intrakranial Perdarahan internal aktif(tidak termasuk menstruasi) Kecurigaan suatu diseksi aorta Luka kepala tertutup yg signifikan atau trauma facial dalam 3 bulan Kelainan struktural atau pembuluh darah cerebral
ACC/AHA guideline of STEMI 2004

Fibrinolitik :indikasi kontra relatif

Hipertensi berat saat datang ke unit emergency yaitu BP> 180 / 110 mmHg Pungsi vaskuler yg tak dapat dikompresi Perdarahan internal 2 4 mgg sebelumnya Konsumsi antikoagulan oral prolonged CPR ( > 10 minutes) or operasi mayor dlm jangka waktu 2-4 minggu Untuk Streptokinase : pemberian sebelumnya ( 5 hari-2 tahun) atau riwayat reaksi alergi Kehamilan Active peptic ulcer Riwayat hipertensi kronis yg tak terkontrol Riwayat stroke iskemik lebih dari 3 bulan,demensia atau patologi serebral lainnya yg blm tercantum dalam indikasi kontra
ACC/AHA guideline of STEMI 2004

CARA PEMBERIAN FIBRINOLITK

Streptokinase ( Streptase )

1.5 million Unit in 100 ml D5W or 0.9% saline selama 30-60 mnt without heparin : Inferior MI with heparin : anterior MI tPA 15 mg IV bolus kemudian 0.75 mg/Kg selama 30 mnt,dilanjutkan 0.5 mg/Kg selama 60 mnt berikutnya

Secondary Prevention and LongTerm Management

72

Secondary Prevention
Ask, advise, assess, and assist patients to stop

smoking I (B) Clopidogrel 75 mg daily:

PCI I (B) no PCI IIa (C)

Statin goal: LDL-C < 100 mg/dL I (A) consider LDL-C < 70 mg/dL IIa (A) Daily physical activity 30 min 7 d/wk, minimum 5

d/wk I (B) Annual influenza immunization I (B)

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Secondary Prevention and Long Term Management

Goals Smoking 2007 Goal:
Complete cessation. No exposure to environmental tobacco smoke.

Class I Recommendations
Status of tobacco use should be asked at every visit. Every tobacco user and family member who smoke should be advised to quit at every visit. The tobacco users willingness to quit should NEW be assessed. The tobacco user should be assisted by counseling and developing a plan for quitting. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological rx) should be arranged. Exposure to environmental tobacco smoke at home and work should be avoided. NEW

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Secondary Prevention and Long Term Management

Goals
Blood pressure control:
2007 Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes

Class I Recommendations
If blood pressure is 140/90 mm Hg or 130/80 mm Hg for patients with chronic kidney disease or diabetes: It is recommended to initiate or maintain lifestyle modification (weight control, physical activity, alcohol moderation, sodium , and emphasis on consumption of fresh fruits, vegetables, and low-fat dairy products). It is useful as tolerated, to add blood pressure medication, treating initially with beta-blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal BP.
CHANGED TEXT

75

Secondary Prevention and Long Term Management

Goals
Lipid management: 2007 goal: LDL-C << than 100 mg/dL (if TG 200 mg/dL, nonHDL-C < 130 mg/dL

Class I Recommendations
Starting dietary therapy in all patients is recommended. intake of sat. fats (< 7% of total calories), trans fatty acids and cholesterol (< 200 mg/d).

Adding plant stanol/sterols (2 g/d) and/or viscous fiber (> 10 g/d) is reasonable to further lower LDL-C. (Class IIa; LOE:A)
NEW

Promotion of daily physical activity and weight management is recommended. It may be reasonable to encourage consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction. For treatment of elevated TG, higher doses are usually necessary for risk reduction. (Class IIb; LOE: B)

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Secondary Prevention and Long Term Management

Goals Class I Recommendations

Lipid A fasting lipid profile should be assessed in all patients management: and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized 2007 goal: patients, initiation of lipid-lowering medication is indicated LDL-C << than as recommended below before discharge according to 100 mg/dL (if TG the following schedule: 200 mg/dL, nonHDL-C < 130 LDL-C should be < 100 mg/dL. mg/dL Further reduction to < 70 mg /dL is reasonable. (Class
IIa; LOE: A) NEW If baseline LDL-C is 100 mg/dL, LDL-lowering drug rx should be initiated. If on-treatment LDL-C is 100 mg/dL intensify LDLlowering drug rx (may require LDL-lowering combination is recommended. If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C < 70 mg/dL. (Class IIa; LOE: B)
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NEW

Secondary Prevention and Long Term Management

Goals
Lipid management: (TG 200 mg/dL or greater) Primary goal: NonHDL-C < 130 mg/dL

Class I Recommendations
If TG are 150 mg per dL or HDL-C < 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. If TGs are 200 to 499 mg per dL, nonHDL-C target should be less than 130 mg per dL. If TGs are 200 to 499 mg/dL, nonHDL-C target is < 130 mg/dL. (Class I; LOE: B); further reduction of nonHDL-C to < 100 mg dL is reasonable. (Class IIa; LOE: B)

NEW Therapeutic options to reduce nonHDL-C include: More intense LDL-C-lowering rx is indicated Niacin (after LDL-C-lowering rx) can be beneficial (Class IIa; LOE B) Fibrate therapy (after LDL-C-lowering rx) can be beneficial (Class IIa; LOE B)
If TG are 500 mg/dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering rx; and treat LDL-C to goal after TGlowering rx. Achieving nonHDL-C < 130 mg/dL is recommended.
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Secondary Prevention and Long Term Management

Goals
Physical activity: 2007 Goal: 30 min 7 d per wk; minimum 5 d per wk

Class I Recommendations
For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription.

For all patients, encouraging 30 to 60 min of moderateintensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).
Advising medical supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, HF) is recommended.

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NEW

Encouraging resistance training 2 d per week may be reasonable (Class IIb; LOE: C)

Secondary Prevention and Long Term Management

Goals Weight management: Goal: BMI 18.5 to 24.9 kg/m2 Waist circumference: Women: < 35 in. (102 cm) Men: < 40 in. (89 cm) Class I Recommendations
It is useful to assess body mass index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. If waist circumference (measured horizontally at the iliac crest) is 35 inches (102 cm) in women and 40 inches (89 cm) in men, it is useful to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.

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Secondary Prevention and Long Term Management

Goals
Diabetes management: Goal: HbA1c < 7%

Class I Recommendations
It is recommended to initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c. Beginning vigorous modification of other risk factors (e.g., physical activity, weight management, BP control, and cholesterol management as recommended above) is beneficial.

Coordination of diabetic care with patients primary care physician or endocrinologist is beneficial. NEW
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Secondary Prevention and Long Term Management

Goals Class I Recommendations

Antiplatelet agents/ For all post-PCI STEMI stented patients anticoagulants: without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162 to 325 mg daily Aspirin
should be given for at least 1 month after baremetal stent implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 to 162 mg daily.
CHANGED TEXT
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Secondary Prevention and Long Term Management

Goals Antiplatelet agents/ anticoagulants: Aspirin Recommendations In patients where the physician is concerned about the risk of bleeding lowerdose 75 to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Class IIa; LOE: C)

NEW REC
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Secondary Prevention and Long Term Management

Goals Antiplatelet agents/ anticoagulants: Clopidogrel Class I Recommendations

For all post-PCI patients who receive a drug-eluting stent (DES), clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a bare metal stent (BMS), clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).

CHANGED TEXT
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Secondary Prevention and Long Term Management

Goals Antiplatelet agents/ anticoagulants: Clopidogrel Recommendations

For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 d. (Class I; LOE: B)
Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (Class IIa; LOE: C)

NEW RECS
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Secondary Prevention and Long Term Management

Goals Antiplatelet agents/ anticoagulants: Warfarin
NEW REC

Class I Recommendations
Managing warfarin to INR = 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-STEMI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). CHANGED
TEXT

Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2 to 2.5 is recommended with low dose aspirin (75 to 81 mg) and a 75 mg dose of clopidogrel.

NEW REC
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Secondary Prevention and Long Term Management

Antiplatelet agents: NSAIDs
I IIa IIb III

NEW REC

At the time of preparation for hospital discharge, the patients need for treatment of chronic musculoskeletal discomfort should be assessed and a stepped care approach to pain management should be used for selection of treatments. Pain relief should begin with acetaminophen or aspirin, small doses of narcotics, or non-acetylated salicylates.

I IIa IIb III

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NEW REC

It is reasonable to use non-selective NSAIDs such as naproxen if initial therapy with acetaminophen, small doses of narcotics, or non-acetylated salicylates is insufficient.

Secondary Prevention and Long Term Management

Antiplatelet NSAIDs with increasing degrees of relative COX-2 agents: NSAIDs selectivity may be considered for pain relief only for
I IIa IIb III

NEW REC

situations where intolerable discomfort persists despite attempts at stepped care therapy with acetaminophen, small doses of narcotics, nonacetylated salicylates, or non-selective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. NSAIDs with increasing degrees of relative COX-2 selectivity should not be administered to STEMI patients with chronic musculoskeletal discomfort when therapy with acetaminophen, small doses of narcotics, non-acetylated salicylates, or nonselective NSAIDs provides acceptable levels of pain relief.

I IIa IIb III

CHANGED TEXT
88

Stepped Care Approach To Pharmacologic Therapy for Musculoskeletal Symptoms with Known Cardiovascular Disease or Risk Factors for Ischemic Heart Disease Acetaminophen, ASA, tramadol, narcotic analgesics (short term) Nonacetylated salicylates Non COX-2 selective NSAIDs NSAIDs with some COX-2 activity
Regular monitoring for sustained hypertension or worsening of prior blood pressure control), edema, worsening renal function, or gastrointestinal bleeding. If these events occur, consider reduction of the dose or discontinuation of the offending drug, a different drug, or alternative therapeutic modalities, as dictated by clinical circumstances.

Select patients at low risk of thrombotic events Prescribe lowest dose required to control symptoms Add ASA 81 mg and PPI to patients at increased risk of thrombotic events *

COX-2 Selective NSAIDs

* Addition of ASA may not be sufficient protection against thrombotic events 89 Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print

Secondary Prevention and Long Term Management

Goals
ReninAngiotensinAldosterone System Blockers: ACE Inhibitors
NEW REC

Class I Recommendations
ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. CHANGED
TEXT

ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Class IIa; LOE: B)

NEW REC
90

Secondary Prevention and Long Term Management

Goals
ReninAngiotensinAldosterone System Blockers: ARBs
NEW REC

Class I Recommendations
Use of ARBs is recommended in patients who are intolerant of ACE inhibitors and have HF or have had a STEMI with LVEF 40%. CHANGED
TEXT

It is beneficial to use ARB therapy in other patients who are ACE-inhibitor intolerant and have hypertension.

NEW REC
91

Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable.

Secondary Prevention and Long Term Management

Goals
ReninAngiotensinAldosterone System Blockers: Aldosterone Blockade
CHANGED TEXT

Class I Recommendations

Use of aldosterone blockade in post-STEMI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of 40% and have either diabetes or HF.

92

Secondary Prevention and Long Term Management

Goals BetaBlockers

Class I Recommendations It is beneficial to start and continue betablocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without HF symptoms, unless contraindicated.
CHANGED TEXT

93

Secondary Prevention and Long Term Management

Goals Influenza Vaccination

Class I Recommendations

Patients with cardiovascular disease should have an annual influenza vaccination.

NEW REC

94

TERIMA KASIH