ACUT CORONARY

SYNDROME
Dr. Rus Munandar SpJp
Dr. Darimi Azuddin, SpJp
Dr. Sri Murdiati

FAKTOR RESIKO
Angina Pectoris
Clinical Presentation
Angina Pectoris
O
2
Supply
O
2
Demand
Heart Rate
SBP
Wall Stress
Coronary flow

Hb
O
2
Acute Coronary Syndromes
Unstable angina and evolving
myocardial infarction are
different clinical presentations
resulting from a common
underlying pathophysiological
mechanism
CAUSES OF UA/NSTEMI
Thrombosis
Thrombosis
Mechanical
Obstruction
Mechanical
Obstruction
Dynamic
Obstruction
Dynamic
Obstruction
Inflammation/
Infection
Inflammation/
Infection
MVO
2

MVO
2

Braunwald, Circulation
98:2219, 1998
.
.
UA/NSTEMI
THREE PRINCIPAL PRESENTATIONS
Rest Angina* Angina occurring at rest and
prolonged, usually > 20 minutes

New-onset Angina New-onset angina of at least CCS
Class III severity

Increasing Angina Previously diagnosed angina that
has become distinctly more frequent,
longer in duration, or lower in
threshold (i.e., increased by > 1 CCS)
class to at least CCS Class III severity.
Braunwald
Circulation 80:410; 1989
* Pts with NSTEMI usually present with angina at rest.
POST-HOSPITAL DISCHARGE CARE
A Aspirin and Anticoagulants
B Beta blockers and Blood Pressure
C Cholesterol and Cigarettes
D Diet and Diabetes
E Education and Exercise
UA/NSTEMI 9/00
ANTI - ISCHEMIC Rx
Class I
1. Bed rest with continuous ECG monitoring in pts
with ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.
3. Supplemental O
2
for pts with hypoxemia, cyanosis
or respiratory distress; finger pulse oximetry or
arterial blood gas determination to confirm
SaO
2
>90%.
4. Morphine sulfate IV when symptoms are not
immediately relieved with NTG or when acute
pulmonary congestion and/or severe agitation is
present.

ANTI - ISCHEMIC Rx
Class I
1. Bed rest with continuous ECG monitoring in pts
with ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.
3. Supplemental O
2
for pts with hypoxemia, cyanosis
or respiratory distress; finger pulse oximetry or
arterial blood gas determination to confirm
SaO
2
>90%.
4. Morphine sulfate IV when symptoms are not
immediately relieved with NTG or when acute
pulmonary congestion and/or severe agitation is
present.

Q-Wave (ST-segment elevation)
Myocardial Infarction
Occlusion of coronary artery by thrombus
Progression of necrosis with time
Diagnosis
Clinical symptoms
Electrocardiogram
Cardiac enzymes
Q-Wave (ST-segment elevation)
Myocardial Infarction
Occlusion of coronary artery by thrombus
Progression of necrosis with time
Diagnosis
Clinical symptoms
Electrocardiogram
Cardiac enzymes
POST-HOSPITAL DISCHARGE CARE
A Aspirin and Anticoagulants
B Beta blockers and Blood Pressure
C Cholesterol and Cigarettes
D Diet and Diabetes
E Education and Exercise
UA/NSTEMI 9/00
Thrombolysis in Acute MI
Absolute Contraindications
Previous hemorrhagic stroke
CVA within previous yr
Intracranial neoplasia or AVM
Active internal bleeding (not
menses)
Suspected aortic dissection
Uncontrolled HTN (BP > 180/110) on
presentation
History prior CVA beyond 1 yr
Anticoagulant Rx with INR > 2-3; bleeding
diathesis
Recent trauma (within 2-4 wks)
Noncompressible vascular punctures
Recent internal bleeding (within 2-4 wks)
Pregnancy
Active peptic ulcer
Prior exposure (5 day - 2 yr) for SK or APSAC
Thrombolysis in Acute MI
Relative Contraindications
The Management of
Patients with Acute
Myocardial Infarction
Hospital Management
Sample Admitting Orders
Condition Serious
IV NS or D
5
W to keep vein open
Vital signs q 1/2 hr until stable, the q 4 hrs and p.r.n.
Notify if HR <60 or >110; BP <90 or >150;
RR <8 or >22. Pulse oximetry x 24 hrs
Activity Bed rest with bedside commode and progress as
tolerated after approximately 12 hrs
Diet NPO until pain free, then clear liquids. Progress to a heart-
healthy diet
Medications Nasal O
2
2L/min x 3 hrs
Enteric-coated aspirin daily (165 mg)
Stool softener daily
Beta-adrenoreceptor blockers ?
Consider need for analgesics, nitroglycerin, anxiolytic

T H A N K Y O U