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AKUT
(LK 3b)
Scope of Problem
(2004 stats)
Definitions
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Family Historyevent
in first degree
relative >55 male/65
female
Fatty
Streak
Fibrous
Plaque
Atherosclerotic
Plaque
Plaque
Rupture/
Fissure &
Thrombosis
Myocardial
Infarction
Ischemic
Stroke
Clinically Silent
Angina
Transient Ischemic Attack
Claudication/PAD
Critical
Leg
Ischemia
Cardiovascular Death
Increasing Age
3
Unstable
coronary
artery disease
Thrombus forms
forms
Thrombus
and extends
extends into
into
and
the lumen
lumen
the
Thrombus
Lipid core
Adventit
ia
Local Factors
Cap
Fatigue
Smoking
Cholesterol
Atheromatous Core
(size/consistency)
Cap
Thickness/
Consistency
Cap
Inflammation
Diabetes
Mellitus
Homocysteine
Fibrinogen
Impaired
Fibrinolysis
Plaque
Rupture
Fuster V, et al. N Engl J Med. 1992;326:310-318.
Falk E, et al. Circulation. 1995:92:657-671.
Acute Coronary
Syndrome
Unstable Angina
Non-ST-Segment
Elevation MI
(NSTEMI)
ST-Segment
Elevation MI
(STEMI)
Similar pathophysiology
Similar presentation and
early management rules
STEMI requires
evaluation for acute
reperfusion intervention
Diagnosis of Angina
Atypical angina
1 of the above
Diagnosis of Acute MI
STEMI / NSTEMI
At least 2 of the
following
Ischemic
symptoms
Diagnostic ECG
changes
Serum cardiac
marker elevations
Small
Smallthrombus
thrombus
(non-flow
(non-flowlimiting)
limiting)
Partially
Partiallyocclusive
occlusive
thrombus
thrombus
Transient
ischemia
No
NoECG
ECG
changes
changes
Healing
Healingand
and
Plaque
enlargement
Plaque enlargement
ST
STsegment
segment
Depression
Depressionand/or
and/or
TTwave
inversion
wave inversion
Negative
Serum
biomarkers
UNSTABLE
UNSTABLE
ANGINA
ANGINA
Positive
Serum
biomarkers
NON-ST
NON-STSEGEMENT
SEGEMENT
ELEVATION
ELEVATION
Occlusive
Occlusive
thrombus
thrombus
Prolonged
ischemia
ST
STelevation
elevation
(Q
(Qwave
wavelater)
later)
Positive
Serum
biomarkers
ST
STSEGMENT
SEGMENT
ELEVATION
ELEVATION
The Three Is
The Three Is
The Three Is
Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes
Occluding
thrombus
sufficient to
cause
tissue damage &
mild
myocardial
necrosis
NSTEMI
ST depression
+/T wave inversion
on
ECG
Elevated cardiac
enzymes
STEMI
Complete thromb
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms
Acute Management
Initial evaluation
& stabilization
Efficient risk
stratification
Focused cardiac
care
Evaluation
Occurs
simultaneo
usly
labs
and tests
12 lead ECG
Obtain initial
cardiac enzymes
electrolytes, cbc
lipids, bun/cr,
glucose, coags
CXR
care
IV access
Cardiac
monitorin
g
Oxygen
Aspirin
Nitrates
&
Physical
Establish
diagnosis
Read ECG
Identify
complicati
ons
Assess for
reperfusio
Focused History
Palliative/Provocative
factors
Quality of discomfort
Radiation
Symptoms associated
with discomfort
Cardiac risk factors
Past medical history
-especially cardiac
Reperfusion
questions
Timing of
presentation
ECG c/w STEMI
Contraindication
to fibrinolysis
Degree of STEMI
risk
Targeted Physical
Examination
Vitals
Cardiovascular
system
Respiratory
system
Abdomen
Neurological
status
Recognize factors
that increase risk
Hypotension
Tachycardia
Pulmonary rales, JVD
, pulmonary edema,
New murmurs/heart
sounds
Diminished
peripheral pulses
Signs of stroke
ECG assessment
NSTEMI
Non-specific ECG
Unstable Angina
ST-Segment Elevation MI
New LBBB
Cardiac markers
Troponin ( T, I)
CK-MB isoenzyme
amount of myocardial
necrosis
Preserve LV function
Prevent major adverse cardiac
events
Treat life threatening
complications
STEP 1: Assessment
Fibrinolysis Indications
Fibrinolysis
preferred if:
PCI available
Door to balloon <
90min
Door to balloon
minus door to
needle < 1hr
Fibrinolysis
contraindications
Late Presentation >
3 hr
High risk STEMI
Killup 3 or higher
Medical Therapy
MONACLO + BAH
Morphine
Analgesia
Reduce pain/anxietydecrease sympathetic
tone, systemic vascular resistance and oxygen
demand
Careful with hypotension, hypovolemia,
respiratory depression
Nitroglycerin
Analgesiatitrate infusion to keep patient pain
free
Dilates coronary vesselsincrease blood flow
Reduces systemic vascular resistance and preload
Careful with recent ED meds, hypotension,
bradycardia, tachycardia, RV infarction
ACE-Inhibitors / ARB
(class I, level A)
Start in patients with anterior MI, pulmonary
congestion, LVEF < 40% in absence of
contraindication/hypotension
Start in first 24 hours
ARB as substitute for patients unable to use ACEI
Heparin
LMWH or UFH
Post-STEMI patients
no significant renal failure (cr < 2.5 men or
2.0 for women)
No hyperkalemis > 5.0
LVEF < 40%
Symptomatic CHF or DM
Rekomendasi
pengobatan SKA
INTERMEDIATE
likelihood of ACS in
absence of highlikelihood findings
in absence of high- or
intermediate-likelihood
findings
History
Probable ischemic
symptoms
Recent cocaine use
Physical
examination
Extracardiac vascular
disease
Chest discomfort
reproduced by palpation
ECG
Fixed Q waves
Abnormal ST segments or
T waves not documented
to be new
T-wave flattening or
inversion of T waves in
leads with dominant R
waves
Normal ECG
Serum cardiac
markers
Normal
Normal
Intermediate Risk
ACS
Moderate to high likelihood
of CAD
Low
risk
Intermediate
risk
High
risk
Chest Pain
center
Conserva
tive
therapy
Invasive
therapy
Secondary Prevention
Disease
Behavioral
HTN, DM
smoking, diet, physical activity, weight
Cognitive
Secondary Prevention
disease management
Blood Pressure
Goals < 140/90 or <130/80 in DM /CKD
Maximize use of beta-blockers & ACE-I
Lipids
LDL < 100 (70) ; TG < 200
Maximize use of statins; consider
fibrates/niacin first line for TG>500;
consider omega-3 fatty acids
Diabetes
A1c < 7%
Secondary prevention
behavioral intervention
Smoking cessation
Physical Activity
Goal 30 - 60 minutes daily
Risk assessment prior to initiation
Diet
DASH diet, fiber, omega-3 fatty acids
<7% total calories from saturated
fats
Secondary prevention
cognitive
Patient education
Medication Checklist
after ACS
Antiplatelet agent
Statin*
Fibrate / Niacin / Omega-3
Antihypertensive agent
Beta blocker*
ACE-I*/ARB
Aldactone (as appropriate)
Summary
Conclusions: Treatment
of NSTEMI/UAP
ASA
NTG (consider MSO4 if pain not relieved)
Beta Blocker
Heparin/LMWH
ACE-I
+/- Statin
+/- Clopidogrel (dont give if CABG is a
possibility)
+/- IIBIIIA inhibitors (based on TIMI risk
score)
Conclusions: Treatment
of STEMI
ASA
NTG (consider MSO4 if pain not relieved)
Beta Blocker
Heparin/LMWH
ACE-I
Clopidogrel (based on possibility of CABG)
IIB-IIIA
+/- Statin
Activate the Cath Lab!!!
Terima Kasih