Acute Coronary Syndrome

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
2

Chief Complaint
Chest Pain
Angina Equivalent
Accompanied symptom ?; associated
with cardiac function

Angina Pectoris
A syndrome resulting from myocardial
ischemia
Demand and supply imbalance
Careful history taking; risk factor, activity
/stress-induced pain, location,character of
pain, duration, etc

Spectrum Of ACS

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
7

Physical Examination
Alert-Unconscious
BP: Hypertension-Normal-Hypoptension
HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
RR: Tachypnea-apnea
Cor: Regular-iregular, murmur, gallop
Pulmo: Normal-Rales- wheezing
Ext: cold, pulsation, edema, etc.
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Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
9

UAP/Acute NSTEMI

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Acute NSTEMI

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Acute STEMI- Evolution

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LOKASI ISKEMIA
BERDASARKAN PERUBAHAN DI SANDAPAN EKG
SANDAPAN
II ,III, aVF
V1,V2
V3-V4
V1-V6, I, aVL
I,aVL ,V5,V6
I, V6
V7-V9
V3R, V4R

LOKASI ISKEMIA / INFARK

Inferior
Septal
Anterior
Anterior ekstensif
Lateral
Apikal
Posterior
Ventrikel kanan
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ECG demonstrates large anterior infarction

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Inferior STEMI

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LBBB

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RBBB

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Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
21

Increased serial cardiac marker

Troponin T/Troponin I
CKMB

22

Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
23

Treatment of ACS
Treat the emergency condition;
complication of ACS; asystole, apneu,
syock, acute lung edema, etc
Confirm the diagnosis
Treat the cause
Treat co-morbid
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DRUGS for AMI

MONACo greets all MI patients
M = Morphine
O = Oxygen
N = Nitrate
A = Aspirin
Co= Clopidogrel

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The time is muscle

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Emergency Department
(1)
AMI Protocol
-ECG screening within 10 minutes
-Door-to-drug time < 30 minutes
-Door-to-balloon time inflation < 90
minutes
For all patients with ischemic-type chest
pain, provide supplementary oxygen, IV
access, and continuous ECG monitoring
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Emergency Department
(2)
Reperfusion therapy for ST-segment
elevation MI (STEMI)
- Rule out contraindications and
assess risk-benefit ratio
-Consider PCI if ineligible for
fibrinolytics
-angiography for cardiogenic shock
(angioplasty or CABG if indicated)
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Fibrinolytic Use in Myocardial Infarction ( AHA 2004 )

Absolute Contraindications

Cautions/Relative Contraindications

Previous hemorrhagic

Severe uncontrolled HT on presentation

stroke at any time

(BP >180/110 mm Hg)

Ischemic strokes 3 mo
( except 3 hrs )

History of prior CV accident or known intracerebral pathology not covered in CI

Known intracranial
malignant neoplasm

Current use of anticoagulants (INR 2-3);

known bleeding diathesis

Active internal bleeding

/ bleeding diasthesis
( not include menses )

Recent trauma ( 2-4 wks ), head trauma

Noncompressible vascular punctures

Recent ( 2-4 wks ) internal bleeding
Suspected aortic dissection For streptokinase : prior exposure
( within 5d-2y ) or prior allergic rx
Head / facial trauma
Pregnancy
Active peptic ulcer
within 3 mo
History of chronic HT 29

PCI

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Topics
Angina Pectoris and Accompanied
symptoms
Physical Examination
ECG
Laboratory finding
Treatment
ACS Algorithm
32

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Thank You

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