Abdul Qodir

Outlines

• Anatomy of coronary artery

• Coronary artery disease : atherosclerosis
• Progression of CAD  IMA
• Diagnosing IMA
• IMA Treatment
Mencakup
1. IMA/STEMI (ST Elevation Myocardial Infarction)
2. NSTEMI (Non ST Elevation Myocardial Infarction)
3. ATS (Angina Pectoris Tidak Stabil)
 Prevalensi
• Di Amerika : kejadian IMA lebih 1 Juta/tahun
• 200,000 – 300,000 pasien IMA meninggal sebelum sampai RS
• Total : Warga negara Amerika mengalami IMA setiap 29 detik
dan meninggal setiap menit.
• Indonesia ?
• Tahun 2008: PJN Harapan Kita 7 pasien ACS , 50-60% IMA
• 10% IMA < 40 thn
• Penyebab kematian no 2 di UGD RSSA
Topol EJ. CV med 2009
Saifur et al. unpublished data, 2008, 2011
 Coronary Arteries
• Coronary arteries branch off at base of aorta &
supply blood to the electrical conduction system &
myocardium.

• 3 main arteries:
– RCA
– LCA
– Circumflex
 Atherosclerosis
• Disease of cardiovascular system affecting vessel
wall.
• It leads to the narrowing of arteries or complete
blockage.
• Its main components are endothelial disfunction,
lipid deposition, inflammatory reaction in the
vascular wall.
• Remodeling of vessel wall.
 Risk factors for CVD

Modifiable Non-modifiable
– Smoking – Personal history of CVD
– Dyslipidaemia – Family history of CVD
• raised LDL cholesterol – Age
• low HDL cholesterol – Gender
• raised triglyceride
– Raised blood pressure
– Diabetes mellitus
– Obesity
– Dietary factors
– Thrombogenic factors
– Lack of exercise
– Excess alcohol consumption

— Stress
 Levels of risk associated with smoking,
hypertension and hypercholesterolaemia

Hypertension
(SBP 195 mmHg)

x3

X4.5 x9
x16
X1.6 x6 x4
Smoking

Serum cholesterol level

(8.5 mmol/L, 330 mg/dl)

(Adapted from Poulter et al, 1993)

The development of atherosclerosis
• The key event – damage to the endothelium
caused by excess of lipoproteins, hypertension,
diabetes, components of cigarette smoke.
• Endothelium becomes more permeable to
lipoproteins.
• Lipoproteins move below the endothelial layer (to
intima).
• Endothelium loses its cell-repelent quality.
• Inflammatory cells move into the vascular wall.
The process of atherogenesis
Aterosklerosis Acute Coronary Syndrome (ACS)

Chest Pain
Plaque Rupture Toward
Occlusion
 Spektrum ACS
• Unstable Angina Pectoris :
(EKG normal, Trop T/I (-))
• Acute Non ST-Elevation Myocardial Infarction
(NSTEMI) :
(EKG normal/ST depresi/T inversi dan Trop T/I (+))
• Acute ST-Elevation Myocardial Infarction (STEMI) :
EKG ST elevasi dan Trop T/I(+)
 ACS

ST- Segment ST- Segment

depresion Elevation

Biomarkers of Biomarkers of Biomarkers of

cadiac injury (-) cadiac injury (+) cadiac injury (+)

UA NSTEMI STEMI
(Non-ST Elevation (ST Elevation
(Unstable angina)
Myocardial Infarction) Myocardial Infarction)
European Heart (2007)
 Nyeri (tidak enak) dada ….. ?
• Sifat :Berat/ tertindih (pressure, tightness, or heaviness,
strangling, constricting, or compression), Panas
(burning) ; Masuk angin, Sesak,”maag”
• Lokasi: Di dada kiri/tengah tidak bisa ditunjuk
• Penjalaran : ke bahu/lengan, leher, dagu,
• belakang,epigastrium
• Lama : 5-30’
• Pencetus :aktifitas/stres/dingin
• Berkurang: Nitrat/Istirahat
• Tidak khas: Pingsan/kejang/tidak sadar/berdebar

ESC guidelines for SAP 2006

ESC AMI ST elevation guidelines 2008
 Stable vs. Unstable
• Stable : There is no substantial deterioration in
symptoms over several weeks. Stability or
quiescence of an atherosclerotic plaque;
depending on increased oxygen demand

• Unstable : symptom pattern worsen abruptly

without an obvious caused of increased oxygen
consumption, decreased supply . Unstable
plaque: ACS
KLASIFIKASI ANGINA PEKTORIS
I. Aktivitas sehari-hari tidak timbul angina
II. Pembatasan ringan dari aktivitas sehari-hari
III. Aktiviatas sehari-hari sangat terbatas
IV. Tidak mampu melakukan aktivitas fisik dan
angina timbul saat istirahat
 Hati-hati : Angina Equivalent

• Indigestion, belching, dyspnea

• DM, wanita, manula (post operative)
• Didapatkan 5% dari ACS
• 2% dipulangkan ternyata ACS
Braunwalds Heart Disease 8th Ed 2008
 Non Angina Pain
• Hanya terasa pada sebagian kecil dada
kiri/kanan (bisa di tunjuk)
• Berkahir berjam jam sampai berhari hari.
• Biasanya tidak berkurang dengan nitrogliserin
• Mungkin dicetuskan oleh debaran.

ESC guidelines for SAP 2006

ESC AMI ST elevation guidelines 2008
• Secepat mungkin – 10’ setelah pasien tiba
• Diulang apabila meragukan adanya kenaikan
segmen ST (ST elevasi)
• Bandingkan dengan EKG sebelumnya
• Pasang monitor EKG
EKG : Gambaran aktifitas listrik jantung
 EKG pada ACS

EKG dapat menentukan adanya:

• Old/Recent/Acute infarction
• Pericarditis
• Arrhythmias
• Pembesaran jantung
 ST-T changes in STEMI
• The acute phase is marked by ST segment elevations
(current of injury pattern) and sometimes tall positive T
waves (hyperacute T waves)
• Within several hour, myocytes death leads to loss of R
amplitude and Q wave appeared
• During the 1-2 days ST remains elevated, T inverted , Q
wave deepen
• Several days later ST segment return to baseline, T
remains inverted,
• Weeks to months following infarct, Q persist
Gambaran EKG pada Iskemik/AMI
UAP/Acute NSTEMI
Acute NSTEMI
Acute STEMI- Evolution
Systolic Current Theory
 Diastolic current Theory

• Leaky K+
• Never fully repolarize
• Relatively more negative than normal
• Current directed away from infarct area
• Baseline shift downward
Acute STEMI-Q wave
ECG subsets and correlated infarct-related artery

Category Anatomy of Occlusion ECG Findings

Proximal LAD Proximal to septal ST elevation V1-6, I, avL,

perforator and fascicular or bundle
branch block

Mid LAD Proximal to large diagonal ST elevation V1-6, I, avL

but distal to first septal
perforator

Distal LAD or diagonal Distal to large diagonal or ST elevation V1-4, or I, avL,

diagonal itself V5-6

Moderate to large inferior Proximal RCA or left ST elevation II, III, avF, and
(posterior, lateral, right circumflex any of the following:
ventricular) a. V1, V3R, V4R
b. V5-6
c. R>S in V1-2

Small inferior Distal RCA or left circumflex ST elevation II, III, avF only
branch
Anterior STEMI

ECG demonstrates large anterior infarction

 Inferior STEMI
Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
Inferior STEMI
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

 Diagnostic
Laboratory
Creatine Kinase/Craetine Kinase MB band
Positive bila CK-MB > 5% dari total CK dan atau CK-MB > 2 kali
normal
Mulai meningkat 4-6 jam sesudah injuri dan mencapai
puncaknya 24 jam.
Tetap meningkat 36- 48 jam.
Peningkatan CK-MB mempunyai hubungan dengan mortalitas
False positive disebabkan oleh olahraga keras, dm.
Diagnostic of Acute Myocardial Infarction
Laboratory
 Diagnostic
Laboratory
Troponin T and I
Very specific
Detects myocardial necrosis
More sensitive than CK
Begins to rice 4-8 hour after injury
Remains elevated for 7-10 days
Provides prognostic information
 Diagnostic of
Laboratory: Troponin
 Pemeriksaan Fisik
• Sadar-Koma
• TD: Hypertensi-Normal-Hypoptensi
• HR: Regular-irregular/ Bradycardia-Tachycardia
pulseless
• RR: Tachypnea-apnea
• Cor: Regular-iregular, murmur, gallop
• Pulmo: Normal-Rales- wheezing
• Ext: dingin/hangat, edema+/-, etc.
Universal Definition of Myocardial Infarction

Diagnosa AMI ditegakkan apabila min memenuhi 2 dari

kriteria:
• Gejala Ischemic
• Perubahan EKG
• Kenaikan/penurunan Troponin T/I
 Prinsip Terapi
• Cepat (time responsif), obati penyebab 
buka sumbatan
• Terlambat: Fatal
• Monitor ketat tanda vital sejak awal
• Antisipasi dini tanda tanda perburukan
dan komplikasi
 Terapi Awal ACS
• Atasi keadaan kegawat daruratan : asistol,
apneu, syock, lung edema, gagal jantung
dll.
• Terapi reperfusi : PCI, Fibrinolitik, heparin
• Antiischemic
• Turunkan oksigen demand : Bed rest total,
pendekatan psikologis, dll
• Terapi komorbid; hipertensi, DM, dll
 Pentingnya Reperfusi
• Sumbatan total15-30 menit tanpa
kolateral IMA
• Reperfusion  selamatkan miorkard
• Kematian1 bulan: 25-30% 4-6% dengan
reperfusi (PCI, fibrinolytic, antithombotic)

ESC AMI ST elevation guidelines 2008

Kerusakan Miokard Irreversibel
• Miokard tidak mengalami regenerasi
• Terlambat/tidak dibuka  Miokard mati 
Gagal Jantung  rawat ulang  biaya besar,
kualitas hidup kurang baik
• Obat gagal Jantung hanya mencegah
perburukan, tidak memperbaiki miokard yang
mati/infark
• Alternatif terapi : Stem cell
The time is muscle
 Terapi NSTEMI

• O2
• Bed rest
• Pain killer
• Nitrate and anti-ischemia
• Antiplatelet : Aspirin, Clopidogrel
• Heparin
• Hyperglicemia
• Treat the complication etc
 Tips
• Obat anti ischemik atau anti nyeri segera di berikan
• Anti platelet dan heparin dimasukkan secepatnya
setelah diagnosis ACS-NSTEMI ditegakkan, jangan di
tunda
• Turunkan kebutuhan/kerja jantung dengan berikan
rasa nyaman dan aman pasien dan bed rest total
• Setengah duduk pada pasien dengan gagal jantung
• Pikirkan immediate/urgent PCI pada pasien resiko
tinggi/hemodinamik tidak stabil/nyeri
berkepanjangn/aritmia maligna dll
Alat diagnosis dan monitoring Perawat
• Keluhan berhubungan dengan fungsi dan
beban jantung, deteksi dini komplikasi
• Monitor tanda vital, saturasi, perfusi, EKG,
intake- output, balance. dll
• Kalau perlu ukur CVP, arteri line dll
• Laboratorium : Enzyme jantung, analisa gas
darah, fungsi ginjal, elektrolit, komorbid
(infeksi, dm, dll)
 Intervensi keperawatan
• Turunkan kebutuhan dan bebang jantung
misalnya istirahat fisik dan mental, kondisi
hangat, tenang, rasa aman, pemilihan diet :
NGT atau bantuan makanan, dilarang
mengejan, atasi febris, rasa sakit atau sesak dll
• Bantu fungsi jantung: Inotropic, anti iskemik, dll
• Atasi komorbid/komplikasi: hipertensi, DM,
infeksi, gagal jantung, gangguan ginjal, dll
• Atasi kekurangan atau kelebihan cairan, kalori,
oksigen, PH, elektrolit, dll
 Terapi STEMI
• O2
• Bed rest
• Pain killer
• Nitrate and anti-ischemia
• Antiplatelet : Aspirin, Clopidogrel
• Fibrinolytic time to neddle : 30 m/PCI
(Percutaneous Coronary Intervention)
• Hyperglicemia
• Treat the complication etc
Treatment of STEMI
 Prevention
Lifestyle modification
- Dietary counseling
- Exercise
- Smoking cessation
Healt care maintenence
Routine screening:
- Weight
- Blood pressure
- Lipid
- glocuse