Toni Mustahsani Aprami, dr., SpPD, SpJP

1
Toni Mustahsani Aprami, dr., SpPD,
SpJP Department of Cardiology and Vascular
Medicine Division of Cardiovascular, Department
of Internal Medicine Padjadjaran University
School of Medicine/Hasan Sadikin Hospital ,
Bandung
2
DEFINISI

• Suatu sindroma klinik yang menandakan
• adanya iskemia miokard akut, terdiri dari
• Infark miokard akut Q wave (STEMI)
• Infark miokard akut non-Q (NSTEMI)
• Angina pektoris tidak stabil (UAP)
• Ketiga kondisi ini sangat berkaitan erat, berbeda
  hanya dalam derajat beratnya iskemi dan luasnya
  miokard yang mengalami nekrosis.

3
PATOGENESIS

• Umumnya disebabkan oleh aterosklerosis koroner
• Plak aterosklerosis ruptur ? terbentuk trombus
  diatas ateroma yang secara akut menyumbat lumen
  koroner
• Apabila sumbatan terjadi secara total ? hampir
  seluruh dinding ventrikel akan nekrosis

4
Risk Factors

• Uncontrollable

Controllable

• High blood pressure
• High blood cholesterol
• Smoking
• Physical activity
• Obesity
• Diabetes
• Stress and anger

• Sex
• Hereditary
• Race
• Age

5
The cardiovascular continuum of events
Ischemia oxygen supply and demand imbalance
Myocardial Ischemia
CAD
plaque
Atherosclerosis
Risk Factors ( ,? BP,
DM, Insulin Resistance, Platelets, Fibrinogen,
etc)
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J.
19911211244-1263
6
The cardiovascular continuum of events
Coronary Thrombosis
Myocardial Ischemia
CAD
Atherosclerosis
Risk Factors ( ,? BP,
DM, Insulin Resistance, Platelets, Fibrinogen,
etc)
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J.
19911211244-1263
7
The cardiovascular continuum of events
ACS
Coronary Thrombosis
Myocardial Ischemia
CAD
Atherosclerosis
Risk Factors ( ,? BP,
DM, Insulin Resistance, Platelets, Fibrinogen,
etc)
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J.
19911211244-1263
8
Stable angina
Plaque rupture
Coronary thrombosis
UA/NSTEMI
STEMI
9
Penyempitan Pembuluh darah
10
Clinical Spectrum of Acute Coronary Syndrome
Acute Coronary Syndrome
ST Segment Elevation
Non-ST Segment Elevation
STEMI
NSTEMI
Unstable Angina Pectoris
Non-Q-wave Q-wave Acute Myocardial Infarction
11
NSTEMI

• Unstable
• Angina

• STEMI

Non occlusive thrombus Non specific
ECG Normal cardiac enzymes
Occluding thrombus sufficient to cause tissue
damage mild myocardial necrosis ST depression
/- T wave inversion on ECG Elevated cardiac
enzymes
Complete thrombus occlusion ST elevations on
ECG or new LBBB Elevated cardiac enzymes More
severe symptoms
12
Diagnosis
Anamnesis Pemeriksaan Fisik Pemeriksaan Penunjang
1. Laboratorium 2. Elektrokardiografi 3
. Thoraks Foto
13
HISTORY

• PRODROMAL SYMPTOMS
• History very valuable to establish D/. Prodoma
  chest discomfort unstable angina
• 1/3 symptoms for 1 4 wks
• 20 symptoms for lt 24 hrs
• Malaise, exhaustion
• NATURE OF PAIN
• Most patients
• severe prolonged, ? 30 minutes - hours
• Constricting, crushing, oppressing, compressing
• heavy weight or squeezing in chest
• Choking, vise-like, heavy pain or stabbing,
  knife-like, boring or burning discomfort
• Location retrosternal, spreading frequently to
  both sides of the chest with predilection to the
  left side
• Often pain radiates down ulnar aspect of left
  arm, producing tingling sensation in left wrist,
  hand and fingers

14

• NATURE OF PAIN
• SOME INSTANCES pain begins in epigastrium, and
  simulates abdominal disorder
• Sometimes pain radiates to shoulders, upper
  extremities, neck, jaw and interscapular region
  favoring the left side
• Elderly no chest pain but acute left
  ventricular failure and chest tightness or marked
  weakness or syncope
• Pain arises from nerve endings in ischemic or
  injured, but not necrotic, myocardium
• OTHER SYMPTOMS
• 50 nausea or vomiting in transmural infarcts
• Occasionally diarrhea, profound weakness,
  dizziness, palpitation, cold perspiration, sense
  of impending doom
• Occasionally cerebral embolism or systemic
  arterial embolism

15
Pain Patterns with Myocardial Ischemia
16

• Anamnesis untuk UAP
• 3 kategori presentasi klinik UAP
• Angina saat istirahat (resting angina)
• Angina awitan baru (new onset angina)
• Angina yang bertambah berat (increasing angina)
• Riwayat penyakit dahulu
• Riwayat angina on effort, infark atau operasi
  pintas
• Riwayat penggunaan nitrogliserin
• Identifikasi faktor-faktor risiko

17
PHYSICAL EXAMINATION
GENERAL APPEARANCE Anxious, considerable
distress, restless, fist on chest (Levine
sign) LV failure symp. stimulation cold
perspiration, pallor, dyspnea, cough with frothy
pink or blood-streaked sputum. Shock cool,
clammy skin, facial pallor, cyanosis, confusion
or disorientation HEART RATE Variable depending
on underlying rhythm and degree or ventr.
failure Most commonly, HR 100 110/min gt 95
patients VPBs within first 4 hours
18
BLOOD PRESSURE Majority normotensive, but syst.
BP may decline and diast. BP may rise ? Half of
pts with inferior MI ? parasympathetic
stimulation hypotension, bradycardia or both
(Bezold Jarisch reflex) ? half of pts with
anterior MI, ? sympathetic excess hypertension,
tachycardia or both TEMPERATURE AND
RESPIRATION Most pts with extensive MI ? fever
within 24-48 hrs, fever resolves by 4th or 5th
day Respiration ? due to anxiety and pain, in LV
failure resp. rate correlates with degree of
heart failure
19
JUGULAR VENOUS PULSE JVP usually normal RV
infarction marked jug. venous
distension CAROTID PULSE Small pulse ? reduced
stroke volume Pulse alternans severe LV
dysfunction
20
CHEST LV failure and/or LV compliance ? moist
rales Severe failure diffuse wheezing, cough
hemopthysis 1967 Killip Kimball prognostic
classification Class I patients free of rales
or S3 II rales lt 50 lung fields /-
S3 III rales gt 50 lung fields, frequently
pulm. edema IV cardiogenic shock
21

• Pemeriksaan Penunjang
• Pemeriksaan EKG
• Gambaran EKG infark miokard akut Q-wave (STEMI)
• Elevasi segmen ST ? 1 mm pada ? 2 sadapan
  extremitas
• Atau ? 2 mm pada ? 2 sadapan prekordial yang
  berurutan
• Atau gambaran LBBB baru atau diduga baru

22
ST-segment elevation
23
(No Transcript)
24
(No Transcript)
25

• Gambaran EKG infark miokard akut non-Q-wave
  (NSTEMI) atau angina pektoris tidak stabil (UAP)
  
• Depresi segment ST atau gelombang T terbalik pada
  ? 2 sadapan berurutan
• Inversi gelombang T minimal 1 mm pada 2 sadapan
  atau lebih yang berurutan.
• Perubahan segment ST saat keluhan dan kembali
  normal saat keluhan hilang ? sangat menyokong UAP

26
ST-segment depression
27
T-wave inversion
28
ELEKTROKARDIOGRAM
Current-of-injury patterns with acute ischemia
29

• Pemeriksaan Penanda Jantung/Enzim jantung
• (Cardiac Markers)
• Yang lazim adalah CKMB, dapat pula troponin T
  (TnT) atau troponin I (TnI)
• Peningkatan marka jantung akan terlihat pada
  infark miokard akut Q-wave (STEMI) dan non-Q-wave
  (NSTEMI)

30
Plot of the appearance of cardiac markers in
blood versus time after onset of symptoms
A myoglobin C CK-MB B troponin D troponin in UA
31
Diagnosis Banding

1. Diseksi aorta
2. Perikarditis
3. Nyeri angina atipikal pada kardiomiopati
   hipertrofi
4. Penyakit esofageal, GI atas atau traktus biliaris
5. Penyakit paru-paru pneumotoraks, emboli,
   pleuritis
6. Sindroma hiperventilasi
7. Gangguan dinding dada muskuloskeletal, neurogen
8. Psikogen

32
Manajemen
33
The cardiovascular continuum of events
ACS
Coronary Thrombosis
Arrhythmia and Loss of Muscle
Myocardial Ischemia
Remodeling
Ventricular Dilatation
CAD
Atherosclerosis
Congestive Heart Failure
Risk Factors ( ,? BP,
DM, Insulin Resistance, Platelets, Fibrinogen,
etc)
End-stage Heart Disease
DYSLIPIDEMIA
Adapted from Dzau et al. Am Heart J.
19911211244-1263
34
DELAY TO THERAPY
1. From onset of symptoms to patient recognition
2. Out-hospital transport
3. In-hospital evaluation
35
ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
36
(No Transcript)
37
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
38
Chest discomfort suggestive of ischemia
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
39
Acute coronary syndrome algorithm
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
40
Acute coronary syndrome algorithm
ST elevation or new or presumably new LBBB
strongly suspicious for injury
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
41
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST-depression or dynamic T-wave inversion
strongly suspicious for injury
ST elevation or new or presumably new LBBB
strongly suspicious for injury
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
42
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
ST-depression or dynamic T-wave inversion
strongly suspicious for injury (UA/NSTEMI)
ST elevation or new or presumably new LBBB
strongly suspicious for injury (STEMI)
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
43
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
Start adjunctive treatment
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
44
ADJUNCTIVE TREATMENT (Do not delay reperfusion)

1. Beta-adrenergic receptor blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)

2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
45
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
Start adjunctive treatment
2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
46
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
Start adjunctive treatment
Start adjunctive treatment
Time from onset of symptoms
? 12 hours

• Reperfusion strategy PCI (90 min) or
  fibrinolysis (30 min)
• ACE-I/ARB within 24 hours of onset
• Statin

2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
47
Adjunctive treatment

• Heparin (UFH/LMWH)
• Glycoprotein IIb/IIIa receptor inhibitors
• ?-Adrenoreceptor blockers
• Clopidogrel

2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
48
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
Start adjunctive treatment
Start adjunctive treatment
Time from onset of symptoms
? 12 hours

• Reperfusion strategy PCI (90 min) or
  fibrinolysis (30 min)
• ACE-I/ARB within 24 h of symptom onset)
• Statin

2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
49
(No Transcript)
50
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general
treatment
Review initial 12 lead ECG
Start adjunctive treatment
Start adjunctive treatment
Time from onset of symptoms
? 12 hrs
Admit to monitored bed Assess risk status
? 12 hours

• High risk early invasive strategy
• Continue ASA, heparin, ACE-I, statin

• Reperfusion strategy PCI (90 min) or
  fibrinolysis (30 min)
• ACE-I/ARB within 24 h of symptom onset)
• Statin

2005 AHA-ILCOR Guidelines for CPR and ECC.
Circulation 2005112 (Suppl)IV-90
51
(No Transcript)
52
(No Transcript)
53
Pengobatan Pasca Perawatan

• Obat-obat untuk mengontrol keluhan iskemia harus
  dilanjutkan
• Aspirin
• Beta-blocker
• ACE inhibitor

Modifikasi Faktor Risiko

• Berhenti merokok
• Pertahankan BB optimal
• Aktivitas fisik sesuai dengan hasil treadmill
• Diet
• Rendah lemak jenuh dengan kolesterol, bila perlu
  dengan target LDL lt 100 mg/dL
• Pengendalian hipertensi
• Pengendalian ketat gula darah pada penderita DM

54

• Get regular medical checkups.
• Control your blood pressure.
• Check your cholesterol.
• Dont smoke.
• Exercise regularly.
• Maintain a healthy weight.
• Eat a heart-healthy diet.
• Manage stress.

Prevention
55
Thank you for your attention
56

• Anamnesis
• Nyeri dada atau nyeri epigastrium hebat yang
  mengarah pada iskemia miokard
• Seperti dihimpit benda berat
• Terasa tercekik
• Rasa ditekan, ditinju, ditikam
• Rasa terbakar
• Biasanya dirasakan dibelakang stenum ? seluruh
  dada
• terutama kiri, dapat ke tengkuk, rahang, bahu,
  punggung, lengan kiri atau kedua lengan
• Terutama laki-laki gt 35 tahun dan Wanita gt 40
  tahun
• Seringkali disertai mual atau muntah, dapat pula
  rasa tidak enak disertai sesak nafas, lemah,
  penurunan kesadaran, dan keringat banyak

57

• Pemeriksaan Fisik
• Biasanya penderita tampak cemas, gelisah, pucat,
  dan keringat dingin
• Periksa tanda-tanda vital
• Denyut nadi cepat, reguler tetapi dapat pula
  bradi atau tachycardia, irama ireguler
• Tekanan darah biasanya normal bila belum terjadi
  komplikasi, dapat pula terjadi hipo atau
  hipertensi
• Bunyi jantung dapat terdengar redup
• S3 dapat terdengar bila kerusakan miokard luas
• Paru-paru dapat terdengar ronkhi basah dan atau
  wheezing yang menandakan terjadinya bendungan
  paru ? tergantung ada tidaknya gangguan fungsi
  ventrikel kiri