Mengenali ACS: Cegah dan tangani dg cepat dan benar

Mohammad Saifur Rohman, dr.SpJP, PhD.FICAMohammad Saifur Rohman, dr.SpJP, PhD.FICA

Mengapa Penting?

Jantung adalah organ yang sangat vitalMenjamin pasokan kebutuhan seluruh organ

tubuhJantung memompa lebih dari 1 juta gallon

pertahunBerhenti ----- DeathPertanda awal Kenali !Terlambat Irreversible (?)

Kegawatdarutan kardiak Cardiac arrestCardiac arrest Acute coronary syndromeAcute coronary syndrome Cardiac dysrhythmiasCardiac dysrhythmias Acute pulmonary oedemaAcute pulmonary oedema Trauma – both blunt & penetratingTrauma – both blunt & penetrating Cardiogenic shockCardiogenic shock Aortic dissectionAortic dissection Valve insufficiencyValve insufficiency

Slide No.Slide No. 33Bgm Keluhan & Tanda ?

Mengapa Harus Cepat?

Serangan Jantung Serangan Jantung Proses adaptasi terhadap perubahan yang Proses adaptasi terhadap perubahan yang

sangat cepatsangat cepat KompensasiKompensasi DekompensasiDekompensasi

Dapat di kenali dan diantisipasi serta dicegah

Diperbaiki? Tidak!, Dicegah? Ya !

Prevalensi SKA

Di Amerika : kejadian Infark miokard Akut Di Amerika : kejadian Infark miokard Akut (IMA) lebih 1 Juta/tahun(IMA) lebih 1 Juta/tahun

200,000 – 300,000 pasien IMA meninggal 200,000 – 300,000 pasien IMA meninggal sebelum sampai RS sebelum sampai RS

Total : Warga negara Amerika mengalami IMA Total : Warga negara Amerika mengalami IMA setiap 29 detik dan meninggal setiap menit.setiap 29 detik dan meninggal setiap menit.

Indonesia ? Indonesia ? Tahun 2008: PJN Harapan Kita 7 pasien SKA , Tahun 2008: PJN Harapan Kita 7 pasien SKA ,

50-60% IMA50-60% IMA !0% IMA < 40 thn!0% IMA < 40 thn

Topol EJ. CV med 2009Data PJN HK 2008

59 patients death cases among 356 patients

The second deadliest diseases

The mortality rate was 16,6% in 2010

SKA DI RSSA MALANG

Apa penyebab KEMATIAN?

keterlambatan pasien datang ke RS

Penanganan di RS

Apa penyebab KEMATIAN?

keterlambatan pasien datang ke RS

Penanganan di RS

Seeking care behaviour pattern

PatientSaiful

Anwar Hospital

Self Medication

PHC

General Practitioner role

Aterosklerosis SKA

Atherogenesis

Progression of Plaque toward Progression of Plaque toward rupturerupture

Progression of Plaque toward rupture

Plaque RupturePlaque Rupture

Platelet aggregation in Platelet aggregation in ruptured plaque ruptured plaque

Adventitia

Lipid core

Platelets aggregate at the site of rupture / erosion

Weissberg, 1999

Thrombus forms and extends into the lumen

Adventitia

Lipid core

Thrombus

Weissberg, 1999

Thrombus formationThrombus formation

Plaque Rupture Toward Plaque Rupture Toward OcclusionOcclusion

Spektrum SKA

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(+)

Bagaimana Diagnosa SKA ?

Membedakan Nyeri dada: SKA?

1. Cardiac or non cardiac1. Cardiac or non cardiac2. Cardiac : Ischemic non Ischemic2. Cardiac : Ischemic non Ischemic3. Ischemic : Coronary non Coronary3. Ischemic : Coronary non Coronary4. Angina pektoris stabil atau SKA4. Angina pektoris stabil atau SKA

Nyeri (tidak enak) dada ….. ?

Sifat :Berat/ tertindih (pressure, tightness, or heaviness, pressure, tightness, or heaviness,

strangling, constricting, or compression),strangling, constricting, or compression), Panas

(burning) 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 2006ESC AMI ST elevation guidelines 2008

Angina PectorisAngina Pectoris A syndrome resulting from myocardial A syndrome resulting from myocardial

ischemiaischemia Demand and supply imbalanceDemand and supply imbalance Careful history taking; mode of onset, Careful history taking; mode of onset,

location, quality of pain, duration, precipitating location, quality of pain, duration, precipitating factors, pattern of disappearance, risk factor, factors, pattern of disappearance, risk factor, etcetc

Angina PectorisAngina Pectoris A syndrome resulting from myocardial A syndrome resulting from myocardial

ischemiaischemia Demand and supply imbalanceDemand and supply imbalance Careful history taking; mode of onset, Careful history taking; mode of onset,

location, quality of pain, duration, precipitating location, quality of pain, duration, precipitating factors, pattern of disappearance, risk factor, factors, pattern of disappearance, risk factor, etcetc

Hati-hati : Angina Equivalent

Indigestion, belching, dyspneaDM, wanita, manula (post operative)Didapatkan 5% dari ACS2% dipulangkan ternyata ACS

Braunwalds Heart Disease 8th Ed 2008

DD Chest pain

Ischemic Stenosis AortaRegurgitasi AortaHypertrophic CardiomyopathyAngina pada HypertensiHipertensi pulmonal berat

11th ed Hurst’s the heart 2005

DD Chest Pain

Non Ischemic Diseksi AortaPericarditisMitral valve prolaps

11th ed Hurst’s the heart 2005

DD Chest Pain

Gastro intestinalEsophageal spasm/reflux/rupturePeptic Ulcer

NeuromusculoskeletalCostochondritisHerpes zosterChest wall pain dan tenderness etc

11th ed Hurst’s the heart 2005

DD chest pain

PulmonaryPulmonary emboliPneumothoraxPenumonia with pleural involvement

Pleurisy

PsychogenicAxiety/depression/cardiac psychosis etc

11th ed Hurst’s the heart 2005

Non Angina Pain

Hanya terasa pada sebagian kecil dada kiri/kanan (bisa di tunjuk)

Berkahir berjam jam sampai berhari hari. Biasanya tidak berkurang dengan

nitrogliserinMungkin dicetuskan oleh debaran.

ESC guidelines for SAP 2006ESC AMI ST elevation guidelines 2008

Nyeri dada khas SKA

Angina awitan baru derajat 3 menurut klasifikasi kanada kardiovaskuler group

( nyeri dada timbul pada aktifitas ringan sehari-hari)

Angina saat istirahat > 20 menitPerburukan derajat angina menjadi derajat

3 dalam beberapa hari – 1 bln terakhir (Crescendo angina)

Atypical

Pemeriksaan Fisik

Sadar-KomaSadar-Koma TD: Hypertensi-Normal-HypoptensiTD: Hypertensi-Normal-Hypoptensi HR: Regular-irregular/ Bradycardia-TachycardiaHR: Regular-irregular/ Bradycardia-Tachycardia

pulselesspulseless RR: Tachypnea-apneaRR: Tachypnea-apnea Cor: Regular-iregular, murmur, gallopCor: Regular-iregular, murmur, gallop Pulmo: Normal-Rales- wheezingPulmo: Normal-Rales- wheezing Ext: dingin/hangat, edema+/-, etc.Ext: dingin/hangat, edema+/-, etc.

EKGEKG

Secepat mungkin – 10’ setelah pasien tibaSecepat mungkin – 10’ setelah pasien tibaDiulang apabila meragukan adanya Diulang apabila meragukan adanya

kenaikan segmen ST (ST televasi)kenaikan segmen ST (ST televasi)Bandingkan denga EKG sebelumnyaBandingkan denga EKG sebelumnyaPasang monitor EKGPasang monitor EKG

EKG : Gambaran aktifitas listrik jantung

EKG pada SKA

EKG dapat menentukan adanya:Old/Recent/Acute infarctionPericarditisArrhythmiasPembesaran jantung

Gambaran EKG pada Iskemik/IMAGambaran EKG pada Iskemik/IMA

UAP/Acute NSTEMI

Acute NSTEMI

Acute STEMI- Evolution

Acute STEMI-Q wave

Occluded artery

ECG demonstrates large anterior infarction

Anterior 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

Inferior STEMI

EKG

Gangguan IramaGangguan Irama Infark baru atau lamaInfark baru atau lamaPerikarditisPerikarditisPembesaran jantung dllPembesaran jantung dll

2nd degree Type 1

1st degree

3rd degree

2nd degree Type II

Ventricular Tachycardia (VT)

Ventricular Tachycardia (V T)

Unable to determine rhythmUnable to determine rhythmRegularRegular ventricular rate (100-250) ventricular rate (100-250)No P waves presentNo P waves presentQRS complex > 0.10 secQRS complex > 0.10 sec

Ventricular Fibrillation (Ventricular Fibrillation (VF))

Coarse

Fine

Peningkatan Enzym jantung

Troponin T/Troponin ITroponin T/Troponin ICKMBCKMB

Chest x-ray

CTR 62%

Aorta elongation

Po normal

Cardiac Waist (+)

Apex lat downward

Congestion (+)

Non Invasif

Invasif

Universal Definition of Myocardial Infarction

Diagnosa AMI ditegakkan apabila min memenuhi 2 dari kriteria:

Gejala Ischemic Perubahan EKG Kenaikan/penurunan Troponin T/I

Stratifikasi Resiko

High risk Intermediate risk Low risk

Angina saat Istirahat Angina > 20 kurang dengan istirahat

Angina dengan aktivitas

ALO Riwayat CVD

LBBB/RBBB baru Ada Q, ST depresi

ENZYME (+) Sedikit meningkat ENZYM (-)

MR ATAU S3 Baru,

HYPOTENSI, BRADIKARDI, TAKIKARDI. VT

Usia > 70 tahun

ST DEPRESI> 0.5 T inversi EKG TETAP

Prinsip Terapi

Cepat (time responsif), obati penyebab buka sumbatan

Terlambat: FatalMonitor ketat tanda vital sejak awalAntisipasi dini tanda tanda perburukan dan

komplikasi

Terapi Awal SKA

Atasi keadaan kegawat daruratan : Atasi keadaan kegawat daruratan : asistol, apney, syock, lung edema, asistol, apney, syock, lung edema, gagal jantung dll. gagal jantung dll.

Terapi reperfusi : PCI, Fibrinolitik, Terapi reperfusi : PCI, Fibrinolitik, heparinheparin

AntiischemicAntiischemicTerapi komorbid; hipertensi, DM, dllTerapi komorbid; hipertensi, DM, dll

Pentingnya Reperfusi

Sumbatan total15-30 menit tanpa kolateral IMA

Reperfusion selamatkan miorkardKematian1 bulan: 25-30% 4-6% dengan

reperfusi (PCI, fibrinolytic, antithombotic)

ESC AMI ST elevation guidelines 2008

Kerusakan Miokard IrreversibelKerusakan 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 muscleThe time is muscle

Terapi NSTEMI

O2O2 Bed restBed rest Pain killerPain killer Nitrate and anti-ischemiaNitrate and anti-ischemia Antiplatelet : Aspirin, ClopidogrelAntiplatelet : Aspirin, Clopidogrel HeparinHeparin HTNHTN Hyperglicemia Hyperglicemia Treat the complication etcTreat the complication etc

Terapi STEMI

O2 Bed rest Pain killer Nitrate and anti-ischemia Antiplatelet : Aspirin, Clopidogrel Fibrinolytic time to neddle : 30 m/PCI HTN Hyperglicemia Treat the complication etc

Fibrinolitik

Manfaat bila onset < 12 jam, optimal bila onset < 3 jam

Bila dikirim ke RS dengan PCI > 90 menit, fibrinolitik

Konsep baru : Fibrinolitik di Ambulan menuju RS Perhatikan kontraindikasi fibrinolitik Awasi ketat komplikasi fibrinolitik seperti

perdarahan, stroke, syok dll Perhatikan tanda tanda keberhasilan: nyeri

hilang, ST elevasi turun >50%, Junctional VES(+), bila gagal rescue PCI

Kontra Indikasi AbsolutKontra Indikasi Absolut

Any prior ICH Known structural cerebral vascular lesion (eg, AVM) Known malignant intracranial neoplasm (primary or

metastatic) Ischemic stroke within 3 months EXCEPT acute

ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within 3 months

Kontra Indikasi RelatifKontra Indikasi Relatif

History of chronic severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg

or DBP greater than 110 mm Hg)† History of prior ischemic stroke greater than 3 months, dementia, or known

intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less

than 3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior

allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

Treatment of STEMI Treatment of STEMI

Percutaneous Coronary Intervention

•Primary PCI : Pasien langsung di lakukan tindakan reperfusi dengan membuka sumbatan di arteri koroner tanpa dilakukan fibrinilotik terlebih dahulu•Rescue PCI : Dilakukan PCI setelah gagal dengan terapi fibrinolitik•Facilitated PCI : Pasien dilakukan fibrinolitik terlebih dahulu meskipun sudah ada rencana PCI •Urgent PCI: As soon as possible•Early PCI : Dalam waktu 24 jam pertama

Early/urgent PCI: Resiko tinggi, hemodinamik tidak stabil, aritmia maligna, angina (+) dgn terapi, EF <40%,Gagal jantung, Riwayat PCI, CABG dl 6 bl

Tim PCITim PCI

TargetTarget

1. Time to balloon : 90 m2. Yang dibuka hanya Culprit lesion (pembuluh darah tersumbat yang menyebabkan IMA kali ini) saja3. Aliran darah yang diintervensi kembali lancar

A 53 yo man reffered from a private A 53 yo man reffered from a private hospital for primary PCIhospital for primary PCI

A typical chest after exercise 2 hr prior to A typical chest after exercise 2 hr prior to admission admission

ECG send by faxECG send by faxPCI appointment via phonePCI appointment via phonePatient directly transfer red to cath labPatient directly transfer red to cath lab

Primary PCI Case

Komplikasi MI

MechanicalElectricalIschemiaEmbolicInflammation

Komplikasi Mekanik

Ventricular Septal RuptureMitral RegurgitationCardiac free wall ruptureLarge ventricular aneurysmsLV pump failure and cardiogenic shockDynamic LVOT obstructionRV failure

Gagal Jantung (Kriteria Framingham)

MajorMajor Acute pulmonary edemaAcute pulmonary edema PND or orthopneaPND or orthopnea CracklesCrackles S3 gallopS3 gallop HJR/Increased JVPHJR/Increased JVP CardiomegalyCardiomegaly Wt loss >4.5 kg 5d into Wt loss >4.5 kg 5d into

RxRx

MinorMinor Night coughNight cough Tachycardia >120Tachycardia >120 Pleural effusionPleural effusion HepatomegalyHepatomegaly Ankle edemaAnkle edema Vital capacity decrease Vital capacity decrease

>1/3 from max>1/3 from max

*Two major or one major and two minor*

SA Dysfunction Atrial FibrillationFirst-Second degree AV block Total AV Block Left Bundle Branch BlockRight Bundle Branch BlockVentricular TachycardiaVentricular Fibrillation

Komplikasi Elektrik

Perluasan InfarkPerluasan InfarkAngina Post-infarkAngina Post-infark

Komplikasi IschemikKomplikasi Ischemik

Systemic embolism ;

stroke, limb ischemia, renal infarction, intestinal ischemia

Komplikasi EmboliKomplikasi Emboli

Early PericarditisLate Pericarditis (Dresslers syndrome)

Komplikasi Inflamasi

Primary PCI Case

CASE 2CASE 2

CABGCABG

Failed PCI with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery.

Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, have a significant area of myocardium at risk, and are not candidates for PCI or fibrinolytic therapy.

At the time of surgical repair of postinfarction ventricular septal rupture (VSR) or mitral valve insufficiency.

CABGCABG

Cardiogenic shock in patients less than 75 years old with ST elevation, LBBB, or posterior MI who develop shock within 36 hours of STEMI, have severe multivessel or left main disease, and are suitable for revascularization that can be performed within 18 hours of shock

Life-threatening ventricular arrhythmias in the presence of greater than or equal to 50% left mainstenosis and/or triple-vessel disease.

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

Yang sering di lupakan…..

Edukasi pasien mengenai : Mengapa bisa sampai sakit….. Pola hidup Kepatuhan untuk merubah pola hidup Faktor resiko di kendalikan, rokok, HT, dll Kepatuhan minum obat Mencegah serangan jantung berikutnya

dengan…..merubah pola hidup, atur pola makan, olah raga teratur dan terukur

Reperfusi adalah awal dimulainya hidup baru …agar koroner tetap terbuka

SimpulanSimpulan

Tegakkan diagnosa dengan cepat dan tepat Tegakkan diagnosa dengan cepat dan tepat Terapi dengan cepat dan tepat : ReperfusiTerapi dengan cepat dan tepat : Reperfusi Monitor ketat Monitor ketat Cegah komplikasiCegah komplikasi Edukasi untuk prevensi dan rehabilitasiEdukasi untuk prevensi dan rehabilitasi

……..…….Kerja keras di awal……..…….Kerja keras di awal……

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