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Acute Coronary Syndrome

BAGUS RAHMAT SANTOSO


Introduction

 Cause of Cardiac Arrest


 Life Threatening Condition
 Mortality rate 12.000.000 / year
 30% Mortality during first 2 hours from onset
 Six-month mortality rates in the Global
Registry of Acute Coronary Events (GRACE)
were 13% for patients with NSTEMI ACS and
8% for those with unstable angina.
Con’t

 Peringkat 9 penyebab kematian di


Indonesia (2007)
 Peringkat 1 penyebab kematian di rumah
sakit di Indonesia
 30 % kematian terjadi dalam 2 jam
perawatan
 Bisa menyebabkan Silent Infarct dan
Cardiac arrest
Karakteristik Pasien ACS di RSUD Ulin
Banjarmasin (APRIL – MEI 2015) Penyebab Mencari
Pertolongan

Persepsi Terhadap Penyebab Nyeri


30%
Dada

70%

Harus ditangani segera Perburukan Kondisi

100% Anjuran Orang Lain

Gambaran waktu untuk mengambil keputusan


(Menit)

Min Max Mean SD


Sakit Jantung masuk Angin Magis Jeda waktu serangan
sampai memutuskan 90 1440 432.8 486
mencari pertolongan
Definition

 Acute coronary syndrome (ACS) is conditions


compatible with acute myocardial ischemia and/or
infarction that are usually due to an abrupt reduction in
coronary blood flow
Terminology ACS:
1. STEMI
2. NSTEMI
3. Unstable angina
Acute Coronary Syndrome

http://www.nejm.org/doi/full/10.1056/NEJMra1216063
Sign & Symtoms

 Nyeridada yang khas (Cardiac


Chest Pain)
 Perubahan ECG : ST Deviasi
 Kenaikan enzim jantung
Cardiac Chest Pain

 Site : Retrosternal area – often qiute diffuse


 Onset : Usually rapid (over 5-10 menit)
 Character : Heavy, tight, band-like
 Radiation :To neck, jaw, left shoulder and arm
 Associated Symtom : Sweating, anxiety, pallor
 Time Course : MI usually result in pain lasting >30 minutes,
angina may resilt in briefer episodes
 Exacerbating / Relieving factors : Angina ussually
exacerbated by exertion, relieves by rest or GTN, MI pain
usually only relieved by opiate analgesia
 Severity : MI pain usually very severe
ECG
Cardiac Enzim

 CKMB
 Troponin
Acute Coronary Syndrome
Chest Pain

ECG Changes

Yes No

ST Elevasi ST Depression / T Inversion Normal ECG

Cardiac Marker Cardiac Enzim


Cardiac Enzim Rise
Normal

STEMI NSTEMI UNSTABLE ANGINA


Primary Goal Theraphy

 Reduce the amount of myocardial


necrosis
 PreventMACE : Death, MI 
revascularization immediatly
 Preserving Left Ventricular Function
 Threatlife threatening conditions (such as
VT, VF, Ect)
Robert E. O'Connor et al. Circulation. 2010;122:S787-S817
Treatment

Prehospital
Rumah sakit
IGD
Perawatan lanjut
Prehospital Management of Acute
coronary Syndrome
EMS Triage &
Early
Assessment Hospital
Recognition
& Care Destination

Patient &First
Monitoring
Responder
Health care
Treatment
provider

Prehospital ECG

Fibrinolitic
Cheklist
Improving System Care of Acute
Coronary Syndrome

Sanford Health
Early Recognition of ACS
Focused History and Physical Exam

 Chest discomfort
Don’t
 Spread to Arms, Soulders, neck, Forget
jaw, back, or upper abdomen

 Shortness of breath

 Chest discomfort

 Cool, clammy skin

 Nausea
Call for Help
911
 Lightheadedness

Advanced Cardiovascular Life Support American Heart Association (2010)


EMS Assessment, Care, and
Hospital Preparation
Instruction & Treatment  Vital sign and cardiac
rhythm
Monitor and support ABC
 Prepare to Provide
CPR (30:2)
 Using a defibrillator
Administer Aspirin, O2, Nitroglicerin if needed
and Morfine (MONA)

Obtain a 12-lead ECG

Complete a fibrinolytic checklist

Notify Hospital
Prehospital Triage & Hospital
Destination
 Direct triage from the scene to a PCI capable hospital
may reduce the time to definitive therapy and improve
outcome
 Mortality rate ACS Patient was significantly reduced
(8.9% versus 1.9%) when transport time was less than 30
minutes.
 Fibrinolytic therapy is recommended if patient arrived in
2 hours since sign and symptoms are appear

Robert E. O'Connor et al. Circulation. 2010;122:S787-S817


Kapan PCI lebih diutamakan
daripada fibrinolitik ?
 The ability to perform PCI within 90 minute from
presentation to hospital
 The presence of Q wave on initial ECG
 Time to presentation >3 hours
 Cardiogenic shock
 Severe heart failure
 Contraindication to thrombolisis
 Doubt about diagnosis of STEMI
PCI
Robert E. O'Connor et al. Circulation. 2010;122:S787-S817
Kontraindikasi Trombolitik

 Stroke
 Ada riwayat trauma mayor/bedah/luka kepala
dalam 3 minggu
 Perdarahan Gastro Intestinal dalam 1 bulan
terakhir
 Kelainan darah
 Dissecting aneurisma
Kontraindikasi relatif

 Serangan iskemia transient dalam 6 bulan


terakhir
 Terapi coumadin/walfarin
 Kehamilan
 Puncture atau kebocoran yang tidak bisa
ditekan saja
 Resusitasi trauma
 Hipertensi refrakter (sistolik>180mmHg)
 Riwayat terapi laser retina.
Fase perawatan lanjut

 12 - 24 jam setelah serangan, pasien harus


diobservasi di ruang perawatan intensif:
 cardiac monitor
 Tanpa komplikasi, pasien boleh duduk pada hari
pertama. Hari kedua, pasien bisa berjalan 200 m
Komplikasi

Syok kardiogenik
Cardiac arrest
Gagal jantung
Ruptur muskulus papilaris
Aritmia
Edukasi pada saat pemulangan

 Cemas
 Merubah kebiasaan buruk
 Terapi antiplatelet: aspirin 165 mg PO /
hari