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of myocardial ischemia that ranges from unstable angina at one end of the spectrum to nonST segment elevation myocardial infarction (MI) at the other end. Unstable angina is distinguished from stable angina by the new onset or worsening of symptoms in the previous 60 days or by the development of post-MI angina 24 hours or more after the onset of MI. When the clinical picture of unstable angina is accompanied by elevated markers of myocardial injury, such as troponins or cardiac isoenzymes, nonST segment elevation MI is diagnosed. The distinction between nonST segment elevation MI and MI with ST segment elevation is clinically important because acute recanalization therapy is critical for improving the outcome in ST elevation MI but is less urgent in nonST segment elevation MI.
Definition
Myocardial infarction (MI) is myocardial necrosis
caused by ischemia. Practically, MI can be diagnosed and evaluated by clinical, electrocardiographic, biochemical, radiologic, and pathologic methods.
SINDROMA KORONER AKUT spektrum sindrom klinis yang mencakup angina tak stabil sampai ke non ST elevasi MI dan ST elevasi MI
No ST Elevation
ST Elevation
NSTEMI
Unstable Angina
Angina Stabil Angina Tidak stabil Infark Miokard Akut Kematian Gagal Jantung
Normal
Fatty Streak
Fibrous Plaque
Clinically Silent
Cardiovascular Death
Increasing Age
3
Pathway to Thrombosis
Faktor predisposisi
faktor yang memperbesar risiko PJK akibat faktor risiko yang kausal 1.Obesitas (BMI >25 Kg/m2) 2.Obesitas abdominal (lingkar pinggang >94cm(pria)>80cm(wanita); waist-hip ratio>0,9(pria) dan >0,8 (wanita) 3.Sedentary 4.Riwayat keluarga terkena PJK usia muda (pria:<55 thn, wanita:<65 thn) 5.Etnik tertentu 6.Psikososial
Pedoman tata laksana SKA dengan ST elevasi , PERKI 2004
KELUHAN UTAMA: Sakit dada atau nyeri ulu hati yang berat, asalnya nontraumatik, dengan ciri-ciri tipikal iskemia miokard atau infark:
Dada bgn tengah/substernal rasa tertekan atau sakit seperti diremas Rasa sesak, berat/tertimpa beban , mencengkeram, terbakar,sakit Penjalaran ke leher, rahang, bahu, punggung atau 1 atau ke 2 lengan Disertai sesak Disertai mual dan/atau muntah Disertai berkeringat
Start ECG
Gastrointestinal :
Reflux esofagus Ruptur esofagus Penyakit kel empedu Ulkus peptikum Pankreatitis
Vaskuler
Paru :
NYERI KARDIAK :
Tidak berhubungan dengan gerakan respirasi dan batuk Tidak berhubungan dengan posisi dan gerakan tubuh Tidak berhubungan dengan kondisi lain seperti herpes zoster, trauma, dll
ANGINA PEKTORIS
Sifat & kualitas Lokasi Penjalaran Durasi Gejala dan tanda klinis yang menyertainya
atau rasa tidak enak sewaktu adanya beban (aktivitas, beban mental) dimana kebutuhan miokardium tidak dapat dipenuhi dengan suplai yang cukup. Angina Stabil dapat diprediksi dan dapat hilang atau berkurang dengan istirahat dan nitrogliserin.
ST elevation in leads II, III, aVF, V5, and V6 with precordial ST depression
Early repolarization
Unstable angina
Elevasi seg ST
Observasi EKG serial Ulang petanda 6-12 jam stlh onset nyeri dada*
Perubahan seg ST Petanda (+) Nyeri dada menetap
APTS/NSTEMI
ST Elevasi = STEMI
> 0.1 mV pd > 2 sadapan ekstrimitas yang bersebelahan dan/atau > 0,2 mV pd > 2 sadapan prekordial yang bersebelahan atau LBBB baru (yang dianggap baru)
High Risk (Risiko Tinggi) -Perubahan EKG yang dinamis meliputi ST depresi - hemodinamik -irama yang tidak stabil (aritmia malignan) - diabetes melitus = Non STEMI, jika nilai troponin positif (T atau I) Low Risk (Risiko rendah) Tidak ada tanda-tanda high risk = UAP , jika nilai troponin negatif
EKG
Atasi Nyeri : Nitrogliserin 0,4 mg (max 1,2 mg) SL bila TD > 90 mmHg + morfin (dapat di ulang) 3-6 mg sampai nyeri teratasi
STEMI
NSTEMI-UAP
Early invasive strategy UFH (target aPTT 50-70 det) Gp IIbIIIa inhibitor utk pasien risiko tinggi
Konsevatif atau delayed invasive strategy UFH atau LMWH (enoxaparin) Pertimbangkan tirofiban atau eptifibated
Lebih memilih Fibrinolitik bila: Tdk ada kontra indikasi dan PCI menunggu > 90 menit Onset gejala < 3 jam dan PCI menunggu > 60 menit Terapi adjuvan : UFH,LMWH pada pasien < 75 tahun
Nilai dan tatalaksana segera (<10 menit) Monitor EKG Akses IV Saturasi O2 EKG 12 Sadapan Riwayat Penyakit Kontra indikasi trombolitik Foto Rho Thorax
Pengobatan segera: O2 4 L/menit Aspirin 160-325 mg Nitrogliserin SL atau spray Morphin IV (bila sakit dada tidak hilang dgn nitrogliserin) Ingat : MONA
Elevasi ST atau BBB Baru Pertimbangkan pemberian: Penyekat beta IV Nitrogliserin IV Heparin IV Penghambat ACE (sesuai indikasi tanpa menunda trmbolitik)
Terapi trombolitik : pilih jenis Tak ada kontra indikasi Atau alternatif ekuivalen PTCA primer
Pasien risiko tinggi Gejala menetap Iskemia berulang Penurunan fungsi ventrikel kiri Perubahan EKG luas Baru mengalami IMA, PTCA, CABG
Tdk
Ya
Nilai dan tatalaksana segera (<10 menit) Monitor EKG Akses IV Saturasi O2 EKG 12 Sadapan Riwayat Penyakit Kontra indikasi trombolitik Foto Rho Thorax
Pengobatan segera: O2 4 L/menit Aspirin 160-325 mg Nitrogliserin SL atau spray Morphin IV (bila sakit dada tidak hilang dgn nitrogliserin) Ingat : MONA
Pertimbangkan pemberian: Penyekat beta IV Nitrogliserin IV Heparin IV Penghambat ACE (sesuai indikasi tanpa menunda trmbolitik)
Kriteria ATS ?
Tdk
Nilai status klinis Pertimbangkan : Unit ED sakit dada Serum serial EKG serial Echo/radionuklir Pasien risiko tinggi Gejala menetap Iskemia berulang Penurunan fungsi ventrikel kiri Perubahan EKG luas Baru mengalami IMA, PTCA, CABG Klinis stabil
PTCA primer
Ya
Tdk Adakah iskemia/ Infark > 8-12 jam ?
Tdk ICCU : Terapi sesuai indikasi Serum serial EKG serial Echo/radionuklir
PTCA: waktu tiba-lab:< 60 mnt Revaskularisasi PTCA CABG Boleh Rawat jalan & kontrol teratur
TERAPI PADA SINDROMA KORONER AKUT PERAWATAN DI RUMAH SAKIT 1.Pain killer (morfin) 2.Suplemen O2 M 3.Terapi anti iskemia O Nitrat Beta Bloker N CCB A 4.Antiplatelet dan antikoagulan Aspirin,Ticlopidine, Clopidogrel Heparin atau Low Molecular Weight Heparin Tranquilizer 5.Fibrinolisis ( pada infark miokard dengan elevasi ST) 6. Revaskularisasi koroner Tata laksana pasca perawatan di rumah sakit
pemakaian secara IV Berkaitan dengan kejadian perdarahan yang kecil, namun bukan perdarahan besar Stimulasi trombosit kurang dari UFH dan jarang menimbulkan HIT (Heparin induced thrombocytopenia) Penghematan biaya perawatan (dari studi ESSENCE)
UFH
Initial I.V BOLUS 60 UI/Kg max 4000 UI Infus :12-15 UI/kg BB/jam max 1000 UI/jam Monitor APTT : 3, 6, 12, 24 jam setelah mulai
TERAPI FIBRINOLITIK
Fibrinolitik : Indikasi
Sakit dada khas IMA 12 jam EKG : 1 mm elevasi seg ST pada 2 sandapan yg
bersebelahan 2mm elevasi seg ST pada 2 sandapan prekordial Bundle branch block yg baru Syok kardiogenik pd IMA ( bila kateterisasi dan revaskularisasi tdk dapat dilakukan ) Fibrinolitik door to needle time < 30 menit !! PCI pada IMA lebih unggul bila dpt dilakukan dlm 90 30 menit
iskemik dengan onset < 3 jam Neoplasma intrakranial Perdarahan internal aktif(tidak termasuk menstruasi) Kecurigaan suatu diseksi aorta Luka kepala tertutup yg signifikan atau trauma facial dalam 3 bulan Kelainan struktural atau pembuluh darah cerebral
ACC/AHA guideline of STEMI 2004
Streptokinase ( Streptase )
1.5 million Unit in 100 ml D5W or 0.9% saline selama 30-60 mnt without heparin : Inferior MI with heparin : anterior MI tPA 15 mg IV bolus kemudian 0.75 mg/Kg selama 30 mnt,dilanjutkan 0.5 mg/Kg selama 60 mnt berikutnya
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Secondary Prevention
Ask, advise, assess, and assist patients to stop
Statin goal: LDL-C < 100 mg/dL I (A) consider LDL-C < 70 mg/dL IIa (A) Daily physical activity 30 min 7 d/wk, minimum 5
Class I Recommendations
Status of tobacco use should be asked at every visit. Every tobacco user and family member who smoke should be advised to quit at every visit. The tobacco users willingness to quit should NEW be assessed. The tobacco user should be assisted by counseling and developing a plan for quitting. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological rx) should be arranged. Exposure to environmental tobacco smoke at home and work should be avoided. NEW
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Class I Recommendations
If blood pressure is 140/90 mm Hg or 130/80 mm Hg for patients with chronic kidney disease or diabetes: It is recommended to initiate or maintain lifestyle modification (weight control, physical activity, alcohol moderation, sodium , and emphasis on consumption of fresh fruits, vegetables, and low-fat dairy products). It is useful as tolerated, to add blood pressure medication, treating initially with beta-blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal BP.
CHANGED TEXT
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Class I Recommendations
Starting dietary therapy in all patients is recommended. intake of sat. fats (< 7% of total calories), trans fatty acids and cholesterol (< 200 mg/d).
Adding plant stanol/sterols (2 g/d) and/or viscous fiber (> 10 g/d) is reasonable to further lower LDL-C. (Class IIa; LOE:A)
NEW
Promotion of daily physical activity and weight management is recommended. It may be reasonable to encourage consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction. For treatment of elevated TG, higher doses are usually necessary for risk reduction. (Class IIb; LOE: B)
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Lipid A fasting lipid profile should be assessed in all patients management: and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized 2007 goal: patients, initiation of lipid-lowering medication is indicated LDL-C << than as recommended below before discharge according to 100 mg/dL (if TG the following schedule: 200 mg/dL, nonHDL-C < 130 LDL-C should be < 100 mg/dL. mg/dL Further reduction to < 70 mg /dL is reasonable. (Class
IIa; LOE: A) NEW If baseline LDL-C is 100 mg/dL, LDL-lowering drug rx should be initiated. If on-treatment LDL-C is 100 mg/dL intensify LDLlowering drug rx (may require LDL-lowering combination is recommended. If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C < 70 mg/dL. (Class IIa; LOE: B)
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NEW
Class I Recommendations
If TG are 150 mg per dL or HDL-C < 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. If TGs are 200 to 499 mg per dL, nonHDL-C target should be less than 130 mg per dL. If TGs are 200 to 499 mg/dL, nonHDL-C target is < 130 mg/dL. (Class I; LOE: B); further reduction of nonHDL-C to < 100 mg dL is reasonable. (Class IIa; LOE: B)
NEW Therapeutic options to reduce nonHDL-C include: More intense LDL-C-lowering rx is indicated Niacin (after LDL-C-lowering rx) can be beneficial (Class IIa; LOE B) Fibrate therapy (after LDL-C-lowering rx) can be beneficial (Class IIa; LOE B)
If TG are 500 mg/dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering rx; and treat LDL-C to goal after TGlowering rx. Achieving nonHDL-C < 130 mg/dL is recommended.
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Class I Recommendations
For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription.
For all patients, encouraging 30 to 60 min of moderateintensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).
Advising medical supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, HF) is recommended.
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NEW
Encouraging resistance training 2 d per week may be reasonable (Class IIb; LOE: C)
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Class I Recommendations
It is recommended to initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c. Beginning vigorous modification of other risk factors (e.g., physical activity, weight management, BP control, and cholesterol management as recommended above) is beneficial.
Coordination of diabetic care with patients primary care physician or endocrinologist is beneficial. NEW
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Antiplatelet agents/ For all post-PCI STEMI stented patients anticoagulants: without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162 to 325 mg daily Aspirin
should be given for at least 1 month after baremetal stent implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 to 162 mg daily.
CHANGED TEXT
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NEW REC
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For all post-PCI patients who receive a drug-eluting stent (DES), clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a bare metal stent (BMS), clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).
CHANGED TEXT
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For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 d. (Class I; LOE: B)
Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (Class IIa; LOE: C)
NEW RECS
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Class I Recommendations
Managing warfarin to INR = 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-STEMI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). CHANGED
TEXT
Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2 to 2.5 is recommended with low dose aspirin (75 to 81 mg) and a 75 mg dose of clopidogrel.
NEW REC
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NEW REC
At the time of preparation for hospital discharge, the patients need for treatment of chronic musculoskeletal discomfort should be assessed and a stepped care approach to pain management should be used for selection of treatments. Pain relief should begin with acetaminophen or aspirin, small doses of narcotics, or non-acetylated salicylates.
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NEW REC
It is reasonable to use non-selective NSAIDs such as naproxen if initial therapy with acetaminophen, small doses of narcotics, or non-acetylated salicylates is insufficient.
NEW REC
situations where intolerable discomfort persists despite attempts at stepped care therapy with acetaminophen, small doses of narcotics, nonacetylated salicylates, or non-selective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. NSAIDs with increasing degrees of relative COX-2 selectivity should not be administered to STEMI patients with chronic musculoskeletal discomfort when therapy with acetaminophen, small doses of narcotics, non-acetylated salicylates, or nonselective NSAIDs provides acceptable levels of pain relief.
CHANGED TEXT
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Stepped Care Approach To Pharmacologic Therapy for Musculoskeletal Symptoms with Known Cardiovascular Disease or Risk Factors for Ischemic Heart Disease Acetaminophen, ASA, tramadol, narcotic analgesics (short term) Nonacetylated salicylates Non COX-2 selective NSAIDs NSAIDs with some COX-2 activity
Regular monitoring for sustained hypertension or worsening of prior blood pressure control), edema, worsening renal function, or gastrointestinal bleeding. If these events occur, consider reduction of the dose or discontinuation of the offending drug, a different drug, or alternative therapeutic modalities, as dictated by clinical circumstances.
Select patients at low risk of thrombotic events Prescribe lowest dose required to control symptoms Add ASA 81 mg and PPI to patients at increased risk of thrombotic events *
* Addition of ASA may not be sufficient protection against thrombotic events 89 Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print
Class I Recommendations
ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. CHANGED
TEXT
ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Class IIa; LOE: B)
NEW REC
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Class I Recommendations
Use of ARBs is recommended in patients who are intolerant of ACE inhibitors and have HF or have had a STEMI with LVEF 40%. CHANGED
TEXT
It is beneficial to use ARB therapy in other patients who are ACE-inhibitor intolerant and have hypertension.
NEW REC
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Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable.
Class I Recommendations
Use of aldosterone blockade in post-STEMI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of 40% and have either diabetes or HF.
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Goals BetaBlockers
Class I Recommendations It is beneficial to start and continue betablocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without HF symptoms, unless contraindicated.
CHANGED TEXT
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Class I Recommendations
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TERIMA KASIH