Acute Coronary

Syndrome
Sindroma Koroner Akut

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.
2

PATOGENESIS
Umumnya
disebabkan
aterosklerosis koroner

oleh

Plak
aterosklerosis
ruptur

terbentuk trombus diatas ateroma

yang secara akut menyumbat lumen
koroner
Apabila sumbatan terjadi secara total
hampir seluruh dinding ventrikel
akan nekrosis
3

Risk Factors
Uncontrollable
Sex
Hereditary

Controllable
High blood
pressure

Race

High blood
cholesterol

Age

Smoking
Physical activity
Obesity
Diabetes
Stress and anger

The cardiovascular continuum of events

Ischemia = oxygen supply
and demand imbalance
Myocardial
Ischemia

CAD

plaque
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)

Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

Coronary
Thrombosis
Myocardial
Ischemia

CAD
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)

Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

ACS
Coronary
Thrombosis
Myocardial
Ischemia

CAD
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)

Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263

Stable angina

Penyempitan
Pembuluh darah

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

Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes

NSTEMI
Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI

Complete thrombu
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto

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 > 35 tahun dan Wanita > 40
tahun
Seringkali disertai mual atau muntah, dapat pula
13
rasa tidak enak disertai sesak nafas, lemah,

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
14
atau wheezing yang menandakan terjadinya

Pain Patterns with Myocardial

Ischemia

15

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
16

PHYSICAL EXAMINATION
GENERAL APPEARANCE
Anxious, considerable distress,
(Levine sign)
LV failure & symp. stimulation :
dyspnea, cough with frothy
sputum.
Shock : cool, clammy skin,
confusion or disorientation

restless, fist on chest

cold perspiration, pallor,
pink or blood-streaked
facial pallor, cyanosis,

HEART RATE
Variable depending on underlying rhythm and degree or
ventr. failure
Most commonly, HR 100 110/min; > 95% patients :
VPBs within first 4 hours 17

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
18

JUGULAR VENOUS PULSE

JVP usually normal
RV infarction : marked jug. venous distension
CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction

19

CHEST
LV failure and/or LV compliance : moist rales
Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification
Class

: patients free of rales or S3

II

: rales < 50% lung fields +/- S3

III : rales > 50% lung fields, frequently

pulm. edema
IV : cardiogenic shock

20

Pemeriksaan Penunjang
Pemeriksaan EKG
Gambaran EKG infark miokard akut Q-wave
(STEMI) :
Elevasi segmen ST
sadapan extremitas

1 mm pada

Atau 2 mm pada 2 sadapan prekordial

yang berurutan
21
Atau gambaran LBBB baru atau diduga baru

ST-segment elevation

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

25

ST-segment depression

T-wave inversion

ELEKTROKARDIOGRAM
Current-of-injury patterns with acute
ischemia

28

 Pemeriksaan
jantung

Penanda

Jantung/Enzim

(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-Qwave (NSTEMI)

29

Plot of the appearance of cardiac markers in

blood versus time after onset of symptoms

A myoglobin
B troponin

C CK-MB
D troponin in UA

30

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
emboli, pleuritis

pneumotoraks,

6. Sindroma hiperventilasi
7. Gangguan dinding dada : muskuloskeletal,
neurogen
8. Psikogen

31

Manajemen

The cardiovascular continuum of events

ACS
Coronary
Thrombosis

Myocardial
Ischemia

CAD
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)

Arrhythmia and
Loss of Muscle
Remodeling

Ventricular
Dilatation
Congestive
Heart Failure
End-stage Heart
Disease
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263

DELAY TO THERAPY

1. From onset of symptoms to patient

recognition
2. Out-hospital transport

3. In-hospital evaluation

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of ischemia

ISCHEMIC CHEST PAIN

TYPICAL ANGINA

EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT

2. LOCATION

2. LOCATION

3. INDIGESTION

3. RADIATION

4. UNEXPLAINED WEAKNESS

4. UNLIKELINESS

5. DIAPORESIS
6. SHORTNESS OF BREATH

Acute coronary syndrome

algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min)

Immediate ED general treatment

Vital sign

O2 at 4 L/min (maintain O2 sat 90%)

Oxygen saturation

Aspirin 160-325 mg

Obtain IV access

Nitroglycerin SL, spray, or IV

Obtain ECG 12 lead

Morphine IV 2-4 mg repeated every

Brief history and physical exam

5-10 minutes (if pain not relieved

Check contraindication for fibrinolytic

with nitroglycerine)

Initial serum cardiac markers

Initial electrolyte and coagulation

Memory: MONA greets all patients

study
Portable chest x-ray ( 30 minutes)
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury (STEMI)

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury
(UA/NSTEMI)

Normal or nondiagnostic changes

in ST-segment or Twaves (intermediate/
low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury (STEMI)

ST-depression or
dynamic T-wave
inversion strongly
suspicious for injury
(UA/NSTEMI)

Normal or nondiagnostic changes

in ST-segment or Twaves (intermediate/
low-risk UA)

Start adjunctive treatment

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or dynamic
T-wave inversion strongly
suspicious for injury

Normal or nondiagnostic changes in

ST-segment or Twaves

Start adjunctive treatment

Time from onset of
symptoms
12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or dynamic
T-wave inversion strongly
suspicious for injury

Start adjunctive treatment

Start adjunctive treatment

Normal or nondiagnostic changes in

ST-segment or Twaves

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 2005;112 (Suppl):IV-90

Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors
-Adrenoreceptor blockers
Clopidogrel

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or dynamic
T-wave inversion strongly
suspicious for injury

Start adjunctive treatment

Start adjunctive treatment

Time from onset of

symptoms

12 hrs

Normal or nondiagnostic changes in

ST-segment or Twaves

Admit to monitored bed

Assess risk status

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

- High risk: early invasive

strategy
- Continue ASA, heparin,
ACE-I, statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

VERY HIGH-RISK PATIENT

1. Refractory chest pain
2. Recurrent/persistent ST
deviation
3. Ventricular tachycardia
4. Hemodynamic instability
5. Sign of pump failure
6. Shock within 48 hours
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

ST-depression or dynamic
T-wave inversion strongly
suspicious for injury

Normal or nondiagnostic changes in

ST-segment or Twaves

Start adjunctive treatment

Start adjunctive treatment

Develops high or
intermediate risk criteria
or troponin-positive

Time from onset of

symptoms

12 hrs

Admit to monitored bed

Assess risk status

Monitored bed in ED

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

- High risk: early invasive

strategy
- Continue ASA, heparin,
ACE-I, statin

Develops high or
intermediate risk criteria
or troponin-positive

No evidence of ischemia and MI: discharge with follow-up

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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 < 100 mg/dL
Pengendalian hipertensi
Pengendalian
ketat
gula
darah
pada
penderita DM

53

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.