ACUTE CORONARY SYNDORME

STEMI

DIAGNOSIS AND MANAGEMENT

Dr.Afdhalun Hakim
,SpJP,FIHA,FAsCC
Acute Coronary Syndrome
Definisi
Pengertian SKA merujuk pada sekumpulan
keluhan dan tanda klinis yang sesuai
dengan iskemia miokardium akut.
Sindrom koroner akut merupakan suatu spektrum
dalam perjalanan penderita penyakit jantung

koroner (aterosklerosis koroner). SKA

dapat berupa angina pektoris tidak stabil, infark

miokard dengan non-ST elevasi, infark miokard

dengan ST elevasi dan atau kematian jantung
mendadak.

 SPEKTRUM ACS
AMI (ACS STEMI)
UAP
ACS NSTEMI
SUDDENT CARDIAC DEATH
Acute Coronary Syndrome
ACS STEMI (AMI)

ACS NSTEMI (UAP/ACUTE NON Q MI)

ACS STEMI/ AMI
 EPIDEMIOLOGY
ACS NSTEMI > STEMI
HOSPITAL MORTALITY STEMI > NSTEMI
(7 % VS 5 % )
6 BULAN MORTALITY EQUAL (12 VS 13
%)
LONG TERM FOLLOW UP MORTALITY
NSTEMI > STEMI
PENYEBAB UTAMA KEMATIAN KV
PATOFISIOLOGY
PATOFISIOLOGY
 DIAGNOSIS
SYMPTOM (TYPICAL CHEST PAIN)

ECG CHANGES (ST ELEVATION/NEW LBBB

OR ST DEPRESSION/T INVERTED/FLAT)

CARDIAC MARKER (ENZYME)

 Assessing Chest pain
Character
Time of onset, duration, frequency
Changes in tempo
Exacerbating and alleviating factors
Pain during situation associated with
increased myocardial O2 demand ( e.g.
exertion, stress )
Angina

Levine Sign
 ECG
ST ELEVATION

NEW LBBB
BIOMARKER (CARDIAC ENZYME)

CK-MB
TROP-T/I
MYOGLOBIN
 TIMI Risk Score for
UA / NSTEMI

HISTORICAL POINTS RISK OF CARDIAC EVENTS (%)

Age 65 1 BY 14 DAYS IN TIMI 11B*
RISK DEATH DEATH, MI OR
3 CAD risk factors
(FHx, HTN, chol, DM, active smoker) 1 SCORE OR MI URGENT REVASC

Known CAD (stenosis 50%) 1 0/1 3 5

ASA use in past 7 days 1 2 3 8
PRESENTATION 3 5 13
Recent ( 24H) severe angina 1 4 7 20
cardiac markers 1 5 12 26
ST deviation 0.5 mm 1 6/7 19 41
RISK SCORE = Total Points (0 - 7)
*Entry criteria:UA or NSTEMI defined as ischemic pain
Low = 0-2 points, Medium = 3-4 points
at rest within past 24H, with evidence of CAD (ST segment
High = 5-7 points deviation or +marker)
Antman et al JAMA 2000; 284: 835 -
ISIKO TINGGI

ekurang-kurangnya 1 dari berikut hasus ada:

. Anamnesis
Simtom nyeri dada iskemik meningkat cepat
dalam 46 jam terakhir
Prolonged rest pain (berlangsung >20 min)
. Temuan klinis
Tanda edema paru
S3 atau rhpnki baru / bertambah
Hypotensi,bradikardia,takicardia
Usia > 75 yrs
. ECG
Angina waktu istirahat dgn perubahan transien segm ST
>0.05 mV,BBB (baru a diperkirakan baru ),Sustained VT
. Cardiac markers : kenaikanTnT or TnI >0.1ng/ml
MANAGEMENT
 PRE HOSPITAL
MANAGEMENT
SYMPTOMS COMPATIBLE
WITH STEMI

PREHOSP
D/,TRIAGE GP/CARDIO
EMS SELF DECISION
AND CARE LOGIST

PRIVATE PRIVATE
AMBULANCE TRANSPORT TRANSPORT

PCI CAPABLE NONPCI CAPABLE

HOSPITAL HOSPITAL
MANAGEMEN EARLY HOSPITAL
O 2 ( 4 L/M, NASAL KANUL)
ASPIRIN 160-325 MG CHEWING
NITRAT SL/IV
ISDN 5 MG SL (3X)
NITRAT IV (INITIAL DOSE : 10 MCG/M
>>200 MCG/M)
MORPHINE SULPHATE (2,5-5 MG IV)
CLOPIDOGREL (LOADING DOSES 300 MG)
 MANAGEMENT
FOR STEMI ( ST ELEVATION/NEW LBBB)
ONSET <12 JAM :
PCI

PHARMACOLOGIST

REPERFUSION(TROMBOLYSIS)

PCI 2 JAM FMC (FIRST MEDICAL

CONTAC) FOR PTS LARGE AMOUNT
MYOCARDIAL RISK DELAY < 90 MIN
 TROMBOLISIS
INDIKASI :
ACS STEMI
ONSET < 12 JAM

KONTRA INDIKASI ABSOLUT

:
STROKE HEMORAGIK KAPAN PUN
STROKE NH <3 BLN>3 JAM
DISEKSI AORTA
ACTIVE INTEERNAL BLEEDING
TRAUMA KEPALA TERTUTUP/WAJAH < 3 BLN
TUMOR CEREBRI/AV MALFORMATION
 Trombolisis Terapi
Streptokinase
Dosis : 1,5 Juta IU (+ Dx 5%/NaCl 100
cc/30-60 min)
Kabikinase
Ateleptase
rTPA
Dosis : bolus 15 mg IV, 0,75 mg/Kg
BB/30,kmd 0,5 mg/KgBB/60 min (dosis
total tidak lebih 100 mg)
 PCI
DOOR TO BALLON < 90 MENIT
RS DENGAN FASSILITAS PCI DAN TENAGA
SKILL
 KOMPLIKASI
CARDIAC ARREST ( EC VT/VF)
SHOCK CARDIOGENIC
HF
AV BLOCK
MECHANICAL RUPTUR
(VSD/MR/TAMPONADE)
CARDIAC ARREST
NEW GUIDELINES CPR AHA 2010
BLS
FROM
SAFETY TO
RESPONSE SAFETY
A RESPONSE/GASPIN
B G
C
C
A
D
B

D
cpr aha 2010.htm
BRADICARDIA/AV
BLOCK
TPM (TEMPORARY
PACEMAKER)
BRADIARITMIA AND
PACEMAKER
Pemasangan TPM
PPM
RSOB OK !!!!

RSOB OK !
Arigato Gozaimaz