Coronary Heart

Disease
dr Muhamad Taufik Ismail Sp.JP
Definition

• Coronary heart disease (CHD) describes heart disease

caused by impaired coronary blood flow.
• In most cases, CHD is caused by atherosclerosis.
• Diseases of the coronary arteries can cause:
• angina, myocardial infarction or heart attack,
• cardiac dysrhythmias, conduction defects,
• heart failure, and
• sudden death.
• During the past 50 years, there have been phenomenal
advances in understanding the pathogenesis of CHD and in
the development of diagnostic techniques and treatment
methods for disease.
• However, declines in morbidity and mortality have failed to
keep pace with these scientific advances, probably
because many of the outcomes are more dependent on
lifestyle factors and age than on scientific advances.
Epidemiology: Top 10 Diseases in
Sardjito Hospital Yogyakarta
(January-April 2013)
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Epidemiology – sudden death
Epidemiology – sudden death
Epidemiology in Indonesia
Epidemiology in Indonesia
 Anatomy

Left Main CA Layers of the Arterial Wall

Circumflex

Adventitia
Media
Intima

Right CA Intima composed of

Marginal Branch endothelial cells
Pathogenesis
Pathogenesis
Critical factors in meeting cellular
demands for oxygen are:

the rate of coronary perfusion the myocardial workload

can be impaired in next ways depends on

Large, stable Vasospasm Heart rate

atherosclerotic plaque
Preload
Acute platelet aggregation Poor perfusion
and thrombosis pressure Afterload

Failure of autoregulation Contractility

by the microcirculation
MI type
 Type of CHD
Coronary heart disease

Chronic ischemic heart disease Acute coronary syndrome

Stable Variant No ST-segment ST-segment

angina angina elevation elevation

Microvascular angina Unstable Q-wave

angina AMI

Non-ST-segment
elevation AMI
Stable angina
• Clinical syndrome characterized by
1. discomfort (pressure, tightness, or heaviness, sometimes
strangling, constricting, or burning) no more than 10 minutes in
the chest, jaw, shoulder, back, or arms,
2. typically elicited by exertion or emotional stress and
3. relieved by rest or nitroglycerin.
• Less typically, discomfort may occur in the epigastric area.
• The most common cause of myocardial ischaemia is
atherosclerotic, but may be induced by hypertrophic or
dilated cardiomyopathy, or aortic stenosis
Variant angina (Prinzmetal)

• Caused by abnormal vasospasm of normal vessels

(15%) or near atherosclerotic narrowing (85%)
• Occurs unpredictably and almost exclusively at
rest.
• Often occurs at night during REM sleep
• May result from hyperactivity of sympathetic
nervous system, increased calcium flux in muscle or
impaired production of prostaglandin
• Vasoconstriction is due to platelet thromboxane A2
or an increase in endothelin
Microvascular angina

Characteristics:
1. Typical exercise-induced angina (with or without
additional resting angina & dyspnoea)
2. Positive exercise stress ECG or other stress
imaging modality
3. Normal coronary arteries
Dx: Normal or non-obstructed coronary arteries
by arteriography but objective signs of exercise-
induced ischaemia (ST-depression in exercise
ECG, ischaemic changes by scintigraphy).
ACS Acute Coronary Syndrome 17

1 2
Non STEMI STEMI

3
Unstable Angina Pectoris
(UAP)

Non Q MI Q MI
ACS

• Unstable angina = sudden worsening of angina

symptoms, which become more frequent,
more prolonged, and more severe and/or
occur at a lower threshold or at rest.
• MI = prolonged angina (>30 min) associated
with myocardial necrosis.
• The common pathological background of ACS is
erosion, fissure, or rupture of an
atherosclerotic coronary plaque
 Diagnosis ACS

Diagnosis UAP STEMI Non STEMI

1. Nyeri Dada < 15 Menit > 15 Menit >15 Menit
Angina
2. EKG Normal ST Elevasi Normal
ST Depresi ST Depresi
T Inversi T Inversi

3. Enzym
19 Normal Meningkat Meningkat
1. Nyeri Dada Kardial / Angina

 Lokasi: Di Dada Kiri / Sub Sternal

 Sifat:
- Seperti Ditusuk / Diremas-remas
- Ada Beban Yang Berat / Menindih
- Rasa Terbakar
- Rasa Tercekik
- Nyeri Epigastrium
 Penjalaran: Ke Lengan Kiri, Leher, rahang
 Diperberat Emosi, Aktifitas Fisik
 Membaik dengan nitrat
21
 2. Perubahan EKG
ELEKTROKARDIOGRAFI

Segmen ST
 ST (J point) Elevasi  minimal 2 lead berdekatan
≥ 2 mv di lead V2 dan V3 (laki2 ≥40 th)
≥ 2,5 mv di lead V2 dan V3 (laki2 <40 th)
≥ 1,5 mv di lead V2 dan V3 (wanita)
≥ 1mv di lead lain

 Depresi ST (J point)  minimal 2 lead berdekatan

 ≥ 0,5 mV di V2 dan V3, ≥ 1 mV di lead lain
 Bila disertai angina, ST depresi ≥ 0,5 mV atau T inversi
dinamis (>0,2 mv)
GAMBARAN EKG PADA IMA

23
DIAGNOSIS BANDING

24
3. Enzim Jantung

• CKMB Enzym Meningkat Puncak Normal

36 – 48 Jam
• Troponin I CKMB 6 Jam 24 Jam
GOT 6 -8 Jam 36 – 48 Jam 48 – 96 Jam
• SGOT
LDH 24 Jam 48 – 72 Jam 7 – 10 Hari
• LDH Troponin T 3 Jam 12 – 24 Jam 7 - 10 Hari
Troponin I 3 Jam 12 – 24 Jam 7 - 14 Hari

Bila Ada 2 dari 3

1. Angina
2. Perubahan EKG
3. Peningkatan Enzim Jantung SKA / ACS
 Faktor Risiko

Dikendalikan: Tak dpt Dikendalikan:

• Diabetes Mellitus • Seks
• Hipertensi Laki-laki > 40 th Th
• Dislipidemi Wanita Menopause
• Perokok • Keturunan
• Obesitas
• Olah raga

26
Anamnesis dan Pemeriksaan
Schnohr et al., 2002
28
29
31
37
38
Penatalaksanaan SKA
MONA – CO :
• Morphin  2,5-5 mg sc.iv, tiap 5-15 menit
atau pethidin  25-50 mg iv, tiap 15-30
menit
• Oksigen  4 l / menit jika sat.O2 <95%, sesak nafas,
gagal jantung
• Nitrat  S.L., Spray, iv (bila ada edema paru/nyeri
dada menetap.
• Aspirin  mula-mula 160-325 mg dikunyah
dilanjutkan 80-160 mg /hari

• Clopidogrel  300 mg loading dose, dilanjutkan 75

mg /hari
Penatalaksanaan - lainnya

STEMI Onset < 12Jam :

 Tindakan reperfusi :
a. Trombolitik terapi : Streptokinase, TPA
b. PCI primer bila :
- ada kontraindikasi trombolitik TX
- pasien dengan syok kardiogenik, AHF
- fasilitas ada

Obat medikamentaosa lain (Non STEMI, UAP, STEMI)

 Antiplatelet, Penyekat beta
 ACE inhibitor, statin
 Antikoagulan (Heparin, LMWH)
 PCI
 Obat dihindari: NSAID
Algoritma penanganan STEMI
Indikasi angiografi/ PCI pada UAP/STEMI

Immediate(<2 jam) utk very high risk:

 Hemodinamik tidak stabil atau syok kardiogenik, nyeri dada berulang
atau menetap refrakter thd obat yg diberikan, aritmia mengancam
jiwa atau henti jantung, komplikasi mekanik, gagal jantung akut,
perubahan segmen ST-T berulang terutama dengan intermittent ST-
elevation
Early invasive strategy (<24 jam), utk high risk
 Peningkatan atau penurunan troponin khas AMI, Perubahan dinamis
segmen ST-T, GRACE score >140
Invasive strategy (dalam 72 jam), utk intermediate
 DM, RF (eGFR <60 mL/min/1.73 m²), ↓ fungsi LV (EF fraction
<40%), Angina pasca recent MCI, Riwayat PCI/ CABG, GRACE
risk score >109 and <140
GRACE Score

Low ≤ 108; Intermediate 109-140; High >140

Kondisi khusus

STEMI yang akan dilakukan fibrinolitik pada usia >75th

 loading clopidogreal hanya 75 mg.
DM  dipertahankan GDS 90-180 mg/dL
Gagal ginjal  fondaparinux KI pada CCT <20 mL/min
Anemia  tunda transfusi apabila hemodinamik stabil
sampai Hb <7 g/dL atau Hct <25%
HIT  ↓ AT 50% atau AT <100.000/uL
Komplikasi

Aritmia
Disfungsi ventrikel kiri / Gagal
Jantung
Hipotensi / Syok Kardiogenik
Lain-lain:
Emboli Paru Dan Infark Paru
Emboli Arteri Sistemik
Stroke Emboli
Ruptur Jantung
45 Disfungsi & Ruptur m. Papilaris