Acute Coronary

Syndromes
&
Practice ECG
Wayan Sutarmawan
BRSUD Tabanan
 Acute Coronary Syndrome
Definition: a constellation of symptoms related to obstruction
of coronary arteries with chest pain being the most common
symptom in addition to nausea, vomiting, diaphoresis etc.

Chest pain concerned for ACS is often radiating to the left

arm or angle of the jaw, pressure-like in character, and
associated with nausea and sweating. Chest pain is often
categorized into typical and atypical angina.
 Acute Coronary Syndrome
Definition: Simptom yang diakibatkan oleh menyempit-
buntunya arteri coroner.

Chest pain/chest discomfort:

• Substernal Faktor risiko
• Menyebar
• Tumpul
• Panas
• Tertindih benda berat
• Sehabis exercise
ATHEROSCLEROSIS

START

END
Acute Coronary Syndrome
UAP NSTEMI STEMI
 Acute Coronary Syndrome
UAP NSTEMI STEMI
Klinis

ECG

Laboratorium /
Cardiac Marker
 Acute Coronary Syndrome
UAP NSTEMI STEMI
Klinis Positive Positive Positive

ECG N / Ischemic sign N / Ischemic sign ST Elevasi

ST depresi/T inversi ST depresi/T inversi

Laboratorium / Negative Positive Positive

Cardiac Marker
 Symptoms
Pain – Pressure
– Burning (hot)
– Chest/arms/jaw/back
Sympathetic response – Sweats
– Tachycardia
– Cool, clammy skin
Parasympathetic response – Nausea
– Vomiting
– Weak
Inflammatory response – Mild fever

Other – Dyspnea
– Asymptomatic
 Unstable Angina (UA) and
Non ST Elevation Myocardial Infarction
(NSTEMI)
• 5,315,000 annual ER presentations for chest pain

• 1,433,000 annual U.S. hospital admissions for

UA/NSTEMI

• 50 patients per month at BIDMC coded as:

AMI, SUBENDOCARDIAL ISCHEMIA
 Acute Coronary Syndrome
UAP NSTEMI STEMI
Klinis Positive Positive Positive

ECG N / Ischemic sign N / Ischemic sign ST Elevasi

ST depresi/T inversi ST depresi/T inversi

Laboratorium / Negative Positive Positive

Cardiac Marker
Acute Coronary Syndrome:
Risk Factors
Risk factors: Medical
– Diabetes mellitus (DM)
– Hypertension
– Hyperlipidemia: Includes fats, oils, waxes,
sterols, nucleic acids, triglycerides
– Hypercholesterolemia: Cholesterol is a lipid
– Prior cerebrovascular accident: Over 7% of
patients with ACS had prior stroke
 American College of Cardiology
(ACC) 2002 Guidelines for
UA/NSTEMI
Medications with Class I indication

First 24 hours Discharge

•Aspirin •Aspirin
•Clopidogrel •Beta Blocker
•Nitroglycerin •Clopidogrel
•Beta Blocker •ACE Inhibitor
•ACE Inhibitor •Statin
•Heparin
•IIB/IIIA
Inhibitors
•Morphin/Mo
 Acute Treatment: STEMI
• Reperfusion: Thrombolysis vs. PTCA
• O2
• ASA
• Clopidogrel
• Beta blockers
• Nitrates
• ACE inhibitors
• Morphine
• Anticoagulants
 Electrocardiogram
 STEMI:
 Q waves , ST elevations, hyper acute T waves; followed by T wave inversions.
 Clinically significant ST segment elevations:
 > than 1 mm (0.1 mV) in at least two anatomical contiguous leads
 or 2 mm (0.2 mV) in two contiguous precordial leads (V2 and V3)

 Note: LBBB and pacemakers can interfere with diagnosis of MI on

EKG
ST-Elevation MI
 The ECG shows:
• Sinus rhythm
• Normal axis Summary
• Small Q waves in lead III but not elsewhere
• Elevated ST segments in leads II, III, VF, with upright T wavesAcute inferior
• T wave inversion in lead VL 18
myocardial infarction
 The ECG shows: Summary
• Sinus rhythm
Acute anterolateral myocardial
• One ventricular extrasystole
• Normal axis infarction.
• Q waves in leads V2-V3; small Q waves in leads VL, V4
• Raised ST segments in leads I, VL, V3-V5 19
 The ECG shows:
• Sinus rhythm Summary
• Normal axis
• Q waves in leads II, III, VF Old inferior and acute anterior
• Normal QRS complexes in the anterior leads
• Marked ST segment elevation in leads V1-V6
myocardial infarctions.
20
Sinus Tachycardia 110 x /mnt, First degree AV Block, IMA inferior

21
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
Fibrilasi atrial
A. Gelombang fibrilasi
B. Fibrilasi atrial dengan respon ventrikuler cepat
C. Fibrilasi atrial dengan respon ventrikuler lambat
Cardiac Marker
Deferential Diagnosis
Chest Pain
 Complications of MI

CHF
Dysrhythmias
Pericarditis
Thromboembolic Complications
Rupture of Ventricular Free Wall
Rupture of Interventricular septum
Mitral Valve Insuffisiency
 TIMI RISK SCORE –increase in mortality with increasing score
~40% all cause mortality at 14 days for patients requiring urgent
revascularisation
Classification of Recommendations and Levels of Evidence
A recommendation with
Level of Evidence B or C
does not imply that the
recommendation is weak.
Many important clinical
questions addressed in
the guidelines do not lend
themselves to clinical
trials. Although
randomized trials are
unavailable, there may be
a very clear clinical
consensus that a
particular test or therapy
is useful or effective.

*Data available from

clinical trials or registries
about the usefulness/
efficacy in different
subpopulations, such as
sex, age, history of
diabetes, history of prior
myocardial infarction,
history of heart failure,
and prior aspirin use.

†For comparative
effectiveness
recommendations (Class I
and IIa; Level of Evidence
A and B only), studies
that support the use of
comparator verbs should
involve direct
comparisons of the
treatments or strategies
being evaluated.