Management of Acute Coronary Syndrome

dr. Safir S, SpJP(K),FIHA,FAPSC

INTRODUCTION

• Cardiovascular Disease remains the No. 1 cause of death in the US and

Worldwide
• In 2020, approximately 19.1 million (37%) deaths were attributed to CVD
globally.
• Acute coronary syndromes (ACS) are life threatening conditions that can
punctuate the course of patients with coronary artery disease at any time
• Approximately every 40 seconds, someone in the US will have a
myocardial infarction
• In Indonesia, CAD account for 1.5% (3.7 million)

Heart Disease and Stroke statistics-2022 Update : A report from the AHA. Circulation. 2022;145:e153–e639
World Health Organization; IHME, Global Burden of Disease 2022
Kementerian Kesehatan Badan Penelitian dan Pengembangan Kesehatan,2018.
 Acute Coronary Syndrome (ACS)
A spectrum of conditions compatible with acute myocardial ischemia
and/or infarction that are usually due to an abrupt reduction in coronary
blood flow

Bentzon JF et al. Circ Res. 2014;114:1852-1866; Roffi M et al. Eur Heart J 2016;37(3):267-315; Ibanez B, et al. Eur Heart J. 2018;39:119-177
 The spectrum of clinical
presentations,
electrocardiographic
findings, and high-
sensitivity cardiac
troponin levels in patients
with acute coronary
syndrome.

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107

 Faktor Risiko Penyakit Jantung Koroner
Tidak dapat dimodifikasi
Usia : Tua > Muda
Gender : Laki-laki > Perempuan
Riwayat Keluarga ( PJK )
Dapat dimodifikasi !!!

Stress Diabetes Mellitus

Hipertensi Merokok

Tinggi Lemak Jenuh dan

Obesitas Kurang Aktivitas Fisik Kolesterol
 Atherosclerosis : from plaque to ACS
Foam Fatty Intermediate Fibrous Complicated
Cells Streak Lesion Atheroma Plaque Lesion/Rupture

Endothelial dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen haematoma

Clinically silent Clinically silent or overt

Stary HC, et al. Circulation 1995; 92[5]: 1355-1374.

Diagnostic
Algorithm and
Triage in ACS
Figure 1
Diagnostic algorithm
and triage in acute
1. Clinical
coronary syndrome.
2. Electrocardiography
3. Cardiac Enzyme
Biomarkers

Collet JP, et al. European Heart Journal (2021) 42, 1289-1367

 Symptoms at
presentation in acute
coronary syndrome

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107

 Anamnesis pasien Sindroma Koroner Akut
• Onset nyeri (penting untuk STEMI apakah <12 jam)
• Provocation : muncul ketika apa
• Quality / Deskripsi nyeri: seperti ditekan/ditindih benda berat, dibakar,
Angina diremas, ditusuk, diiris, tercekik
Tipikal
• Radiation / Penjalaran nyeri: ke lengan kiri, bahu, punggung, epigastrium,

leher rasa tercekik atau rahang bawah

• Severity / beratnya nyeri—skala 1-10

• Timing / Lama nyeri: lebih dari 20 menit. Pada STEMI tidak hilang dengan
istirahat atau nitrat SL
• Gejala sistemik : mual, muntah, keringat dingin, berdebar
• Faktor risiko PJK : merokok, hipertensi, DM, dislipidemia, riw.keluarga PJK
 Differential diagnosis of ACS in the
Table 4 Differential diagnoses of acute coronary syndromes in the
setting of acute chest pain
setting of acute chest pain

Bold = common and/or important differential diagnoses.

aDilated, hypertrophic and restrictive cardiomyopathies may cause angina or chest discomfort.

©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
ACS DIAGNOSIS: STEMI AND UA/NSTEMI

ELECTROCARDIOGRAPHIC DIAGNOSIS
 Contoh EKG pada SKA

STEMI Inferior wall (terdapat ST

Elevasi di sadapan II,III, aVF)

NSTEMI Inferior wall (terdapat ST

depresi di sadapan V4-V6, I, aVL)
 Cardiac Biomarkers

Tiwari RP, et al. Mol Diagn Ther (2012) 16:371–381

Management of Acute Coronary Syndrome
 Algoritma Manajemen Sindrom Koroner Akut

1. PERKI, 2020. Algoritma Sindrom Koroner Akut; 2 .PERKI, 2018. Buku Pedoman Tatalaksana Sindrom Koroner Akut
ECG

References: 1. PERKI, 2020. Algoritma

Sindrom Koroner Akut; 2 .PERKI, 2018. Buku
Pedoman Tatalaksana Sindrom Koroner Akut
 STEMI
Modes of presentation and
pathways to invasive
management and myocardial
revascularization in STEMI

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization
Revascularization in STEMI

Indications for Revascularization in STEMI (Patients Without

Fibrinolytics)

Lawton et al. Circulation. 2022;145:e18–e114.

Importance of Revascularization--Time is Muscle
Tujuan reperfusi adalah untuk menyelamatkan otot jantung sebanyak dan secepat mungkin.

Semakin lama reperfusi, kerusakan otot jantung semakin luas dan

100 keluaran pasien semakin buruk
Penurunan Mortalitas %

80

60

40

20
Tingkat Keselamatan
Otot Jantung
0
0 4 8 12 16 20 24
Waktu dari Awitan Gejala hingga Terapi Reperfusi, dalam Jam
Periode kritis tergantung waktu Periode tidak tergantung waktu
Tujuan: menyelamatkan otot jantung Tujuan: membuka arteri yang terkait dengan infark
Adapted from Gersh BJ, et al. JAMA. 2005;293:979.
 Invasive
sk Total Conservative invasive invasive
strategy P value P value
cation (n=3.909) (n=3.220) strategy strategy
(n=689)
(n=262) (n=427)
Prognostic
5 (0-45)
Impact
5 (0-45)
of Revascularization
5 (0-36) 0.001
in Patients
4 (0-30)
with
5 (0-36)
AMI
< 0.001
h risk 5 (0-45) 5 (0-45) 5 (0-30) 0.293 5 (1-30) 5 (0-25) 0.805
5 (0-38) 5 (0-38) 5 (1-19) 0.211 5 (2-17) 5 (1-19) 0.495
iate risk 5 (0-37) 5 (0-37) 5 (0-36) 0.001 4 (0-22) 5 (2-36) < 0.001
Indonesia ACS Multicenter
4 (0-27) 4 (0-17) Registry
4 (1-27) 0.030 4 (1-17) 5 (2-27) 0.001

Figure 1. Hospital mortality rate in ST-ACS based on reperfusion strategies.

Juzar D.A,et al. Indonesian J Cardiol 2022:43:45-55 Marenzi G,et al. J. Clin. Med. 2023, 12, 5629
Terapi Fibrinolisis :
Kontraindikasi
 NSTE-ACS
Selection of invasive
strategy and
reperfusion therapy
in NSTE-ACS

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization

Recommendations for the Timing of Invasive Strategy in Patients With

NSTE-ACS

Lawton et al. Circulation. 2022;145:e18–e114.

Terapi Antitrombotik pada SKA
 Recommended default
antithrombotic therapy
regimens in acute coronary
syndrome patients

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107

 Dosis obat-obatan pada SKA

Aspirin : 160-320 mg (dikunyah lebih baik)

Clopidogrel : 300-600 mg (untuk primary PCI 600 mg)
Nitrat sublingual :
Nitrogliserin 500 mcg atau ISDN 5 mg sublingual (dapat diulang
3x jarak 5 menit)
Nitrogliserin IV mulai 10 mcg/menit iv titrasi s/d max 200
mcg/menit atau ISDN iv 1-10 mg/jam
Morphine 2-4 mg iv bolus pelan
Streptokinase 1.5 juta IU diencerkan dalam 100 c D5/NaCl 0.9%
 LONG TERM TREATMENT

Control Risk factor •hypertension, diabetes, smoking

B Blocker •All patient without contraindication

Antiplatelet •ASA 75 – 100 mg

•DAPT for 12 months
Statin •High Intensity statin
28

ACEI/ ARBs •HF, LVEF dysfunction, diabetes or infarct

anterior
•Valsartan is preffered for intolerant ACEI
Antognist aldosteron •If Ejection fraction ≤ 40% or renal failure or
diabetes or
• if renal failure or hyperkalemia
Byrne R.A,et al. European Heart Journal (2023) 00, 1–107
 TAKE HOME MESSAGE

• ACS merupakan suatu kondisi kegawatan jantung yang mengancam

nyawa dan meningkatkan morbiditas serta mortalitas
• Diagnosis dini dan pemberian terapi segera merupakan kunci dalam
penanganan pasien ACS
• Tatalaksana pada pasien ACS memerlukan pendekatan yang
komprehensif tidak hanya secara medikamentosa, tetapi juga
memperhatikan aspek rehabilitatif, manajemen nutrisi/diet, dan prevensi
sekunder