Acute Coronary Syndrome Slide kuliah CVS

ACS

1. ACUTE CORONARY SYNDROME 2014

2. DEFINITION Acute coronary syndromes (ACS) are lifethreatening conditions that can punctuate the course of patients with coronary artery disease at any time. These syndromes form a continuum that ranges from an unstable pattern of angina pectoris to the development of a large acute myocardial infarction (MI), a condition of irreversible necrosis of heart muscle

3. UNIVERSAL DEFENITION MYOCARDIAL INFARCTION

4. UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION

5. 5 Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI † STEMI 1.24 million Admissions per year .33 million Admissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA .

6. ATHEROSCLEROSIS TIMELINE

7. MECHANISMS OF CORONARY THROMBOSIS Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 171

8. CONSEQUENCES OF CORONARY THROMBOSIS Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 173

9. INITIAL EVALUATION AND MANAGEMENT

10. CHEST PAIN

11. ECG ASSESSMENT

12. ECG ASSESSMENT ECG manifestations of acute myocardial ischaemia (in absence of LVH and LBBB) ECG changes associated with prior myocardial infarction

13. Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182 ACUTE STEMI EVOLUTION

14. COMMON ECG PITFALLS IN DIAGNOSING MYOCARDIAL INFARCTION

15. Atypical ECG presentations that deserve prompt management in patients with signs and symptoms of ongoing myocardial ischaemia

16. From: ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents J Am Coll Cardiol. 2012;60(23):2427-2463. doi:10.1016/j.jacc.2012.08.969

17. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply . Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157 TIMING OF RELEASE OF VARIOUS BIOMARKERS AFTER ACUTE MYOCARDIAL INFARCTION

18. BIOMARKER FOR ACS

19. BIOMARKER FOR ACS European Heart Journal (2011) 32,2999 - 3054

20. TROPONIN KINETICS IN THE INDEX CASES Mahajan V, Jarolim P. Circulation 2011;124:2350-2354 Copyright © American Heart Association, Inc. All rights reserved.

21. Treatment of Acute Coronary Syndromes: STE vs. Non STE

22. Treatment of Acute Coronary Syndromes Anti-ischemic therapies General measures: Antithrombotic therapies Antiplatelet agents: Anticoagulants (use one): Adjunctive therapies: Β -blocker Nitrates +/- Calcium channel blocker Pain control (morphine) Supplemental O 2 if needed Aspirin Clopidogrel (or prasugrel ) GP IIb / IIIa inhibitor (for selected high risk patients; may be deferred until PCI) LMWH ( enoxaparin ) Unfractionated intravenous heparin Fondaparinux Bivalirudin (should be used in ACS patient only if undergoing PCI) Statin Angiotensin converting-enzyme inhibitor

23. STEMI

24. Reperfusion Therapy for Patients with STEMI *Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset ( Class I, LOE: B ). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

25. ASSESMENT OF REPERERFUSION OPTION FOR STEMI PATIENT

26. Component of delay in STEMI and ideal time interval for intervention

27. PRIMARY PCI IN STEMI

28. Indications for Fibrinolytic Therapy When There Is a >120-Minute Delay From FMC to Primary PCI

29. Indications for Transfer for Angiography After Fibrinolytic Therapy *Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

30. Recommendation for Reperfusion Therapy

31. Indications for PCI of an Infarct Artery in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy *Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

32. REPERFUSION THERAPY Modified from Gersh BJ, Stone GW, White HD, Homes DR Jr: Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: Is the slope of the curve the shape of the future? JAMA 293:979, 2005.

33. Uap / nSTEMI

34. Braunwald Clinical Classification of UA/NSTEMI

35. DIAGNOSTIC AND THERAPEUTIC STEPS NSTE ACS

36. Step one - Initial Evaluation CHEST PAIN ECG RISK FACTOR WORKING DIAGNOSIS INITIAL TREATMENT STEMI NSTEMI ACS UNLIKELY

37. Step Two - Diagnosis Validation And Risk Assesment After the patient is assigned to the group NSTE-ACS, i.v. and oral antithrombotic treatments will be started Routine clinical chemistry, particularly troponins (on presentation and after 6–9 h) Repeat or continuous ST-segment monitoring Ischaemic risk score assessment (GRACE score). Echocardiogram Bleeding risk assessment (CRUSADE score) Optional: chest X-ray, CT, MRI or nuclear imaging for differential diagnoses (e.g. aortic dissection, pulmonary embolism, etc.)

38. RISK STRATIFICATION European Heart Journal (2011) 32,2999 - 3054

39. TIMI RISK SCORE FOR UA/NSTEMI Braunwald E Circulation . 2003;108:III-28-III-37 Copyright © American Heart Association, Inc. All rights reserved.

40. GRACE RISK SCORE – Mortality in hospital and at 6 months

41. Step Three – Invasive Strategy Criteria for high risk with indication for invasive management

42. INVASIVE VS CONSERVATIF

43. Decision-making algorithm for the management of patients with non-ST-elevation acute coronary syndrome Bassand J et al. Eur Heart J 2007;28:1598-1660

44. Step Four – Revascularization Modalities

45. STEP FIVE: HOSPITAL DISCHARGE AND POST-DISCHARGE MANAGEMENT MEASURES CHECKED AT DISCHARGE

46. Acute MI: Complications Recurrent ischemic/reinfarction Arrhythmias Myocardial dysfunction Mechanical complications Pericarditis Thromboembolism

47. Complications of MI Myocardial Infarction Ventricular thrombus Contractility Electrical instability Tissue necrosis Pericardial inflammation Embolism Arrhythmias Pericarditis Papillary muscle infarction/ ischemia Ventricular septal defect Ventricular rupture Mitral regurgitation Congestive heart failure Coronary perfusion pressure Ischemia Hypotension Cardiogenic shock Cardiac tamponade

48. TERIMA KASIH