Sindrom Koroner Akut

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Sindrom Koroner Akut merupakan suatu keadaan atau kejadian yang sangat berbahaya karena tingginya angka kematian dan kesakitan.

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By: gotelvia (47 month(s) ago)

dok,, slide nya boleh di download gak ???

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Acute Coronary Syndrome Dr.Edial Dr.Edial www.jantunghipertensi.com

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Spectrum of Acute Coronary Syndromes Unstable Angina Non STEMI STEMI alDr.Edi www.jantunghipertensi.com

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INCIDENCE Acute Coronary Syndromes 1,57 million Hospital Admission = ACS UAP/NonSTEMI STEMI 1,24 Million per year 0,33 Million per year Dr.Edial www.jantunghipertensi.com

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ACS - Predisposing Factors Conventional Risk Factors Smoking Hypertenssion Dyslipidemia Metabolic Syndrome Insuline Resistance & DM Obesity Mental Stress & Depression > 20 % ACS  No Risk Factors Jama 290(7):891-898,Aug 2003 www.jantunghipertensi.com

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Novel Risk Factors * hs CRP * Homocystin * Lpa * Fibrinogen * D-Dimer Dr.Edial

New Risk Factors : 

New Risk Factors Cocain/Meth HIV CKD RA SLE NEJM 2003 Nov 20;349

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ACS - Presentations Typical Angina Definition Of Typical Angina * Typical : atleast 2 out 0f 3 * Atypical : 1 out of 3 * Non-Anginal Chest pain = 0 * “ Asymptomatic “ = o persent Natural Pain Presipitating Factors Relieving Factors Dr.Edial www.jantunghipertensi.com

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Response to Nitroglycerin has no diagnostic Role Sensitivity = 35%, specificity = 50% (Am J Card 90;1264,Des 1 2002) Dr.Edial

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Dr.Edial www.jantunghipertensi.com

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Differential Diagnosis Acute Aortic Dissection Acute Pericarditis Miocarditis Pulmonary Embolism Atypical Angina Vasospastic Angina Hypertropic Cardiomyopathy Hyperkalemia BBB (Bundle Brunch Block) Early Repolarization WPW(Wolf -Parkinson-White) Bruguda Syndrome www.jantunghipertensi.com Cardiac Dr.Edial

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Pleuretic Pain Chest wall pain GERD (Gasro-Esophageal reflux and Spasm) Ulcus pepticum Panic attack Psikogenic Dissorder Differential Diagnosis Non Cardiac Dr.Edial

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Evaluation of patients suspected of having ACS * Clasical Angina at rest or at less than usual activity * Nature of Pain 1. Usually more than 30 min for MI & 20-30 for UAP 2. Squezing, Constricting, Crushing 3. Oppressing, Compressing 4. Retrosternal * Spreading To Both side of anterior chest (more to the left) Ulnar aspect of Arm * In some cases epigastric pain Dr.Edial

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Evaluation of patients suspected of having ACS Others Symptoms Cold Perspirations Nausea/Vomiting (Vagal Stimulations) Profound weakness Dizziness Palpitation Dr.Edial www.jantunghipertensi.com

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Silent ACS Due to aotonomic Disturbance Specially See in Diabetic and Hypertensive patients Older patients Women 40.000/yr.. Chest Pain, in US loss ACS Dr.Edial

Symptoms ACS – for Women : 

Symptoms ACS – for Women Heart disease kills more Women than Men every year. Women symptoms of heart disease differently then Men 1. Shortness of breath, often without chest pain of any kind 2. Flu-like symptoms- specifically nausea,clamminess or cold sweats 3. Unexplained fatique,weakness or dizziness 4. Pain in the chest,upper back,shoulder,neck or jaw 5. Feelings of anxiety, loss of appetite, disconfort Dr.Edial www.jantunghipertensi.com

Los Aneles-Mey 11,2009Archives of Internal Medicine. : 

Los Aneles-Mey 11,2009Archives of Internal Medicine. Women chest pain  without CAD Elevated risk CV event, heart attack or stroke Cedars-Sinai Heart Institute study, Women with Chest Pain Positive Exercise Normarl Coronary Angiography  5 yr,,, more CV evetns then women no chest pain  Cause : microvascular angina, endothelial dysfunction Dr.Edial Sent home without treatment www.jantunghipertensi.com

Atypical Presentations of ACS : 

Atypical Presentations of ACS Classical Angina without severe or prolonged pain Heart failure Atypical location of pain CNS manifestations Apprehension/nervousness Syncope Acute indigestion Dr.Edial www.jantunghipertensi.com

Note ..! : 

Note ..! 1. 46% ACS  no Chest pain 2. Elderly pt , Woman  only 20% have chest pain 3. Thrombolytic not indicated for pt > 75 (Archives of Internal Medicine 3/2003) 4. An ECG that demonstrated ischemia, abn.Cardiac marker, additional pressence of ST elev. in Lead aVR,aVL and V1  indicates an acute Prox.LAD ,LMCA occlusion. 5. ST elev in lead aVR more than 1,5 mm  70% mortality 6. LMCA or 3 VD rarely respons to medical theraphy,should be referred emergently for invasive theraphy. Dr.Edial www.jantunghipertensi.com

Patophysiology : 

Patophysiology ACS  Plaque Rupture not the large clots the small clots tend to cause MI Dr.Edial

TIMI Score : 

TIMI Score 1. Age > 65 2. 3 or more tradiotional Risk Factors (HTN,DM,Hyperchol,FH,Smoking) 3. Known coronary stenosis 0f 50% 0r greater 4. ST-segmen deviation on ECG 5. 2 or more anginal events in past 24 hours 6. ASA use during past week 7. Elevated Cardiac Enzymes Score : 3 or more  Increased risk of death or MI Score 0-2  low risk 3-4  moderate risk 5-7  high risk

Syndrme X : 

Syndrme X Chest Pain Positive Exercise Normarl Coronary Angiography Dr.Edial www.jantunghipertensi.com

EKG in ACS : 

EKG in ACS Myocardial Ischemia Non Q Wave Infarction ST Elevation Q Wave infarction Noninfarction Transmural Ischemia (Including Prinzmetal variant angina) Noninfarction subendocardial Ischemia (Including Classic Angina) ST Depretion or T wave Inverted Without Q wave T Inverted / ST Depressions New Q wave, Usually proceded by Hyperacute T, with ST elevation Folowed by T wave Invertions

ST Segmen Elevation Myocardial Infarction(STEMI) : 

ST Segmen Elevation Myocardial Infarction(STEMI) Dr.Edial

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STEMI Definition ST Elevation (In anterior Leads more than 2 mm, in limb leads more 1 mm) In 2 consecutive EKG leads (except presumably new LBBB) and : Clinical symptoms ( eg : chest pain) Raised markers of Myocardial Injury New wall motion on Echo New perfusion defect on SPECT MPI Dr.Edial www.jantunghipertensi.com

Physical Examination In MI : 

Physical Examination In MI General : Appearance (Anxiety,orthopnoe,Altered sensorium) Fundus Oculi : (HPN,DM,Embolus) Heart : (Tachycardia,Bradicardia, other Arrhytmias) Peripheral : Pulses & Carotid (PAD,HTN,SHOCK) Blood Pressure : (HTN,Hypotension) Temperature : (Due to Shock) Respiration : (Tahypnoea) JVP : (CHF, RVMI,Shock) Chest : Crackless,Bronchospasm, PLEF) Dr.Edial

Physical Examination In MI : 

CVS : Heartsounds : (Soft S1, Loud S2) Murmurs : (MR, VSR) Pericardial Rub Abdomen : (Diaphregmetic Irritation,Liver) Physical Examination In MI Dr.Edial www.jantunghipertensi.com

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Laboratory Findings Mioglobin Troponin – I CK-MB CK-Nac LDH GOT-GPT

Laboratory Findings : 

Laboratory Findings Dr.Edial

EKG : 

EKG Diagnostic Test To Deferentiating Between STEMI and NON-STEMI ACS Serial Standard 12 Lead EKG is Reccomended RV Leads in Case of Inferior Wall MI aVR, aVL, V1  LMCA , >> Mortality Dr.Edial www.jantunghipertensi.com

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General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial www.jantunghipertensi.com

EKG Sequences in Acute Anterolateral STEMI : 

EKG Sequences in Acute Anterolateral STEMI Dr.Edial

Echocardiography : 

Echocardiography Useful in emergency as Being Portable Specially in cases where : 1. EKG non-diganostic (LBBB). 2.ACS vs Aortic disection 3.Suspected complications of STEMI (VSR,Free wall rupture, Chordi rupture). 4.Information about arterial territory involveled 5.Information about EF/MR, Pericardial effusion www.jantunghipertensi.com

Echocardiography – Territory Identification : 

Echocardiography – Territory Identification

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Management of Patient With ST Elevation Myocardial Infarction Dr.Edial www.jantunghipertensi.com

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General Point of Treatment 1. Admission to Acute Coronary Care Unit 2. Control of Pain 3. Antiplatelet Agents 4. Reperfussion Theraphy (Throbolysis vs PCI) 5. Anticoagulans 6. ACE Inhibitors/ARB 7. Aldosteron Antagonists 8. Statins Dr.Edial

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General Point of Treatment (Cont) 9. Glycemic controll 10. Hemodinamic Monitoring 11. Physical Activity (Limitation) 12. Compicatios of STEMI & Their Management 13. Early Risk Stratification 14. Planning Discharge 15. Longterm Management & Secondary Prevention Dr.Edial www.jantunghipertensi.com

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Immediate Management Assess Hemodynamics Strict Bed rest Intranasal Oxygen Aspirin 325mg Uncoated to be chewed Stat Clopidogrel 300mg Stat I/V Betablockers if not containdicated Dr.Edial www.jantunghipertensi.com

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Control of Pain NTG Oral / IV Morphine Betablockers/ NHP Calcium channel blockers Stop NSADS and Steroids www.jantunghipertensi.com

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Reperfusion Therapy First one hour is Golden Hour Within initial 3 hours results of Thrombolysis and primary PCI are same Dr.Edial www.jantunghipertensi.com

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Contraindications & Cautions Absolute Contraindications 1. Any prior intracranial hemorrhage 2. Known structural cerebral vascular lession (eg : arterio- veous malformation) 3. Ischemic Stroke within 3 mo EXCEPT acute ischemic stroke within 3 hr 4. Suspected Aortic dissection 5. Active bleeding or bleeding diathesis (excluding menses) 6. Significant closed head or facial trauma within 3 mo Intracranial neoplasm Active internal bleeding (not menses) Dr.Edial

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Contraindications & Cautions Relative Contraindications History of Chronic severe poorly controled hypertension Severe uncontrolled hypertension on presentation (SBP > 180 Hg or DBP > 110 Hg) 3. History of prior ischemic stroke > 3 mo dementia, or known intracranial pathology not cavered in contraindications Traumatic or prolonged (> 10 min) CPR or major surgery (< 3wk) Recent ( within 2-4 wk) internal bleeding Noncompressible vascular punctures For streptokinase/Anistreplase : prior exposure (> 3 days ago) or prior allergic reaction to these aggens Pregnancy Active peptic ulcers Current use of antycoagulants : the higher the INR, the higher the risk of bleeding 11. INR > 2 or bleeding diatheses

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INJURI :

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EVOLUSI EKG : IMA Dr.Edial

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Nyeri dada Dugaan SKA ST elevasi Saat datang Diagnosis kerja EKG Biokimiawi Stratifikasi risiko Diagnosis Tatalaksana Abnormalitas ST/T EKG normal/tdk khas Troponin positif Troponin negatif Risiko tinggi Risiko rendah NSTEMI Angina tak stabil STEMI Reperfusi Invasif Non invasif Dr.Edial www.jantunghipertensi.com

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Biochemical Cardiac Markers for the Evaluation and Management of Patients Suspected of Having an ACS but Without ST-Segment Elevation on 12-Lead ECG

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Risiko tinggi * Nyeri dada berulang * St Elevalsi persisten * Komplikasi mekanik  syok, gagal jantung akut, mur - mur baru Dr.Edial www.jantunghipertensi.com

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Dr.Edial

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Stratifikasi sebelum pasien dipulangkan STEMI Invasi primer Fibrinolitik Tanpa reperfusi Kateterisasi (+) Kateterisasi (-) EF > 40% EF < 40% Risiko Tinggi (+) Risiko Tinggi (-) EF > 40% EF < 40% Risiko Tinggi (-) Risiko Tinggi (+) Kateterisasi & revaskularisasi sesuai indikasi Revasikulasi sesuai indikasi Evaluasi fungsional Dr.Edial

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Evaluasi fungsional EKG dapat dinilai EKG tak dapat dinilai Mampu uji latih Tak mampu uji latih Mampu uji latih Uji latih submak sebelum pulang Uji latih sesuai kemampuan sebelum atau sesudah pulang Ekokardiografi dobutamin Pemeriksaan nuklir Adenosin/dipiridamol Iskemi signifikan (+) Iskemi signifikan (-) Terapi medikamentosa Pemeriksaan nuklir uji latih Ekokardiografi uji latih Kateterisasi & Revaskularisasi sesuia indikasi Dr.Edial

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Chest pain consistent with coronary ischemia With in 10 mnutes Initial evaluation * 12 leads EKG Establish IV acces * Establish cont EKG monitoring Blood for baseline serum cardiac marker *Aspirin 160-325 mg chewed Therapeutic diagnostic tracking according to 12 leads EKG result Nondiagnostic/normal EKG EKG suggestive of ischemia or T wave inversion or ST segment depression ST segmen elevation or new bundle Continous evaluation monitoring in emergency departement or chet pain unit Serial serum cardiac marker Seria EKG Consider noninvasive evaluation or Consider alternative diagnostic Anti ischemia theraphy Analgesia * Assess suitability for reperfusion Contraindication for fibronolysis Avaiability and appropriate EKG of primery angioplasty inititate . anti ischemia . theraphy Beta-blocker, * Nitroglycerine,Analgesia Adm it to unit of appropriate intensity Admission blood work : -CBC BUN, Electrolyte -Creatinine, -Lipid profile Admission blood work Initiate fibrinolytic if indicated. Goal 30 minutes from entry to ED Primary PTCA if available and suitable (Goal PTCA , 90 +/- 30 minutes Admin it - CCU No evidense of MI or iscehemia Discharge with follw up as appropriate (Goal 8-12 hours MI or demonstrable ischemia

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Dr.Edial

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www.jantunghipertensi.com

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www.jantunghipertensi.com

Dr.Edial

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Siaran Berita SKA

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Treadmil... Normal..:1

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Kesalahan Treadmil... V0l 2

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Treadmil... Senam V0l 2

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TERIMAKASIH