Curriculum Vitae

Prof dr Bambanq Irawan FIHA FAsCC FInaSIM

Internist
[ PB PAPDI ]
Internist Cardiovascular Consultant [ PB PAPDI ]

1981
1996

Cardiologist and FIHA

Cardiologist Consultant

2004
2005

Profesor in Cardiology

FAsCC
FinaSIM

[ PP PERKI ]
[ PP PERKI ]
[ DIRJEN DIKTI ]

[ Asean Society of Cardiology ]

[ PB PAPDI ]

2006
2008
2009

Simple Guideline for Acute Coronary

Syndrome (ACS)
Bambang Irawan SpPD[K], SpJP[K], FIHA,
FInaSIM, FAsCC
Divisi Cardiology Departement of Cardiology
Faculty of Medicine Gadjah Mada University

Coronary Heart Disease

Ischemic heart disease :

epidemiology
Annual incidence of angina: 213/100.000
population > 30 years old
Ischemic heart disease (IHD) is the main cause
of death in Europe and USA
Cardiovascular mortality in patients with chronic
stable angina: 1.3-10 %/year
Chronic stable angina is the initial symptom of
IHD

Murray CJL.,ed,Lopez AD. The Global Burden of Disease: a Comprehensive Assessment of Mortality and Disability from
disease, Injurues and Risk Farctors in 1990 and projected to 2020.Cambridge, Mass:Harvard University Press;1996

Supply-Demand Mismatch

O xygen Supply
- Blood Flow
-O2 Carrying
Capacity

O xygen Dem and

- Heart rate
-Contractility
-W all stress

Hb Level
Exercise

O2 Saturation

O2 Content

Heart rate
Afterload

Collaterals

wall
stress

Coronary blood flow

Heart size
Contractility

O2
O2
VS
Demand Supply

Vasoconstriction
Spasm

Ischemic Oxygen Balance

CLINICAL CLASSIFICATION OF
CHEST PAIN
Typical angina (definite)
Substernal chest discomfort with a characteristic quality
and duration that is
provoked by exertion or emotional stress and
relieved by rest or nitroglycerin

Atypical angina (probable)

meets 2 of the above characteristics
Noncardiac chest pain
meets <=1 of the typical angina characteristics
Diamond GA. J Am Coll Cardiol 1983;1:574

CCS Classification
I : Angina occurring with strenous but not
ordinary physical activity
II : Slight limitation of ordinary physical activity
III : Marked limitation of ordinary physical
activity
IV : Inability to carry on any physical activity
without discomfort, symptoms may be
present at rest.

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

Karakteristik Angina pd ACS

Terlokalisir terutama (tapi tidak selalu) di
daerah prekordium
Menyebar ke lengan, leher, punggung, atau
epigastrium
Tidak berubah dengan posisi atau pergerakan
Sering terasa seperti menekan, constricting
atau crushing
Episode > 20 menit
Diikuti sesak, pusing, mual, atau berkeringat

Possible presentation of ACS

Angina at rest, with pain episodes lasting >
20 min
New onset ( within < 2 months ) exertional
angina of at least CCSC III
Recent increase ( < 2 months ) in anginal
severity to at least CCSC III
Angina post MCI

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

CHARACTER
OF
ANGINAL PAIN
Localized usually at precordium
Radiate to arm, neck, shoulder, back or
epicardium
Feels like being pressed by heavy object, or
constricting or crushing.
Episode > 20 min
Concomitant systemic symptoms: dyspnea,
dizziness, nausea, diaphoresis

The Grip of Angina

Atherosclerosis Timeline
Foam
Cells

Fatty
Streak

Intermediate
Lesion

Atheroma

Fibrous
Plaque

Complicated
Lesion/Rupture

Endothelial Dysfunction
From first decade From third decade From fourth decade
Growth mainly by lipid accumulation

Smooth muscle
and collagen

Thrombosis,
hematoma

Stary HC, et al. Circulation. 1995;92:1355-74. Artery wall often gets

larger with increasing plaque-Glagov NEJM 1987

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

ELEKTROKARDIOGRAM
EKG 12 Sandapan Pertama

TENTUKAN:
Irama
Elevasi SEGMENT ST ?
Depresi SEGMENT ST ?
LEFT BUNDLE BRANCH BLOCK (BARU)?
T inverted ?
Gelombang Q ?
NON DIAGNOSTIK atau EKG normal

.
.

Inferior Wall MI

Anterior Wall MI

New LBBB

T inverted

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

SPEKTRUM KLINIS SKA

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

TIMI Risk Score UA / NSTEMI

HISTORICAL
Age 65
3 CAD risk factors

(FHx, HTN, chol, DM, active smoker)

POINTS
1
1

Known CAD (stenosis 50%) 1

ASA use in past 7 days

PRESENTATION
Recent ( 24H) severe angina 1
cardiac markers
1
1
ST deviation 0.5 mm

RISK OF CARDIAC EVENTS (%)

BY 14 DAYS IN TIMI 11B*
RISK
SCORE

0/1
2
3
4
5
6/7

DEATH
OR MI

DEATH, MI OR
URGENT REVASC

3
3
5
7
12
19

5
8
13
20
26
41

RISK SCORE = Total Points (0 - 7)

Low = 0-2 points, Medium = 3-4 points
High = 5-7 points

*Entry criteria:UA or NSTEMI defined as ischemic pain

at rest within past 24H, with evidence of CAD (ST segment
deviation or +marker)

Pemeriksaan awal pada Sindrom Koroner Akut

SAKIT DADA

Masuk RS
Diagnosis
kerja

ECG
3

Curiga Sindrom Koroner Akut

Elevasi ST
menetap

ST/Tabnormalities

Biochemistry

Troponin (+)

Stratifikasi
risiko

Risiko tinggi

Diagnosis

STEMI

Pengobatan

Reperfusi

NSTEMI
Invasive

Normal atau
Tdk dpt ditentukan ECG
Troponin
2 kali negatif
Risiko rendah

Angina tidak stabil

Non-Invasive

Elevation of oxygen supply

Reduction of the extravasal

coronary resistance
Nitro vasodilatators
ACE-I
In case of HF

Prolongation of the
diastolic interval

Dissolution or Prevention
Of Intravasal obstruction

B Blockers
CCBs

Inhibitor of pletelet
Aggregation
Thrombvolytic agents

Providing relief for the ischemic heart

Nitro
compounds
Reduction of
Preload

CCBs
ACE-I

Reduction of
afterload

B Blockers

Reduction of
contractility

CCBs

Reduction of
Heart rate

Reduction of the oxygen demand

Treatment Delayed is Treatment Denied

Symptom
Recognition

Call to
Medical System

PreHospital

ER

Cath Lab

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

Immediate Assessment in ER

Vital signs, including blood pressure

Oxygen saturation
IV access
12-leads ECG < 10 minutes
Brief, targeted history and physical exam (to
identify reperfusion candidates)
Fibrinolytic check list; check contraindications
Obtain initial cardiac markers

Immediate Assessment in ER
Portable Chest X-ray < 30 min
Assess for the following :
-Heart rate > 100 bpm and SBP < 100 mmHg
-Pulmonary edema/rales or
-Signs of shock
If any of these conditions is present,
consider triage to a facility capable of
cardiac catheterization and
revascularization

TERAPI PADA SINDROMA KORONER AKUT

PERAWATAN DI RUMAH SAKIT
1. Antiplatelet (Aspirin 160 mg)
2. Pain killer (morfin)
M
3. Suplemen O2
O
4. Terapi anti iskemia
Nitrat
N
5. Antiplatelet dan antikoagulan
A
Clopidogrel 300 mg, Ticlopidine
Heparin atau Low Molecular Weight Heparin
Hirudin

Tranquilizer

5. a. STEMI : tentukan segera pilihan revaskularisasi

( Fibrinolitik Vs PCI)
b. Non STEMI : segera lakukan stratifikasi risiko

PAIN KILLER
Morfin:
2.5mg-5 mg IV perlahan
Hati hati pada : inferior MCI,
asthma, bradikardia
Pethidin : 12.5-25 mg IV pelan

OKSIGEN
Pemberian suplemen O2 diberikan pada pasien
dengan desaturasi O2 (SaO2 <90%)
Suplemen O2 mungkin membatasi injury
miokard atau bahkan mengurangi elevasi ST
Pemberian suplemen O2 rutin > 6 jam pertama
pd kasus tanpa komplikasi

ACC/AHA Guideline of STEMI 2004

ANTI ISKEMIK
NITRAT
B BLOKER (jika tidak ada kontraindikasi)
ANTAGONIS KALSIUM (UAP/NSTEMI)

VASODILATOR
INHIBITOR ACE (EF < 40%, anterior MCI, HF)
NITRAT IV (jika AHF)

ANTITROMBOTIK DAN
ANTIKOAGULAN
Heparin ( Unfractionated Heparin)
Low Molecular Weight Heparin
Anti Xa

DOSIS YANG DIREKOMENDASIKAN

UFH

Initial I.V BOLUS 60 UI/Kg max 4000 UI

Infus :12-15 UI/kg BB/jam max 1000
UI/jam
Monitor APTT : 3, 6, 12, 24 jam setelah
mulai terapi
Target APTT 50-70 msec (1,5 -2 x
kontrol)

LMWH
Enoxaparine 1mg/kg, SC , bid (5 hari)
Fondaparinux 2,5 cc , satu kali sehari (5 hari)

REVASKULARISASI
PADA STEMI < 12 jam
Apa pilihan kita?
FIBRINOLITIK
VS
PCI

Fibrinolitik lebih dianjurkan jika:

( 3 Point)
1. Presentasi STEMI akut 3 jam
2. Jika presentasi STEMI > 3 jam namun
tindakan PCI tidak bisa dikerjakan atau
akan terlambat dikerjakan;
Waktu antara pasien tiba sampai dengan
inflasi balon >90 menit

3. Tidak ada kontraindikasi fibrinolitik

Catatan:
Fibrinolitik harus dikerjakan dalam waktu < 30 mnt
(Door to Needle time < 30 menit)

PCI primer lebih dianjurkan jika:

( 5 Point )
1. Presentasi 3 jam
2. Presentasi < 3 jam namun terdapat
kontraindikasi fibrinolitik
3. Tersedia fasilitas PCI dan waktu kontak
antara pasien tiba sampai dengan inflasi
balon <90 menit
4. STEMI akut dengan risiko tinggi ( gagal
jantung Killip 3 dan syok kardiogenikl)
5. Diagnosis STEMI masih diragukan

STRATIFIKASI RISIKO
pada Non-STEMI / UAP

MENENTUKAN STRATEGI
TATALAKSANA NON STEMI/UAP
Strategi Invasif
(angiografi akan dilakukan
dalam 48 jam)
VS
Strategi Konservatif
(angiografi tidak akan
dilakukan/direncanakan elektif)

Complications of Acute MI
Extension / Ischemia

Expansion / Aneurysm

Mechanical

Arrhythmia
Pericarditis

Acute MI

Heart Failure

RV Infarct

Mural Thrombus

Komplikasi awal :
9Aritmia
9Disfungsi LV dan gagal jantung
9Ruptur ventrikel
9Regurgitasi mitral akut
9Gagal fungsi RV
9Syok kardiogenik

Komplikasi lambat :
9Trombosis mural dan
9Emboli sistemik
9Aneurisma LV
9DVT
9Emboli paru
9Sindrome Dressler

How to reduce plaque formation

Intervention on risk fact

How to reduce the risk of plaque

rupture

KESIMPULAN
1. Tatalaksana STEMI dimana tersedia fasilitas PCI
adalah PCI primer. Jika sarana PCI tidak tersedia
diberikan trombolitik sesuai indikasi dan kontraindikasi.
2. Tatalaksana NSTEMI meliputi strategi invasif dini dan
strategi konservatif sesuai stratifikasi risiko.
3. Klopidogrel direkomendasikan sebagai antiplatelet
(klas 1) untuk penanganan ACS baik STEMI maupun
UA/NSTEMII dan diberikan bersama ASA. Clopidogrel
diberikan tunggal jika terdapat kontraindikasi ASA
(ACC-AHA / ESC Guideline).
4. GPIIb-IIIa inhibitor diberikan pada pasien yang
menjalani PCI primer.
5. Fondaparinux dan Enoksaparin efektif pada SKA.