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Tatalaksana ACS HUT Harkit 2015 PDF
Tatalaksana ACS HUT Harkit 2015 PDF
Tatalaksana ACS HUT Harkit 2015 PDF
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Penyakit Arteri
Koroner
Sindroma Angina
Koroner Akut Stabil
Unstable
STEMI NSTEMI
Angina
Tata laksana SKA
ACS with persistent ACS without persistent
STEMI
ST segment elevation UAP/NSTEMI
ST segment elevation
Perempuan, 62 tahun
5
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
ANGINA
Sakit dada (sakit, nyeri, rasa tertimpa beban, rasa
terbakar) di belakang tulang dada
Dipicu oleh aktivitas atau stres emosional
menghilang dengan istirahat atau nitrat
Dapat menjalar ke punggung, bahu, rahang atau
lengan.
Disertai rasa lemah, keringat dingin, rasa cemas dan
bahkan bisa pingsan.
Presentasi Angina pada SKA
EKG 12 Sandapan
Dalam 10 menit !!
Membuat dan menganalisa EKG
Tentukan:
Irama
Elevasi segmen ST ?
Depresi segmen ST ?
LBBB (BARU )?
Gelombang Q ?
Non diagnostik/EKG normal
Dapat diulang dalam 3-6 jam atau
jika pasien melaporkan keluhan lagi
ELEKTROKARDIOGRAM YANG NORMAL
TIDAK MENGEKSKLUSI ADANYA SINDROMA
KORONER AKUT
Rhythm ?
Segmen ST elevation ?
Segmen ST depresssion?
LBBB (new )?
Q Wave?
1 CLINICAL CONDITION
2 3
TIMI SCORE GRACE SCORE
Hamm W et al. European Heart Journal 2007; 28:15981660; Hamm CW et al. Eur Heart J 2011;32:2999 3054
Clinical condition
4 19.9%
Use of aspirin in prior 7 days
5 26.2%
At least 2 anginal events in prior 24 hours?
6- 7 40.9%
Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 e30 High > 140 >3
Initial Treatment
1
Plaque rupture leads
to platelet adhesion
to the exposed
subendothelium
Vorchheimer DA, et al. Mayo Clin Proc. 2006;81:59-68; Davies MJ. Heart. 2000;83:361-366.
Antiplatelet recommendation in
Updated ACS Guidelines
No in vivo
Active compound biotransformation
Intermediate metabolite
Pro-drug
CYP-dependent
oxidation
CYP3A4/5
Ticagrelor CYP2B6
(Active Drug) CYP2C19
Hydrolysis CYP2C9 Binding
by esterase CYP2D6
Prasugrel* Platelet
(Prodrug)
P2Y12
Clopidogrel
(Prodrug) CYP-dependent CYP-dependent
oxidation oxidation
CYP1A2 CYP2C19
CYP2B6 CYP3A4/5
CYP2C19 CYP2B6
11
10 9.8 Ticagrelor
9 Clopidogrel
8 5.4
7
6
5
4 ARR=0.6% ARR=1.9%
4.8
RRR=12% RRR=16%
3 Ticagrelor
P=0.045 NNT=54*
2 HR: 0.88 (95% CI, 0.771.00) P<0.001
1 HR: 0.84 (95% CI, 0.770.92)
0
0 2 4 6 8 10 12
No. at risk Months After Randomization
Ticagrelor 9,333 8,628 8,460 8,219 6,743 5,161 4,147
Ticagrelor Clopidogrel
20
PLATO bleeding criteria TIMI bleeding criteria
K-M estimated rate (% per year)
18
16 HR=1.04 HR=1.05
14 (P=0.43) (P=0.33)
11,6 11,2 11,4 10,9
12 HR=1.03
10 HR=1.03 (P=0.57)
HR=0.87 7,9
8 (P=0.70) 7,7
5,8 5,8 (P=0.6553)
6 5,3 5,2
4
2
0
Total Major Major Fatal/Life- Other Major TIMI Major TIMI Major+Minor
Threatening
60
50
* //
40
30
20
10
0
//
0 0.5 1 2 4 8 24 6 weeks 0 2 4 8 24 48 72 120 168 240
NSTE-ACS
Early invasive or ischemia-guided strategy2
34