Acute Coronary Syndrome

ECG
Simon Salim
Cardiology Division, Department of Internal Medicine
Universitas Indonesia / RSCM
Financial Disclosure
• None to declare
Apa Itu Atherosklerosis ?
Pembuluh darah yang mengalami aterosklerosis & trombosis
Cardiovascular
 Bedside predictors for a diagnosis
of coronary disease
• Presence of typical angina • Nonanginal chest pain
• ( LR=5.8; 95% confidence • (LR=0.1; 95% CI: 0.1 to 0.2)
interval [CI]: 4.2 to 7.8),
• Pain duration >30 minutes
• Serum cholesterol level
>300 mg/dL • (LR=0.1; 95% CI: 0.0 to 0.9)
• (LR=4.0; 95% CI: 2.5 to 6.3) • Intermittent dysphagia
• History of prior myocardial • (LR=0.2; 95% CI: 0.1 to 0.8)
infarction
• (LR=3.8; 95% CI: 2.1 to 6.8)
• Age >70 years
• (LR=2.6; 95% CI: 1.8 to 4.0).
Am J Med. 2004 Sep 1;117(5):334-43
 Bedside predictors for a diagnosis
of myocardial infarction
• New ST elevation
• (LR=22; 95% CI: 16 to 30)
• New Q waves
• (LR=22; 95% CI: 7.6 to 62)
• New ST depression
• (LR=4.5; 95% CI: 3.6 to 5.6)
• A normal electrocardiogram
• (LR=0.2; 95% CI: 0.1 to 0.3)
• Chest wall tenderness
• (LR=0.3; 95% CI: 0.2 to 0.4)
• Pain that was pleuritic
• (LR=0.2; 95% CI: 0.2 to 0.3)
• Sharp
• (LR=0.3; 95% CI: 0.2 to 0.5)
• Positional
• (LR=0.3; 95% CI: 0.2 to 0.5)
Am J Med. 2004 Sep 1;117(5):334-43
Typicality of angina
ESC 2013 guidelines stable CAD
 3 Komponen dalam
mendiagnosa SKA

• Keluhan sakit dada yg berupa

APTS/UAP

• Perubahan EKG, STEMI atau Non

STEMI dengan atau tanpa Q patologik

• Peningkatan Enzim jantung

 Psn Nyeri Dada SINDROM KORONER AKUT
Rwyat nyeri dada Aspirin 300 mg dikunyah dan Nitrat s.l.
khas
EKG 12 sandapan*
Petanda biokimia

•EKG Non diagnostik •Perubahan ST/T Elevasi seg

•Petanda biokimia (-) •Petanda biokimia (+)
ST
•Nyeri dada (-) •Nyeri dada menetap

•EKG tdk Observasi

berubah •EKG serial
Evaluasi utk
•Petanda(-) •Ulang petanda
6-12 jam stlh reperfusi
•Nyeri dada(-)
onset nyeri dada* Rawat Terapi
Pulang • Nitrat
•Perubahan seg ST • ASA
Risiko rendah Risko tinggi •Petanda (+) APTS/NSTEMI •Clopidogrel
Periksa di Periksa •Nyeri dada •UFH/LMWH
Rawat jalan segera •(+/- Antagonis
menetap
Receptor GPIIb/IIIa
Evolusi EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Acute Inferior STEMI

hyperacute T waves with ST elevation in II, III, aVF

Old inferior MI

Pathologic Q waves, T wave inversion in II, III, aVF

Acute inferior STEMI and the right ventricle

ST segment elevation in V4r indicative of proximal RCA

occlusion causing right ventricular infarction
Anteroseptal STEMI

ST elevation in V1-3 before Q waves developed

Fully evolved anteroseptal MI

QS waves in V1-2, qrS complex in V3, resolving ST elevation with deep

inverted T waves
Acute extensive anterior STEMI

ST elevation V2-6, I, aVL

Acute Left Main Sub-total Coronary Occlusion

ST depression in at least 7 leads; ST elevation aVR > any ST elevation in V1

STEMI Anterior-septal dan lateral
STEMI INFERIOR
STEMI Inferior with Right Ventricular
Infarction
63 year old man with epigastric burning, belching,
diaphoresis, and lightheadedness

SB with 1st degree AV block, acute inferior STEMI 


53 year old diabetic woman with four days of nausea,
vomiting, and lightheadedness

T-wave abnormality consistent with anterolateral NSTEMI/UAP 


43 year old man reports eight hours of left chest
and arm pain

SR, acute lateral STEMI 


62 year old woman with nine hours of chest pain and
dyspnea

SR, recent inferior STEMI with persistent ischemia 


68 year old woman with chest pain and dyspnea

SR, T-wave abnormality consistent with anteroseptal NSTEMI/UAP

62 year old man with epigastric burning, nausea, diaphoresis, and
lightheadedness; blood pressure is 80/35

SR with 2nd degree AV block and 2:1 AV conduction, acute inferior STEMI 

 57 year old man with chest pressure, dyspnea, and
nausea

SR with 1st degree AV block, acute inferior-lateral, and right ventricular (RV) STEMI