Acute Coronary Syndrome

Deri Arara

1
 Acute Coronary Syndrome
• Major health problem
• High mortality and morbidity

20% Similar with the

other country
1.1 M 72% patient
experienced ACS
Mortality in Incidence in
European USA
(2016) (2016)

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

ACS in Indonesia
Patients Patients
686 patients 18,446 patients

194 patients 5,507 patients

Unclassified ACS Unclassified ACS

Unclassified ACS: Unclassified ACS:

iSTEMI registry. 2019

 Atheroschlerosis

1. Normal artery
2. Lesion initiation
3. Fibrofatty stage
4. Fibrous cap
5. Rupture of fibrous cap
6. Collagen accumulation
7. Mural thrombus

4
5
ACS Diagnosis

10 minutes

No need to
wait the result

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart
7
8
9
It’s not always about thrombus !

10
 Angina pada SKA
• Angina tipikal persisten lebih dari 20 menit
• Angina de novo CCS kelas III
• Angina kresendo CCS kelas III
• Angina pasca infark
• Rasa tidak nyaman di daerah
substernal
• Dipacu oleh stress atau aktivitas
• Berkurang dengan istirahat atau
pemberian nitrat
Juzar DA, et al. Pedoman Tataalaksana SKA. PERKI. 2018
12
ACS Diagnosis
0-3 h
Algorithm
ACS Diagnosis
0-1 h
Algorithm
INITIAL TREATMENT
2018
Morphine
Morphine • Can be repeated per 10 – 30 min, for
M sulfate
sulfate iv
1-5
1-5 mg
mg
iv patient who not responsive

O O
O22 • when SaO2 < 90% or PaO < 60

N NTG
NTG // ISDN
ISDN
• If ongoing chest pain by the time admitted at ER

A ASPIRIN
ASPIRIN
Loading
Loading
Ticagrelor
Ticagrelor
or
or
• 180 mg loading dose + 90 mg BID
• 300 mg loading dose + 75 mg OD if ticagrelor is
not available or contraindicated
160
160 –– 320mg
320mg clopidogrel*
clopidogrel*

Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

15
 General Approaches in ACS Patients

Bueno H and Vranckx P.

The Acute Cardiovascular
care Association Clinical
Decision-Making Toolkit.
European Society of
Cardiology. 2018. 1-208.
17
STEMI

18
19
Maximum
target times
according to
reperfusion
strategy
selection in
patients
presenting
via EMS or
in a non-
PCI center
20
PPCI Recommendation

Ibanez B, et al. European Heart Journal. 2017;39:119-177.

22
Importance of time to reperfusion in
STEMI patients

23
The STREAM (Strategic Reperfusion
Early After Myocardial Infarction) study

24
35 days
outcome of
fibrinolytic
s in STEMI

25
Estimation of risk for intracranial
hemorrhage (ICH) with fibrinolysis
Risk Factors

1.Age ≥ 75
2.Black
3.Female gender
4.Previous stroke history
5.SBP ≥ 160 mmHg
6.Low BW (Men ≤ 80, Women ≤ 65
Kg)
7.INR > 4 or PT > 24
8.TPA use (vs other thrombolytic
agents)

26
Fibrinolytic Agents for STEMI

27
28
Thrombolytic PPCI 29
NSTE-ACS

30
Ischemic Risk

31
Risk Stratification: GRACE Score
Points for Each Predictive Factor
SBP, Score
Killip Class Score Mm Hg
< 80 63
I 0 80 – 99 58
II 21 100 - 119 47
III 43 120 - 139 37
IV 64 140 - 159 26 High risk: Score >140
160 - 199 11
> 200 0 In-hospital death: >3%
Heart Rate,
Score
Beats/min
Age Score
< 70 0 < 40 0
70-89 7 40 - 49 18
90-109 13 50 - 59 36 Intermediate risk: 109 – 140
110 - 149
150 - 199
23
36
60 - 69
70 – 79
55
73
In-hospital death: 1-3 %
> 200 46 80 91

Predictive Factor Score Creatinine, (µmol/L) Score

0 - 34 2 Low risk: Score ≤ 108

35 – 70 5
• Cardiac arrest at • 43 71 – 105 8 In-hospital death: <1%
admission 106 – 140 11
• Elevated cardiac markers • 15 141 – 176 14
• ST Segment deviation • 30 177 – 353 23
≥ 354 31

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart
33
 Risk Criteria Mandating Invasive Strategy
in NSTE-ACS
• Hemodynamic instability or cardiogenic shock • Relevant rise or fall in troponin
VERY HIGH

• Dynamic ST- or T-wave changes

HIGH RISK
• Recurrent or ongoing chest pain refractory to
medical treatment (symptomatic or silent)
RISK

• Life-threatening arrhythmias or cardiac arrest • GRACE Score > 140

• Mechanical complications of MI
• Acute heart failure
• Recurrent dynamic ST-T wave changes,
particularly with intermittent ST-elevation
INTERMEDIATE

• Diabetes mellitus • Any characteristics not mentioned above

• Renal insufficiency

LOW RISK
(eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF
• Early post infarction angina
• Prior PCI
• Prior CABG
• GRACE risk score 109 - 140

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

Aggressive approach recommended in HIGH
RISK-NSTE-ACS Patient

Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

THANK YOU

36