ACUTE CORONARY SYNDROME (ACS)
ACUTE CORONARY SYNDROME (ACS)Arief Rahman HakimBagian
Farmakologi & Farmasi KlinikFak. Farmasi UGMDefinisiAcute
coronary syndromes (ACS) all clinical syndromes acute myocardial
ischemia imbalance between myocardial oxygen demand and supply.
berkurangnya myocardial blood flow occlusive or partially coronary
artery thrombus.ACS classified according to ECG changes :STEMI
(ST-segment-elevation miocardial infarction)nonSTsegment-elevation
ACS , includes nonST-segment-elevation myocardial infarction
(NSTEMI) and unstable angina (UA).STEMI pathologic Q waves
frequently on the ECG indicate transmural MI.EpidemiologiTiap tahun
>1,5 juta Americans will experience an ACS, and 220,000 will die
(MI)Chest discomfort is the second most frequent reason for patient
presentation to emergency departmentsIn-hospital death rates 4.6%
for patients with STEMI 2.2% for patients with NSTE
ACSPatofisiologiThe formation of atherosclerotic plaques cause CAD
and ACS in most patientsFactors responsible for development of
atherosclerosis include hypertension, age, male gender, tobacco
use, diabetes mellitus, obesity, and dyslipidemia.The cause of ACS
in more than 90% of patients rupture, or erosion of unstable
atheromatous plaque.
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Patogenesis iskemik miokardium8Angina Stabil & MIAngina
klasikInfark MiokardPenyebab : aterosklerosisNyeri : berat, sesak,
bisa menyebarPemicu : aktivitas fisikNyeri berkurang dg
istirahatNyeri hilang oleh GTNKebutuhan oksigen Obstruksi
parsialHipoksia miokardreversibelPenyebab : ateroskelrosisNyeri :
berat, sesak, bisa menyebarPemicu : tidak diketahuiNyeri
menetapNyeri tidak hilang oleh GTNPasokan oksigen Sumbatan
sempurnaAnoksia miokardirreversibelPatofisiologiVentricular
remodeling occurs after MI characterized by changes in the size,
shape, and function of the left ventricle lead to cardiac
failureComplications of MI include cardiogenic shock, heart
failure, valvular dysfunction, arrhythmias, pericarditis, stroke,
venous thromboembolism, and LV free-wall rupturePresentasi
KlinikThe predominant symptom of ACS chest discomfort (most often
occurring at rest), severe new-onset angina, at least 20 minutes.
The discomfort radiate to bahu, lengan kiri, punggung, atau rahang
Accompanying symptoms nausea, vomiting, or shortness of
breath.DiagnosisECG should be obtained within 10 minutes of patient
presentation.Key findings indicating myocardial ischemia or MI
ST-segment elevation, ST-segment depression, and T-wave
inversionBiochemical markers of myocardial cell death important for
confirming the diagnosis rise and gradual fall in troponin I or T
more rapid rise and fall of CK-MB
Outcome yang diharapkanShort-term goals of therapy include:
early restoration of blood flow to the infarct-related artery to
prevent infarct expansion (in the case of MI) or prevent complete
occlusion and MI (in UA), prevention of complications and death,
prevention of coronary artery reocclusion, Relief of ischemic chest
discomfort, andmaintenance of normoglycemia.
Tatalaksana terapiGeneral treatment include :hospital admission,
oxygen administration if saturation is less than 90%,continuous
multilead ST-segment monitoring for arrhythmias and ischemia,
glycemic control, frequent measurement of vital signs, bedrest for
12 hours in hemodynamically stable patients, use of stools
softeners to avoid Valsalva maneuver, andpain reliefTatalaksana
terapiBlood chemistry tests should be performed : potassium and
magnesium (which may affect heart rhythm), glucose (when elevated
places the patient at higher risk for morbidity and mortality),
Serum creatinine (to identify patients who may need drug dosing
adjustments),baseline complete blood cell count and coagulation
tests (because most patients receive antithrombotic therapy, which
increases bleeding risk), and fasting lipid profileTatalaksana
terapiPatients with STEMI high risk of death, and efforts to
reestablish coronary perfusion should be initiated immediately
(without evaluation of biochemical markers)Terapi
nonfarmakologiPatients with STEMI fibrinolysis or PCI (balloon
angioplasty or stent placement) , the treatment of choice for
reestablishing coronary artery blood flow when the patient presents
within 3 hours of symptom onset. Primary PCI may be associated with
a lower mortality rate than fibrinolysis, PCI opens more than 90%
of coronary arteries and 60% opened with fibrinolyticsThe risks of
intracranial hemorrhage (ICH) and major bleeding with
fibrinolysis.
Terapi nonfarmakologiPrimary PCI preferred if : institutions
have skilled interventional cardiologists and other necessary
facilities, patients with cardiogenic shock, patients with
contraindications to fibrinolytics, and patients presenting with
symptom onset more than 3 hours priorPCI (Percutaneus Coronary
Intervention)PTCA (percutaneous transluminal coronary
angioplasty)
PTCA (lanjutan)PTCA (lanjutan)
Coronary Artery Bypass Grafting (CABG)
Farmakoterapi stemiAwalAccording to the American College of
Cardiology/American Heart Association (ACC/AHA) practice
guidelines, early pharmacologic therapy should include: intranasal
oxygen (if oxygen saturation is less than 90%); sublingual (SL)
nitroglycerin (NTG); aspirin; -blocker;unfractionated heparin (UFH)
or enoxaparin; and fibrinolysis in eligible candidatesAwalMorphine
administered to patients with refractory angina as an analgesic.
ACE inhibitor should be started within 24 hours of presentation,
particularly in patients with left ventricular ejection fraction
(LVEF) 40%, signs of heart failure, or an anterior wall MI, if
there are no contraindications.Terapi Fibrinolitikindicated in
patients with STE ACS presenting within 12 hours of the onset of
chest discomfortIt is not necessary to obtain the results of
biochemical markers before initiating fibrinolytic therapy.Terapi
FibrinolitikAbsolute contraindications to fibrinolytic therapy
include: (1) active internal bleeding; (2) previous ICH at any
time; (3) ischemic stroke within 3 months; (4) known intracranial
neoplasm; (5) known structural vascular lesion; (6) suspected
aortic dissection; and (7) significant closed head or facial trauma
within 3 months. Primary PCI is preferred in these
situationsPractice guidelines indicate that a more fibrin-specific
agent (alteplase, reteplase, tenecteplase) is preferred over the
nonfibrin-specific agent streptokinaseTerapi FibrinolitikEligible
patients should be treated as soon as possible, but preferably
within 30 minutes from the time they present to the emergency
department,with one of the following regimens:Alteplase: 15-mg IV
bolus followed by 0.75-mg/kg infusion (maximum50 mg) over 30
minutes, followed by 0.5-mg/kg infusion (maximum 35 mg) over 60
minutes (maximum dose 100 mg).Reteplase: 10 units IV over 2
minutes, followed 30 minutes later withanother 10 units IV over 2
minutes.Tenecteplase: A single IV bolus dose given over 5 seconds
based onpatient weight: 30 mg if
