Guidelines of Implementation for the Management of Acs Focus on Coronary Intervention

CURRICULUM VITAE

Nama : Dr. dr. Budi Yuli Setianto SpPD (K) SpJP (K)

Tempat, tanggal lahir : Purworejo, 14 Juli 1957

Current Education :

Internist : Universitas Gadjah Mada (1995)

Cardiologist-KKV : Universitas Indonesia (1999) (2001)

Intervensionist-Cardiologist : Universitas Indonesia (2005)

Current Position:

Kepala Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah

Mada/RSUP dr. Sardjito Yogyakarta

Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP

dr. Sardjito Yogyakarta

Guidelines of Implementation for

the Management of ACS: Focus on

Coronary Intervention

Budi Yuli Setianto

Department of Cardiology and Vascular Medicine Faculty of Medicine Gadjah Mada University Sardjito Hospital Yogyakarta

2

Spectrum of ACS

3Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Clinical Presentation

Working diagnosis

ECG

Biomarker

Diagnosis

Chest Pain

ST Elevation

ST-T Abnormalities

ECG-NUnclear

Acute coronary syndrome

Management choice

STEMI

Revascularization

Antithrombotic

Antiischemic

NSTEMI/UAP

Antiischemic

Antithrombotic

Revascularization

4

MANAGEMENTSTRATEGY of NSTEMI / UAP

1. Initial treatment and evaluation in the ER

5

2. Validation of the diagnosis and determination of risk (risk of ischemic vs. the risk of bleeding)

3. Invasive strategy

4. Revascularization modality

5. At and post discharge management

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Determining Invasive Strategy

Invasive or conservative strategy is determined by the

risk criteria, namely:

Criteria for high risk profile Criteria GRACE (GRACE score> 140 high) Very high risk criteria (very high risk) Does not meet the criteria of high risk

7

Criteria for high risk profile

The increase/ decrease in the levels of troponin ST and T wave changes (symptomatic/ silent) Diabetes mellitus Renal insufficiency (CCT

Validasi Cepat diagnosis NSTEMI-ACS

dengan Hs Troponin

Very high risk criteria (very high risk)

Refractory angina Acute heart failure Life-threatening ventricular arrhythmias Hemodynamically unstable

12

Timing angiography based on the determination

of four categories of strategies.

Urgent invasive strategy, if it meets one of the criteria is very high risk

Early invasive strategy within 24 hours, if the GRACE score> 140 plus one high-risk criteria

Early Invasive strategy in 72 hours if it meets one of the criteria for high risk

Conservative strategy or elective angiography if not found a high risk criteria

13

Invasive strategy

Revascularization modalities

If the angiogram showed atheromatous lesions but no lesions are critical, then treated with medication

In patients with single-vessel disease, then performed PCI

In patients with multi-vessel disease, PCI or CABG decision made according to individual circumstances.

If the option CABG decided, the anti-platelet drugs must stop 5 days to CABG done.


MANAGEMENTSTRATEGY of STEMI

1. Initial treatment and evaluation in the ER

16

2. Validation of the diagnosis and determination of risk (risk of ischemic vs. the risk of bleeding)

3. Invasive strategy

4. Revascularization modality

5. At and post discharge management


ACS registrys patient distribution

Consecutive ACSN=2797

STEMIN= 869 (31,1%)

NSTEMIN= 789 (28,2%)

FibrinolyticN= 96 (11%)

Primary PCI N= 263 (30%)

No reperfusion N= 510 (59%)

UAPN= 1139 (40,7%)

Source: JAC registry data base 2010, NCCHK

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259

Description of STEMI patient without

reperfusion (N=510, 59%)

Variables Description

Source of referral, n (%)

Walk in / ambulance 145 (28,4)

Primary physician 24 (4,7)

Inter-hospital 294 (57,6)

Intra-hospital 47 (9,2)

Location of STEMI, n (%)

Anterior 333 (65,3)

Non anterior 177 (34,7)

Onset of STEMI, n (%)

< 12 hour 90 (17,6)

12 hour 416 (81,6)

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)

In-hospital mortality

Percentage

(%)

PPCI Fibrinolytic No reperfusion

5,36,2

13,3

P

Prevent delay is an important part in the management

of STEMI

Morris F, Brady WJ. BMJ 2012;324;831-83421 Set area descriptor | Sub level 1

5- 30 min after the onset

1-2 hours

2-6 hours

Resolution segment - anterior to 2 weeks; posterior> 2 weeks

T wave resolution: months

ECG evolution in STEMI

Findings "Left bundle branch block"

STEMI in RBBB

Patients with signs and symptoms of

myocardial ischemia and atypical ECG

LBBB Ventricular pacemaker rhythm Diagnostic patients without ST segment elevation,

but no symptoms of ischemia

Isolated posterior myocardial infarction ST segment elevation in the "lead" aVR

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Revascularization

Fibrinolytic PCIVS.

Start adjuvant therapy

ADP antagonist

Ticagrelor Clopidogrel

Anti-ischemic

Nitrate Beta receptor blockers

Ob

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FIBRINOLYTIC vs. PRIMARY PCI

FIBRINOLYTIC

Onset of symptoms 90 minutes. Contraindications (-) 30 min (door-to-needle

time)

Primary PCI

Performed in 120 minutes Contraindications

fibrinolytic

"Door-to-balloon" 90 minutes

STEMI patients and cardiogenic shock and

severe heart failure

The diagnosis of STEMI doubt

1.Steg PG, et al. European Heart Journal. 2012;33:2569-2619 ; 2. Anderson JL, et al. Circulation. 2007;116:e148-e304.

STEMI Management

Aspirin

ADP antagonist

(Loading)

Clopidogrel75 yrs (-)

Aspirin

ADP antagonist

(Loading)

Ticagrelor 180 mg maintenance 90 mg

bid

600 mg clopidogrelmaintenance 75 mg

bid

Anti-P

late

lets

Fibrinolytic PCIVS.

Revascularization

The target of the treatment of STEMI

management

Delay Target

FMC to diagnosis and ECG < 10 minute

FMC to fibrinolysis (FMC - needle) < 30 minute

FMC to Primary PCI (balloon) at the

hospital with PCI facilities

Co therapy for primary percutaneous coronary

intervention

Antiplatelet

AspirinLoading doses of 150-300 mg po, followed by a maintenance

dose of 75-100 mg / day.

TicagrelorLoading dose of 180 mg po, followed by a maintenance dose of

90 mg bid

ClopidogrelLoading dose of 600 mg po, followed by a maintenance dose of

75 mg / day.

Source: www.google.co.id

The main problem in the capital, what

about your place?

Impact of delay PPCI

Modified from Nallamothu and Bates. Am J Cardiol 2003;92:824-6 (305).

The importance of immediate reperfusion

Documents

Guidelines of Implementation for the Management of Acs Focus on Coronary Intervention