SymCARD

4
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2014
Up Date on
Acute Coronary Syndrome
Management
Dr . Muhammad Fadil, Sp!
SymCARD 2014
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Pendahuluan

Sindrom "oroner A#ut $S"A% Mening#at#an ang#a

pera&atan dan "ematian di 'eluruh dunia

Saat ini !enanganan S"A 'udah mengalami (anya#

#ema)uan di(anding 2 de#ade tera#hir
2
Mar'o S!, et al. Compari'on o* Myocardial Reper*u'ion in !atient' Undergoing
!ercutaneou' Coronary +nter,ention in S-.Segment /le,ation Acute Myocardial
+n*arction 0ith 1er'u' 0ithout Dia(ete' Mellitu'. Am Cardiol 200231004 205.210
"la'i6#a'i S"A
/SC 7uideline' *or the management o* Acute Coronary Syndrome in
patient' &ithout per'i'tent S- /le,ation.2011
SymCARD 2014
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8yeri Dada "ha' +n*ar#

8yeri dada Angina Saat +'tirahat $920

Menit%

8yeri dada angina !ertama "ali $de

8u,o% dengan ting#atan CCS +++

Cre'endo Angina

Angina !a'#a +n*ar#

SymCARD 2014
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/le#tro#ardiogra6

-he mo't important

Serial /"7 i' routinely

Cla''i*y ACS

Determine 'e,erity and

progno'i'
SymCARD 2014
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/le,a'i Segmen S- pada !oint pada 2 lead yg

(erhu(ungan

:0.2; m1 !ada la#i.la#i di(a&ah 40th

:0.2 m1 pada la#i.la#i diata' 40th, or :0.1; m1

pada &anita di lead 12<1= dan>atau :0.1 m1 pada
lead lainnya
Depre'i Segmen S- hori?ontal>do&n'loping (aru : 0.1 m1
pada 2 lead yg (erhu(ungan
- +n,erted : 0.1 m1
/SC 7uideline' *or the management o* acute myocardial in*arction in patient'
pre'enting
&ith S-.'egment ele,ation. 2011.
STE
MI
NSTEMI/UAP
Mar#a antung
!ada pa'ien dg S"A !ening#atan en?inm -roponin ter)adi 4
jam setelah onset gejala
-roponin dapat (ertahan 'elama 2 minggu didalam darah
!emeri#'aan 'erial haru' dila#u#an dlm 5.12 )am )i#a
pemeri#'aan pertama negati*!emeri#'aan C"M@ atau -roponin
- 'angat (erman*aat ut# mendiagno'i' S"A
/SC 7uideline' *or the management o* Acute Coronary Syndrome in
patient' &ithout per'i'tent S- /le,ation.2012
SymCARD 2014
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Angiography Coroner
SymCARD 2014
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@agaimana !enanganan S"AA
SymCARD 2014
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-irah @aring $"ela' 1C%
B#'igen ut# pa'ien dg Satura'iCD;E atau di'tre'
na*a'$+.C%
Suplemen B#'igen di(eri#an ut# 'emua S"A dlm 5 )am pertama tanpa
mempertim(ang#an Satura'i $++a.C%
A'pirin tanpa 'alut 150.=20 mg pd 'emua p' yg toleran
thdp A'pirin $+.C%
Clopidogrel do'i' a&al =00 mg, dilan)ut#an 2; mg>hari$+.C%
10
-inda#an Umum F Gang#ah A&al
5
4
2
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
Suplemen B#'igen di(eri#an ut# 'emua S"A dlm 5 )am pertama tanpa
mempertim(ang#an Satura'i $++a.C%
5
Anti +'#emi#4 8-7 'pray>ta( $+.C%, Mor6n 'ul*at 1.; mg +1 dpt diulang 'etiap
10.=0 menit $++a.@%
5
SymCARD 2014
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Persangkaan
SKA
8on
"ardia#
Angina Sta(il
$"roni#%
"emung#inan
S"A
De6niti* S"A
EK! Normal
atau
nondiagnostik
Marka "antung
a#al! Normal
B('er,a'i 12 )am 'etelah
a&itan Angina
Angina td#
(erulang
/"74td# (eru(ah
Mar#a
)antung48ormal
NEATI$
Diagno'ti#4 @u#an S"A atau
Re'i#o rendah S"A
P%SITI$
Diagno'i'4 De6niti* atau
'angat mung#in S"A
Angina (erulang,atau
/"74 peru(ahan S-
dan>atau gelom(ang
-
Mar#a antung 4
po'iti*
&e'niti(
SKA
Tera)i
NSTEMI
Tan)a Ele*asi
segmen ST
Ele*asi segemen ST
+STEMI, atau -...
.aru
!eru(ahan S-
dan>atau
7elom(ang -
Angina (erlan)ut
Mar#a antung !o'iti*
Hemodinami#
a(normal
E*aluasi tera)i
re)er(usi
!emantauan ra&at alan
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
Algoritma e*aluasi dan
tatalaksana SKA
SymCARD 2014
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Tera)i /e)er(usi )ada STEMI
I!atient' &ith cardiogenic 'hoc# or 'e,ere heart *ailure initially 'een at a non<!C+.capa(le ho'pital 'hould (e tran'*erred *or cardiac catheteri?ation and re,a'culari?ation a'
'oon a' po''i(le, irre'pecti,e o* time delay *rom M+ on'et $Class I, LOE: B%. JAngiography and re,a'culari?ation 'hould not (e per*ormed &ithin the 6r't 2 to = hour' a*ter
admini'tration o* 6(rinolytic therapy.
D+DB K door.in.door.out
SymCARD 2014
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i#a 0a#tu yang di(utuh#an
untu# mecapai RS dg Fa'ilita'
!C+ 9 2)am
-akukan $i0rinolitik &i /S
anda 1
SymCARD 2014
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"ontra +ndi#a'i Fi(rinoliti#
Kontraindikasi A0solut Kontraindikasi /elati(
Stro#e hemoragi# atau 'tro#e yg
penye(a(nya (lm di#etahui dg
a&itan #apanpun
-ran'ient +'chaemic Attact$-+A%
dlm 5 (ulan tera#hir
Stro#e i'#emi# 5 (ulan tera#hir !ema#aian anti#oagulan oral
"eru'a#an 'i'tem 'yara* 'entral
dan neopla'ma
"ehamilan atau dalam 1 minggu
po't.partum
-rauma opera'i>trauma #epala yg
(erat dalam = minggu tera#hir
Re'u'ita'i traumati#
!enya#it perdarahan Hiperten'i re*ra#ter $-DS 91L0
mmHg%
Di'e#'i aorta !enya#it hati lan)ut
+n*e#'i endo#arti'
Ultu' pepti#um yang a#ti*
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Regimen Fi(rinoliti# untu# +n*ar#
Mio#ard A#ut
Agen &osis A#al Ko Tera)i
Antitrom0otik
Kontraindikasi
s)esi'k
Strepto#ina'e $S#% 1,; )uta U dalam
100 ml deMtro'e ;E
atau dlm larutan
'alin 0,DE dlm =0.
50 menit
Heparin i, 'elama
24.4L )am
Se(elum S" atau
Ani'trepta'e
Altepla'e $t!A% @olu' 1;mg +1
0,2; mg>#g 'elama
=0 menit, #emudian
0,; mg>#g 'elama
50 mrnit
Do'i' total tida#
le(ih dari 100 mg
Heparin +1 'elama
24.4L )am
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Anti
+'#emi
#
!enye#at @eta $@eta @loc#er%
$"ela' +.@%
8itrat $"ela' +.C%
Calcium Channel @loc#er $CC@%
$"ela' +.@%
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Anti
!latel
et
A'pirin 4 do'i' loading 1;0.=00 mg, do'i'
pemeliharaan 2;.100 mg
-icagrelor4 do'i' loading 1L0 mg,do'i'
pemeliharaan 2MD0 mg
Clopidogrel4 Do'i' loading =00 mg, do'i'
pemeliharaan 2; mg>hari
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Anti
!latel
et
A'pirin 4 do'i' loading 1;0.=00 mg, do'i'
pemeliharaan 2;.100 mg
-icagrelor4 do'i' loading 1L0 mg,do'i'
pemeliharaan 2MD0 mg
Clopidogrel4 Do'i' loading =00 mg, do'i'
pemeliharaan 2; mg>hari
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Ace
+nhi(itor
$Mengurangi
remodelling,
menurun#an
ang#a
#ematian
pa'ca.in*ar#%
Captopril 4 2.= M 5,2;.;0 mg
Ramipril 4 2,;.10 mg>hari dalam 1
atau 2 do'i'
Gi'inopril4 2,;.20 mg>hari dalam 1
do'i'
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Stati
n
2arus di0erikan pada 'etiap pa'ien S"A $tanpa
#ontraindi#a'i%Anti inNama'i dan 'ta(ili'a'i !la#
$"ela' +.A%
-erapi 'tatin do'i' tinggi henda#nya dimulai '(lm
pa'ien #eluar RS, target -&-3455 mg/d- $"ela'
+.A%
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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Tera)i NSTEMI
Anti
"oagula
n $2A/US
&ITAM.A2KA
N pd terapi
Antiplatelet
Secepat
Mung#in%
$unda)arinuks 4 2,; mg 'u(#utan +Kelas I6A,
/no#'aparin 4 1 mg>#g,dua #ali 'ehari +Kelas I6.,
UFH 4@olu' i., 50 u>g,do'i' ma# 4000 U, +n*u' i., 12 U>#g
'elama 24.4L )am dg do'i' ma#'imal 1000 U>)am, -arget
a!-- 1,; < 2M "ontrol +Kelas I67,
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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-erapi Reper*u'i pada 8S-/M+
/ekomendasi Kelas rekomendasi -e*el
Urgent P7I
+32 jam,
Angiography 'egera
dila#u#an $C2 )am% pd
pa'ien dengan4
Angina re*ra#ter
7agal antung
Aritmia ,entri#el yg
mengancam
Hemodinami# td#
'ta(il
+ C
Earl8
In*asi*e
+324 jam,
!ada pa'ien dengan
S#or 7RAC/ 9 140
atau dengan paling
tida# 1 #riteria re'i#o
tinggi
+ A
In*asi*e
Strateg8 +92
jam setelah
)resentasi,
1 #riteria re'i#o tinggi
7e)ala re#uren
+ A
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
SymCARD 2014
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7race Score
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S"A
Anti
!latelet
Anti
"oagulan
Re'i#o
!erdarahanO
Mencegah
-rom(o'i' Ge(ih
Gan)ut
!rogno'i' @ai# !rogno'i' @uru#
SymCARD 2014
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Hu(ungan !erdarahan dengan Ang#a "ematian
SymCARD 2014
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25:59;
Patients
42:5<2
Patients
SymCARD 2014
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C
u
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u
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a
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i
v
e

H
a
z
a
r
d
0.0
0.01
0.02
0.03
0 3 6 9 12 15 18 21 24 27 30
HR: 0.83
95 C!: 0.71"0.97
#$0.02
%&'(a#ari&
)'&da#ari&u(
0.04
$onda)arinu= Signi'>antl8 /edu>ed Mortalit8
vs. Eno=a)arin u) to &a8 ?5
1. Arixtra
TM
PI BPOM GDS04/IPI04 (23 January 200!.
1. Sa"i# $usu%& 't a". ()#*aris)n )% +)n,a*arinux an, -n)xa*rin' in A.ut' ()r)nary Syn,r)#'.
Th' /%th )r0ani1ati)n t) ass'ss strat'0i's in A.ut' Is.h'#i. Syn,r)#' inv'sti0at)r. 2 -0" J M', 200343544144363.
$onda)arinu= /edu>ed the /ate o( the 7om)osite
o( &eath: MI or Stroke u) to @ Months
0.0
Days
0 20 40 60 80 100 120 140 160 180
C
u
m
u
l
a
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i
v
e

H
a
z
a
r
d
HR: 0.89
95 C!: 0.82"0.97
#$0.007
%&'(a#ari&
)'&da#ari&u(
0.02
0.04
0.06
0.08
0.10
0.12
0.14
1. Arixtra
TM
PI BPOM GDS04/IPI04 (23 January 200!.
1. Sa"i# $usu%& 't a". ()#*aris)n )% +)n,a*arinux an, -n)xa*rin' in A.ut' ()r)nary Syn,r)#'.
Th' /%th )r0ani1ati)n t) ass'ss strat'0i's in A.ut' Is.h'#i. Syn,r)#' inv'sti0at)r. 2 -0" J M', 200343544144363.
SymCARD 2014
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Days
C
u
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u
l
a
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i
v
e

H
a
z
a
r
d
0.0
0.01
0.02
0.03
0.04
0 1 2 3 4 5 6 7 8 9
HR: 0.52
95 C!: 0.44"0.61 #*0.001
%&'(a#ari&
)'&da#ari&u(
$onda)arinu= Patients E=)erien>ed 2al( the /ate o(
Major .leeding Than Eno=a)arin Patients at &a8 <
+Primar8 Sa(et8,
1. Arixtra
TM
PI BPOM GDS04/IPI04 (23 January 200!.
1. Sa"i# $usu%& 't a". ()#*aris)n )% +)n,a*arinux an, -n)xa*rin' in A.ut' ()r)nary Syn,r)#'.
Th' /%th )r0ani1ati)n t) ass'ss strat'0i's in A.ut' Is.h'#i. Syn,r)#' inv'sti0at)r. 2 -0" J M', 200343544144363.
SymCARD 2014
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"e'impulan

S"A merupa#an merupa#an penye(a( utama #ematian

mendada# di dunia

Diagno'i' dan tatala#'ana meliputi, !em(erian antiplatelet,

anti i'#emi#, anti#oagulan, 'tatin dan Ace inhi(itor, -erapi
Re,a'#ulari'a'i $!C+ atau Fi(rinoliti#% untu# S-/M+

!erdarahan Merupa#an re'i#o yg mung#in t)d 'elama terapi

S"A

Fundaparinu# Secara #e'eluruhan memili#i pro6l #eamanan

(er(anding ri'i#o yg paling (ai# $"ela' +.A%
SymCARD 2014
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-erima#a'ih