ACS Lecture

Acute Coronary Syndrome
Sindroma Koroner Akut
Fakultas Kedokteran
Universitas Brawijaya
Malang
DEFINISI
Suatu sindroma klinik yang menandakan
adanya iskemia miokard akut, terdiri dari :
 Infark miokard akut dng elevasi segmen ST
(STEMI)
 Infark miokard akut tanpa elevasi segmen ST
(NSTEMI)
 Angina pektoris tidak stabil (UAP)
Ketiga kondisi ini sangat berkaitan erat, berbeda hanya

dalam derajat beratnya iskemi dan luasnya miokard
yang mengalami nekrosis. 2
PATOGENESIS
• Umumnya disebabkan oleh aterosklerosis
koroner
• Plak aterosklerosis ruptur  terbentuk
trombus diatas ateroma yang secara akut
menyumbat lumen koroner
• Apabila sumbatan terjadi secara total 
hampir seluruh dinding ventrikel akan
nekrosis
3
Faktor risiko penyakit jantung koroner
Non modifiable Modifiable
•Sex •High blood pressure
•Hereditary •High blood cholesterol
•Race •Smoking
•Age •Physical activity

•Obesity
•Diabetes
•Stress and anger
The cardiovascular continuum of events
Ischemia = imbalance of
oxygen supply and demand
Myocardial
Ischemia
CAD
plaque
Atherosclerosis
Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from
ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from
Stable angina
Plaque rupture
Coronary thrombosis UA/NSTEMI
STEMI
Penyempitan
Pembuluh darah
Clinical Spectrum of Acute Coronary Syndrome
Acute Coronary Syndrome
Non-ST Segment ST Segment

Elevation Elevation
STEMI
NSTEMI
Unstable Non-Q-wave Q-wave
Angina Pectoris Acute Myocardial Infarction
Unstable
NSTEMI STEMI
Angina
Occluding thrombus Complete thrombus

Non occlusive occlusion
sufficient to cause
thrombus
tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG
ST depression +/-
T wave inversion on Elevated cardiac
Normal enzymes
ECG
cardiac
enzymes More severe
Elevated cardiac
enzymes symptoms
Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
HISTORY
PRODROMAL SYMPTOMS
History very valuable to establish D/. Prodomal : chest discomfort –
unstable angina
1/3 symptoms for 1 – 4 wks
20% symptoms for < 24 hrs
Malaise, exhaustion
NATURE OF PAIN
• Most patients
severe prolonged,  30 minutes - hours
• Constricting, crushing, oppressing, compressing
heavy weight or squeezing in chest
• Choking, vise-like, heavy pain or stabbing, knife-like, boring or
burning discomfort
• Location : retrosternal, spreading frequently to both sides of the
chest with predilection to the left side
• Often pain radiates down ulnar 13 aspect of left arm, producing
tingling sensation in left wrist, hand and fingers
NATURE OF PAIN
• SOME INSTANCES : pain begins in epigastrium, and simulates
abdominal disorder
• Sometimes pain radiates to shoulders, upper extremities, neck, jaw
and interscapular region favoring the left side
• Elderly : no chest pain but acute left ventricular failure and chest
tightness or marked weakness or syncope
• Pain arises from nerve endings in ischemic or injured, but not necrotic,
myocardium
OTHER SYMPTOMS
50% nausea or vomiting in transmural infarcts
Occasionally diarrhea, profound weakness, dizziness, palpitation, cold
perspiration, sense of impending doom
Occasionally : cerebral embolism or systemic arterial embolism
14
Pain Patterns with Myocardial
Ischemia
15
Anamnesis untuk UAP
• 3 kategori presentasi klinik UAP:
 Angina saat istirahat (resting angina)
 Angina awitan baru (new or first onset angina)
 Angina yang bertambah berat (increasing
angina, crescendo angina)
• Riwayat penyakit dahulu :

 Riwayat angina on effort, infark atau operasi
pintas
 Riwayat penggunaan nitrogliserin
 Identifikasi faktor-faktor risiko
16
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Anxious, considerable distress, restless, fist on chest
(Levine sign)
LV failure & symp. stimulation : cold perspiration, pallor,
dyspnea, cough with frothy pink or blood-streaked
sputum.
Shock : cool, clammy skin, facial pallor, cyanosis,
confusion or disorientation
HEART RATE
Variable depending on underlying rhythm and degree or
ventr. failure
Most commonly, HR 100 – 110/min; > 95% patients :
VPB’s within first 4 hours 17
BLOOD PRESSURE
Majority normotensive, but syst. BP may decline and diast.
BP may rise
 Half of pts with inferior MI  parasympathetic stimulation
: hypotension, bradycardia or both (Bezold – Jarisch
reflex)
 half of pts with anterior MI,  sympathetic excess :
hypertension, tachycardia or both
TEMPERATURE AND RESPIRATION

Most pts with extensive MI  fever within 24-48 hrs, fever
resolves by 4th or 5th day
Respiration  due to anxiety and pain, in LV failure : resp.
rate correlates with degree of heart failure
18
JUGULAR VENOUS PULSE
JVP usually normal
RV infarction : marked jug. venous distension
CAROTID PULSE
Small pulse  reduced stroke volume
Pulse alternans : severe LV dysfunction
19
CHEST
LV failure and/or LV compliance ↓ : moist rales
Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification
Class I : patients free of rales or S3

II : rales < 50% lung fields +/- S3
III : rales > 50% lung fields, frequently
pulm. edema
IV : cardiogenic shock
20
Pemeriksaan Penunjang
• Pemeriksaan EKG
Gambaran EKG infark miokard akut dng elevasi ST

(STEMI) :
 Elevasi segmen ST  1 mm pada  2 sadapan

extremitas
 Atau  2 mm pada  2 sadapan prekordial yang

berurutan
 Atau gambaran LBBB baru atau diduga baru

21
ST-segment elevation
Gambaran EKG infark miokard akut non-Q-
wave (NSTEMI) atau angina pektoris tidak
stabil (UAP) :
– Depresi segment ST atau gelombang T

terbalik pada  2 sadapan berurutan
– Inversi gelombang T minimal 1 mm pada 2

sadapan atau lebih yang berurutan.
– Perubahan segment ST saat keluhan dan

kembali normal saat keluhan hilang 
sangat menyokong UAP 25
ST-segment depression
T-wave inversion
ELEKTROKARDIOGRAM
Current-of-injury patterns with acute

ischemia
28
• Pemeriksaan Penanda Jantung/Enzim jantung
(Cardiac Markers):
Yang lazim adalah CKMB, dapat pula troponin T (TnT)

atau troponin I (TnI)
Peningkatan marka jantung akan terlihat pada infark

miokard akut Q-wave (STEMI) dan non-Q-wave
(NSTEMI)
29
Plot of the appearance of cardiac markers in
blood versus time after onset of symptoms
A myoglobin C CK-MB
30
B troponin D troponin in UA
Diagnosis Banding
1. Diseksi aorta
2. Perikarditis
3. Nyeri angina atipikal pada kardiomiopati
hipertrofi
4. Penyakit esofageal, GI atas atau traktus biliaris
5. Penyakit paru-paru : pneumotoraks, emboli,
pleuritis
6. Sindroma hiperventilasi
7. Gangguan dinding dada : muskuloskeletal,
neurogen
8. Psikogen 31
Algorithm for the diagnosis of acute chest pain
Symptoms from the chest:

Intensity?
Duration?
Localization?
Referred pain?
Changes with posture/movement?
Influenced by food/fluid intake?
Reaction to nitroglycerine?
Cutaneous pain Visceral pain
Cardiac Non cardiac
Ischaemic Non-ischaemic
Muscle Lung
GI
Skeleton Aorta
Mediastinum
Skin Psychiatric
AMI Myocarditis
Cardiomyopathy
ACS Pericarditis
Manajemen
ACS Meninggal
Coronary
Thrombosis Arrhythmia and
Loss of Muscle
Myocardial
Ischemia Remodeling
Ventricular
CAD Dilatation
Atherosclerosis Congestive
Heart Failure
Risk Factors End-stage Heart

( DYSLIPIDEMIA , BP, DM, Disease
Fibrinogen, etc)
Adapted from
Focused History
 Aid in diagnosis and  Reperfusion questions
rule out other causes
 Timing of presentation
 Palliative/Provocative  ECG c/w STEMI
factors
 Contraindication to
 Quality of discomfort fibrinolysis
 Radiation  Degree of STEMI risk
 Symptoms associated
with discomfort
 Cardiac risk factors
 Past medical history -
especially cardiac
Targeted Physical
 Examination  Recognize factors that
 Vitals increase risk
 Cardiovascular  Hypotension
system  Tachycardia
 Respiratory  Pulmonary rales, JVD
system (jugular venous distention),
 Abdomen pulmonary edema,
 Neurological  New murmurs/heart sounds
status  Diminished peripheral
pulses
 Signs of stroke
DELAY TO THERAPY
1. From onset of symptoms to patient recognition
2. Out-hospital transport
3. In-hospital evaluation
ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
ISCHEMIC CHEST PAIN
TYPICAL ANGINA EQUIVALENT ANGINA
1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT 2. LOCATION
2. LOCATION 3. INDIGESTION
3. RADIATION 4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS 5. DIAPHORESIS
6. SHORTNESS OF BREATH
Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Immediate ED assessment ( 10 min) Immediate ED general treatment

• Vital sign • O2 at 4 L/min (maintain O2 sat 90%)
• Oxygen saturation • Aspirin 160-325 mg
• Obtain IV access • Nitroglycerin SL, spray, or IV
• Obtain ECG 12 lead • Morphine IV 2-4 mg repeated every
• Brief history and physical exam 5-10 minutes (if pain not relieved
• Check contraindication for fibrinolytic with nitroglycerine)
• Initial serum cardiac markers
• Initial electrolyte and coagulation Memory: “MONA” greets all patients
study
• Portable chest x-ray ( 30 minutes)
Review initial 12 lead ECG
ECG assessment
ST Elevation or new LBBB

STEMI
ST Depression or dynamic
T wave inversions
NSTEMI
Non-specific ECG
Unstable Angina
Normal or non-diagnostic EKG
ST Depression or Dynamic T
wave Inversions
ST-Segment Elevation MI
New LBBB
QRS > 0.12 sec

L Axis deviation
Prominent S wave 1, aVL, V5-V6

with t-wave inversion
Cardiac Care Goals
 Decrease amount of myocardial necrosis

 Preserve LV function
 Prevent major adverse cardiac events
 Treat life threatening complications
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
ST elevation or new or ST-depression or

presumably new LBBB dynamic T-wave
strongly suspicious for inversion strongly
injury suspicious for injury
ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)
ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)
Start adjunctive treatment
ADJUNCTIVE TREATMENT
(Do not delay reperfusion)
1. Beta-adrenergic receptor blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)
ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves
Start adjunctive treatment
Time from onset of

symptoms
 12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin

injury waves
Start adjunctive treatment Start adjunctive treatment
Time from onset of

symptoms
 12 hours
- Reperfusion strategy: PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin
Adjunctive treatment
• Heparin (UFH/LMWH)
• Glycoprotein IIb/IIIa receptor inhibitors
• -Adrenoreceptor blockers
• Clopidogrel

injury waves
Start adjunctive treatment Start adjunctive treatment
Time from onset of  12 hrs Admit to monitored bed

symptoms Assess risk status
 12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
min) or fibrinolysis (30 min) strategy
- ACE-I/ARB within 24 h of - Continue ASA, heparin,
symptom onset) ACE-I, statin
- Statin
VERY HIGH-RISK PATIENT
1. Refractory chest pain
2. Recurrent/persistent ST deviation
3. Ventricular tachycardia
4. Hemodynamic instability
5. Sign of pump failure
6. Shock within 48 hours

injury waves
Start adjunctive treatment Start adjunctive treatment Develops high or

intermediate risk criteria
or troponin-positive
Time from onset of  12 hrs Admit to monitored bed
symptoms Assess risk status
Monitored bed in ED
 12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
strategy Develops high or
min) or fibrinolysis (30 min)
- Continue ASA, heparin, intermediate risk criteria
- ACE-I/ARB within 24 h of
ACE-I, statin or troponin-positive
symptom onset)
- Statin
No evidence of ischemia and MI: discharge with follow-up
Fibrinolysis indications
 ST segment elevation >1mm in two contiguous

leads
 New LBBB
 Symptoms consistent with ischemia
 Symptom onset less than 12 hrs prior to
presentation
Absolute contraindications for fibrinolysis
therapy in patients with acute STEMI
 Any prior ICH (intracerebral hemorrhage)
 Known structural cerebral vascular lesion (e.g., AVM)
 Known malignant intracranial neoplasm
(primary or metastatic)
 Ischemic stroke within 3 months EXCEPT acute
ischemic stroke within 3 hours
 Suspected aortic dissection
 Active bleeding or bleeding diathesis (excluding
menses)
 Significant closed-head or facial trauma within 3
months
Relative contraindications for fibrinolysis
therapy in patients with acute STEMI
 History of chronic, severe, poorly controlled hypertension
 Severe uncontrolled hypertension on presentation (SBP
greater than 180 mm Hg or DBP greater than 110 mmHg)
 History of prior ischemic stroke greater than 3 months,
dementia, or known intracranial pathology not covered in
contraindications
 Traumatic or prolonged (greater than 10 minutes) CPR or
major surgery (less than 3 weeks)
 Recent (within 2-4 weeks) internal bleeding
 Noncompressible vascular punctures
 For streptokinase/anistreplase: prior exposure (more than 5
days ago) or prior allergic reaction to these agents
 Pregnancy
 Active peptic ulcer
 Current use of anticoagulants: the higher the INR, the higher
the risk of bleeding
Pengobatan Pasca Perawatan
 Obat-obat untuk mengontrol keluhan iskemia
harus dilanjutkan
 Aspirin
 Beta-blocker
 ACE inhibitor
Modifikasi Faktor Risiko

 Berhenti merokok
 Pertahankan BB optimal
 Aktivitas fisik sesuai dengan hasil treadmill
 Diet
 Rendah lemak jenuh dengan kolesterol, bila perlu
dengan target LDL < 100 mg/dL
 Pengendalian hipertensi
 Pengendalian ketat gula darah pada penderita DM 67
•Get regular medical checkups.
•Control your blood pressure.
•Check your cholesterol.
•Don’t smoke.
•Exercise regularly.
•Maintain a healthy weight.
•Eat a heart-healthy diet.
•Manage stress.
Algorithm for the diagnosis of acute chest pain
Symptoms from the chest:

Intensity?
Duration?
Localization?
Referred pain?
Changes with posture/movement?
Influenced by food/fluid intake?
Reaction to nitroglycerine?
Cutaneous pain Visceral pain
Cardiac Non cardiac
Ischaemic Non-ischaemic
Muscle Lung
GI
Skeleton Aorta
Mediastinum
Skin Psychiatric
AMI Myocarditis
Cardiomyopathy
ACS Pericarditis
CONCLUSION
 With increase burden of CVD, and lack of health

resources risk stratification becomes important.
 Emphasis should also be placed on primary

&secondary prevention of ACS.
 Early intervention helps prevent complications,

decreases morbidity & mortality
 The way forward – fully equipped CHEST PAIN

OBSERVATION UNIT
Alhamdulillah
Syukron
katsiraa
Thank You
Arigato
Terima Kasih
Matur
Nuwun
Thank you for your attention
Anamnesis
• Nyeri dada atau nyeri epigastrium hebat yang mengarah
pada iskemia miokard :
 Seperti dihimpit benda berat
 Terasa tercekik
 Rasa ditekan, ditinju, ditikam
 Rasa terbakar
Biasanya dirasakan dibelakang stenum  seluruh dada
terutama kiri, dapat ke tengkuk, rahang, bahu,
punggung, lengan kiri atau kedua lengan
• Terutama laki-laki > 35 tahun dan Wanita > 40 tahun
• Seringkali disertai mual atau muntah, dapat pula rasa

tidak enak disertai sesak nafas, lemah, penurunan
kesadaran, dan keringat banyak 73
Pemeriksaan Fisik
• Biasanya penderita tampak cemas, gelisah, pucat, dan

keringat dingin
• Periksa tanda-tanda vital :
 Denyut nadi cepat, reguler tetapi dapat pula bradi
atau tachycardia, irama ireguler
 Tekanan darah biasanya normal bila belum terjadi
komplikasi, dapat pula terjadi hipo atau hipertensi
 Bunyi jantung dapat terdengar redup
 S3 dapat terdengar bila kerusakan miokard luas
 Paru-paru dapat terdengar ronkhi basah dan atau
wheezing yang menandakan terjadinya bendungan
paru  tergantung ada tidaknya gangguan fungsi
ventrikel kiri 74

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Acute Coronary Syndrome

Sindroma Koroner Akut

Ketiga kondisi ini sangat berkaitan erat, berbeda hanya

Non modifiable Modifiable

•Sex •High blood pressure

•Hereditary •High blood cholesterol

•Age •Physical activity

Acute Coronary Syndrome

Non-ST Segment ST Segment

Occluding thrombus Complete thrombus

• Riwayat penyakit dahulu :

TEMPERATURE AND RESPIRATION

Class I : patients free of rales or S3

Gambaran EKG infark miokard akut dng elevasi ST

 Elevasi segmen ST  1 mm pada  2 sadapan

 Atau  2 mm pada  2 sadapan prekordial yang

 Atau gambaran LBBB baru atau diduga baru

– Depresi segment ST atau gelombang T

– Inversi gelombang T minimal 1 mm pada 2

– Perubahan segment ST saat keluhan dan

Current-of-injury patterns with acute

Yang lazim adalah CKMB, dapat pula troponin T (TnT)

Peningkatan marka jantung akan terlihat pada infark

Symptoms from the chest:

Cutaneous pain Visceral pain

Cardiac Non cardiac

Risk Factors End-stage Heart

1. From onset of symptoms to patient recognition

TYPICAL ANGINA EQUIVALENT ANGINA

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Immediate ED assessment ( 10 min) Immediate ED general treatment

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST Elevation or new LBBB

QRS > 0.12 sec

Prominent S wave 1, aVL, V5-V6

 Decrease amount of myocardial necrosis

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

1. Beta-adrenergic receptor blocker

3. Heparin (UFH or LMWH)

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-