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SYNDROME
Overview
Definition of ACS
ACS refer to a constellation of clinical
symptoms and findings that represent
acute myocardial ischemia.
Common pathophysiological origins related
to coronary plaque progression, instability,
or rupture with or without luminal
thrombosis and vasospasm
ACS Classification :
ST-elevation myocardial infarction (STEMI)
Non-ST-elevation ACS (NSTE-ACS) : NSTEMI and UA
American Heart Association Heart Disease and Stroke Statistics-2008 Update
Hurst's The Heart, 12th Edition, Mayo clinic cardiology 3rd edition
Diagnostic Tools
Clinical symptom and physical
examination
ECG
Cardiac Biochemical markers
Echocardiography
Imaging of the coronary anatomy
Angina Pectoris
SUPPLY
DEMAND
UA/NSTEMI
THREE PRINCIPAL PRESENTATIONS
Rest Angina*
minutes
STEMI
UAP/NSTEM
I
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection
Tension pneumothorax
Pulmonary
Boerhaave syndrome
embolus
Perforating ulcer
mediastinitis)
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other
Cardiovascular and Nonischemic
Pericarditis
Atypical angina
Early repolarization
Wolff-Parkinson-White
syndrome
Deeply inverted Twaves suggestive of
a central nervous
system lesion or
apical hypertrophic
cardiomyopathy
LV hypertrophy with
strain
Brugada syndrome
Myocarditis
Hyperkalemia
Bundle-branch blocks
Vasospastic angina
Hypertrophic
cardiomyopathy
ED Evaluation of
Patients With STEMI
Cervical disc or
neuropathic pain
Chest-wall pain
Somatization and
psychogenic pain
disorder
Pleurisy
Peptic ulcer disease
Panic attack
Fibrinolytics :Contraindications
NSTEMI:
Clinical Presentation:
-Prolonged (>20) angina pain at rest
-New onset angina
-Cresendo angina
Physical examination:
Most often normal, including chest
examination, auscultation and
measurement of HR and BP
ECG:
Jika ada ECG lama, bandingkan
ST depresi > 1mm (0-1mV)
sedikitnya pada 2 lead
T inverted > 1mm
Bundle branch block
Biochemical markers:
CK-MB
Trop T
STEMI:
Gejala IMA:
Nyeri dada > 20,retrosternal, berlokasi di
tengah atau dada kiri, menjalar ke rahang,
punggung atau lengan kiri. Rasa nyeri
dapat digambarkan oleh penderita seperti
tertekan benda berat, diremas, terbakar,
tertusuk, kadang kala nyeri epigastrium.
Nyeri dada ini biasanya diikuti keringat
dingin, mual dan muntah, lemas, pusing,
perasaan melayang dan pingsan.
ECG:
Pada IMA perubahan ECG meliputi
hiperakut T, ST elevasi diikuti Q wave, ST
isoelektris, T inv.
Perubahan ini minimal pada 2 sandapan
berdekatan. Terbentuknya BBB baru atau
yg dianggap baru yang menyertai nyeri
dada yang khas.
Pada infark inferior, harus curigai
kemungkinan infark posterior dan infark
ventrikel kanan. Karena itu pemeriksaan
ECG harus dilakukan pada sandapan V3RV4R dan V7-V9 harus dilakukan.
TERAPI STEMI
TERAPI UAP/NSTEMI