Acut Coronary Syndrome

8/13/2019 Acut Coronary Syndrome

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ACUT CORONARYSYNDROME

Dr. Rus Munandar SpJp

Dr. Darimi Azuddin, SpJp

Dr. Sri Murdiati


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FAKTOR RESIKO


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Angina PectorisClinical Presentation


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Angina Pectoris

O2 SupplyO2 Demand

Heart Rate

SBP

Wall Stress

Coronary flow

Hb

O2


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Acute Coronary Syndromes

Unstable angina and evolvingmyocardial infarction are

different clinical presentationsresulting from a common

underlying pathophysiologicalmechanism


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CAUSES OF UA/NSTEMIThrombosis

Thrombosis

MechanicalObstruction

Mechanical

Obstruction

Dynamic

Obstruction

Dynamic

Obstruction

Inflammation/

Infection

Inflammation/

Infection

MVO2

MVO2Braunwald, Circulation

98:2219, 1998

.

.


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UA/NSTEMI

THREE PRINCIPAL PRESENTATIONS

Rest Angina* Angina occurring at rest andprolonged, usually > 20 minutes

New-onset Angina New-onset angina of at least CCS

Class III severity

Increasing Angina Previously diagnosed angina that

has become distinctly more frequent,

longer in duration, or lower in

threshold (i.e., increased by > 1 CCS)class to at least CCS Class III severit

Braunwald

Circulation 80:410; 1989

* Pts with NSTEMI usually present with angina at rest.


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POST-HOSPITAL DISCHARGE CARE

A Aspirin and Anticoagulants

B Beta blockers and Blood PressureC Cholesterol and Cigarettes

D Diet and Diabetes

E Education and Exercise

UA/NSTEMI 9/00


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ANTI - ISCHEMIC Rx

Class I

1. Bed rest with continuous ECG monitoring in ptswith ongoing rest pain.

2. NTG, sublingual tablet or spray, followed by IV

administration for ongoing chest pain.3. Supplemental O2for pts with hypoxemia, cyanosis

or respiratory distress; finger pulse oximetry orarterial blood gas determination to confirm

SaO2>90%.4. Morphine sulfate IV when symptoms are not

immediately relieved with NTG or when acutepulmonary congestionand/or severe agitation is

present.


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ANTI - ISCHEMIC Rx

Class I

1. Bed rest with continuous ECG monitoring in ptswith ongoing rest pain.

2. NTG, sublingual tablet or spray, followed by IV

administration for ongoing chest pain.3. Supplemental O2for pts with hypoxemia, cyanosis

or respiratory distress; finger pulse oximetry orarterial blood gas determination to confirm

SaO2>90%.4. Morphine sulfate IV when symptoms are not

immediately relieved with NTG or when acutepulmonary congestionand/or severe agitation is

present.


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Q-Wave (ST-segment elevation)

Myocardial Infarction

Occlusion of coronary artery by thrombus

Progression of necrosis with time

Diagnosis Clinical symptoms

Electrocardiogram

Cardiac enzymes


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Q-Wave (ST-segment elevation)


Occlusion of coronary artery by thrombus

Progression of necrosis with time

Diagnosis Clinical symptoms

Electrocardiogram

Cardiac enzymes


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POST-HOSPITAL DISCHARGE CARE

A Aspirin and Anticoagulants

B Beta blockers and Blood PressureC Cholesterol and Cigarettes

D Diet and Diabetes

E Education and Exercise

UA/NSTEMI 9/00


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Thrombolysis in Acute MI

Absolute Contraindications

Previous hemorrhagic stroke

CVA within previous yr

Intracranial neoplasia or AVM

Active internal bleeding (notmenses)

Suspected aortic dissection


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Uncontrolled HTN (BP > 180/110) onpresentation

History prior CVA beyond 1 yr

Anticoagulant Rx with INR > 2-3; bleedingdiathesis

Recent trauma (within 2-4 wks)

Noncompressible vascular punctures

Recent internal bleeding (within 2-4 wks)

Pregnancy

Active peptic ulcer

Prior exposure (5 day - 2 yr) for SK or APSAC

Thrombolysis in Acute MI

Relative Contraindications


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The Management of

Patients with Acute


Hospital Management


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Sample Admitting Orders

Condition SeriousIV NS or D5W to keep vein open

Vital signs q 1/2 hr until stable, the q 4 hrs and p.r.n.

Notify if HR 110; BP 150;

RR 22. Pulse oximetry x 24 hrs

ActivityBed rest with bedside commode and progress astolerated after approximately 12 hrs

Diet NPO until pain free, then clear liquids. Progress to a heart-

healthy diet

Medications Nasal O22L/min x 3 hrs

Enteric-coated aspirin daily (165 mg)Stool softener daily

Beta-adrenoreceptor blockers ?

Consider need for analgesics, nitroglycerin, anxiolytic


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T H A N K Y O U


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Acut Coronary Syndrome