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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)
Myocardial Infarction
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
Myocardial Infarction
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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