2. acute coronary syndrome
TRANSCRIPT
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Syndrome
(Focus on early recognition
and initial management)
Muhammad Yolandi Sumadio
Cardiology and VascularDepartment
University North Sumatera
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&hat 's Acute
Coronary
Syndrome
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Acute coronary syndrome (ACS) !eart Attac*+re,ers to spectrum o, presentations that is consistent to -e
caused -y myocardial ischemia.
ACS De/nition
NS01ACS S01ACS
Unsta-le
AnginaNS0M' S0M'
2y 0C3 di4erentiation
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&hat cause ACS
Sta-le
Angina Acute Coronary Syndrome
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&hat happened in ACS
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&hy
should 5e
care
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ACS is a cardiac emergency
!igh mortality and mor-idity
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3lo-al Ma6or Causes o, Death
Global Atlas on Cardiovascular Disease Prevention And
ACS 5ere
responsi-leto
hal, o, CVD
deaths
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ACS Mor-idity and Mortality
1/3 of S!"# $atients die %it&in 2' &ours of onset ofisc&e(ia
1)* of +A $atients die or e,$erience a reinfarction%it&in 30 da-s of dianosis
u$ to 30* of disc&ared $atients are re&os$italied%it&in (ont&s
1* of (en and 23* of %o(en over ae'0 (a- die %it&in 1 -ear follo%in "# S!"# 4S!"#5
6* 7 16* ACS $atients die in t&e 8rst (ont&s after
dianosed9 %it& about one7&alf of deat&s occurrin%it&in 30 da-s.
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S01ACS vs NS01SCS
'ncidence 7 NS0M' 8 S0M'
!ospital mortality7S!"# : 4S!"# ; * vs ) * 5
%thmonth mortality 7
S!"# < 4S!"# 12 * vs 13 * 5
9ong erm Follo5 Up Mortality4S!"# : S!"#
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Are all -adne5s
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0vidence12ased Medical herapy
Signi/cantly lo5ered mor-idity
: mortality
Started 5ith an ade;uatediagnosis (not an
underdiagnosed one) and an
appropriate treatment
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!o5 to
diagnose
ACS
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$< ACS is A C9'N'CA9D'A3N=S'Snot an 0C3
diagnosis
>ecogni?e the symptom
correctly
Diagnosing ACS
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Symptoms compati-le 5ithischaemic heart disease
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ypical chest
pain@ Anginapectoris
Symtomps compati-le 5ith
ischaemic heart disease
Angina
e;uivalentComplications o, coronary
heart disease
Speci/c
9essspeci
/c
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ypical chest pain
=ualit- S>ueein9 &eaviness9 $ressure9 %ei&t9ver- stron $ain9 burnin9 ti&tness
?ocation Centre of t&e c&est9 left c&est %it&radiation to s&oulder9 nec@9 a%9 innerar(9 e$iastriu( can occur %it&outc&est $ain5
Duration +nstable anina 10720 (in."-ocardial infarction last loner
Settin riered b- e,ercise9 se,ual activit-9e,$osure to cold %eat&er9 e(otional
stress aner9 fri&t9 frustration59 or alare (eal.
Believer ore,aerator
4o eect of $osition or res$iration to>uantit- or >ualit- of c&est $ain.
?essened b- nitrat
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ypical chest pain
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ypical chest pain
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Angina 0;uivalent
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9ate resentation
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Atypical Chest ain
i l h t
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ypical chest
pain orang
MedanAN3'N
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"< 9oo* For >is*Factors
Diagnosing ACS
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Diagnosing !eart Disease
Atypicalsymptom and
sign
ypicalsymptomand sign
>is*Factors
>is*Factors
9ess
li*ely
More
li*ely
Most
li*ely
De/ni
te
0vidence
o, heartdisease
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< 0vidence o, ACS
Diagnosing ACS
>ole o, 0C3 in ACS
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Diagnosing !eart Disease
Atypicalsymptom and
sign
ypicalsymptomand sign
&ith or 5ithout>is* Factors
De/nite heart disease
0vidence o, heart disease(diagnostic 0C3 a-normality)
&ith or 5ithout>is* Factors
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ypical@Speci/c
Symptom
Atypical@ 9essSpeci/c
Symptom
Acute Coronary Syndrome
2ut 5ith a
diagnostic 0C3
>oles o, 0C3 in ACS
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0C3 Changes
Unsta-leAnginaNS0
M'
S0M
'
Normal 0C3
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ACSManagement
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he philosophy o,
treating ACS is tolo5er the patient
mortality (not onlyin1hospital -ut also
long term mortality)he mortality -ene/t o, ACStreatment started ,rom the
earliest treatment given
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Clinical diagnosis o, ACS is li*ely
3ive initial pharmacological treatment(M=NAC=)$< =" nasal lpm"< Aspirin ## mg che5 (E)
< Clopidogrel ## mg i, availa-le (E)< 'SDN mg su-lingual (interval minG
maH dose)< Morphin "1 mg iv (i, pain isnIt
responding to nitrate)
>e,er to !ospital 5ith cardiologist
0C3 Analysis
Atypical presentation -ut 5ith diagnostic 0C3
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0C3 Analysis
S0M'J $" hours o,
onset
S0M'8 $" hours
o, onset
NS0 1ACS
>eper,usion7 Fi-rinolytic
rimary C'
Manage conservatively7 'CU@'CCU (E) Continuos nitrat in,usion Dual antiplatelet regimen (aspirin and
clopidogrel) (E) Anticoagulant
(heparin@,ondaparinuH@enoHaparin) (E) !igh intensity statin (E) AC0 inhi-itor (E) 2eta -loc*er (E)
C' in selected high1ris* ,eature patient(E)(E) gives mortality and
mor-idity -ene/t
' iti l h l i l t t ,
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'nitial harmacological reatment ,orAcute Coronary Syndrome
1. O,-en
a. #ndication All ACS Patientb. Contraindication COPD &i& dose
O25
c. Dosae 1 E ?/(in via nasal cannula ' ?/(in for A"# E 10 ?/(in via non7breat&in face
(as@
M=NAC=Morphin1=Hygen1Nitrate1Aspirin1
Clopidogrel
'nitial harmacological reatment ,or
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'nitial harmacological reatment ,orAcute Coronary Syndrome
2. 4itrate F#sosorbid dinitrate #SD45a. #ndication
#sc&e(ic c&est $ainb. Contraindication
Hi$otension SP I 60 ((H5
I ' &ours use of PD! Jiara5c. Caution
e%are of &-$otension9 ive bolus ofsaline if it &a$$en
Bi&t ventricular infatctiond. Dosae ) ( sublinuall- interval ) (in9 (a, 3
doses5e. aret t&era$-
Believe of isc&ae(ic s-($to($s
'nitial harmacological reatment ,or
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'nitial harmacological reatment ,orAcute Coronary Syndrome
3. As$irina. #ndication All ACS $atient for anti$latelet
areation
b. Contraindication Active bleedin or bleedin
tendenc-c. Dosae
?oadin dose of 12732) (usuall- 300(5 c&e%
Continue )7100 ( once dail-e. &era$- bene8t
#($rove survival and outco(e
AS'>'N
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AS'>'N
AS'>'N
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Co($ared %it& $lacebo in t&e #S#S72
trial9 u$ to 1 (ont& of as$irin 12 (
dail- after sus$ected acute "#
$revented about '0 deat&s9 nonfatal
reinfarctions9 or stro@es $er 1000
$atients treated and t&ese earl-
bene8ts $ersisted for at least 10
-ears5.
AS'>'N
'nitial harmacological reatment ,or
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'nitial harmacological reatment ,orAcute Coronary Syndrome
'. Clo$idorela. #ndication All ACS $atient for anti$latelet
areation
b. Contraindication Active bleedin or bleedin
tendenc-c. Dosae
?oadin dose of 300 ( on ti(e Patient : ;0 -o use (aintenance
dose of ;) (e. &era$- bene8t
#($rove survival and outco(e
Clopidogrel
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Clopidogrel
'nitial harmacological reatment ,or
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'nitial harmacological reatment ,orAcute Coronary Syndrome
). "or$&inea. #ndication C&est $ain not res$ondin to nitrate Pul(onar- oede(a
b. Contraindication Hi$otension Bi&t ventricular infarction
c. Dosae
27'( #J =)730(in9 titrate to eecte. Close (onitor to
lood $ressure C4S/res$irator- de$ression
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>esume
ACS is a ,atal cardiac emergency 5ith a risingincidence and high mortality and mor-idity
ACS diagnosis is a clinical diagnosis0C3 role is not important in diagnosing ACS
>ecent advances in treatment o, ACS has
proven to have a huge mortality -ene/t
he treatment mortality -ene/t startseven ,rom the initial treatment given
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+Saving peoples ,romheart attac* starts ,rom you.
han* You