.

Yudi Her Oktaviono , MD. PHD

Departement of cardiology

Dr. Soetomo General Hospital - Airlangga University

Surabaya - indonesia

Acute Coronary Syndrome Management in National Heart Insurance Era

BPJS expenses for catastrophic cases

Stroke remains in the top 4 after 5 years UHC

2,2% 1,9% 1,7% 1,7%4,5% 5,3% 5,2% 6,1%

17,0% 17,1% 16,1% 17,3%

21,8% 22,0% 21,5% 12,7%

45,1% 45,2% 46,7%50,4%

9,4% 8,5% 8,8% 11,9%

2014 2015 2016 2017

expense per total catastrophic case

Adapted from Sudewi NMASR. BPJS presentation at INAHEA Congress, Jakarta, 1 Nov 2018

JANTUNG – GAGAL GINJAL - KANKER

NATIONAL HEALTH INSURANCE85% Coverage per July 2019

Regulator

BPJS Kesehatan

MembersHealthcare providersutilization of service

Delivery of service

Regulation on delivery of health services

Regulation on Quality of

care, HR, Pharmaceutical,

etc

Regulation on standardization of tariff

Government

Referral system

MINISTER OF HEALTH

6

Paket INACBGs - Acute Coronary Syndrome

KaterisasiJantung

Prosedur Kardiovaskularperkutan

Infark MiokardAkut

Top Up PCI

Rawat Jalan

Diagnostik POBA ACS MM Stent

Rawat Inap

Penyakit kronisbesar dan kecil

Gagal Jantung kongestifDan kondisi jantung lainnya

INACBGs – ACSPMK No. 64 Standard Pelayanan Kesehatan

Diagnosa / Tindakan RINGAN BERATA B C A B C

Rawat Inap

ACS - Infark miokard Akut 5,440,800 3,925,200 2,912,200 13,998,200 10,099,000 7,492,600

Katerisasi Jantung (Diagnostik) 6,110,900 4,408,700 3,270,800 16,432,500 11,855,200 8,795,500

Prosedur Kardiovaskular perkutan (POBA) 14,434,100 10,413,400 7,725,900 47,661,100 33,353,400 25,510,700

Top Up PCI14,434,100 10,413,400 7,725,900 14,434,100 10,413,400 7,725,900

ACS PCI with stents 28,868,200 20,826,800 15,451,800 62,095,200 43,766,800 33,236,600 Rawat Jalan

Gagal Jantung Kongestif 799,600 526,600 521,100 799,600 526,600 521,100

Penyakit Kronis Besar477,500 264,800 262,000 477,500 264,800 262,000

* Note menggunakan tarif kelas III

11

1. Roffi M et al. Eur Heart J 2016;37(3):267-315; 2. Ibanez B et al. European Heart Journal 2017; 00; 1–66

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

STEMI ESC 2017

Component of Delay and Solution

Symptom Onset FMC Diagnosis Reperfusion Therapy

Patient delay

≤ 10 min

System Delay

Time to reperfusion Therapy

Wire passage in culprit artery if primary PCI

Bolus or infusion start if fibrinolytic

Note: All delays are related to first medical contactIbanez B et al. European Heart Journal 2017; 00; 1–66

Improve Public Awareness

ACS NetworkReferral System

Diagnose capabilities

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Recommended / indicated

Should be considered

Not recommended

Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042

Recommended / indicated

Should be considered

Not recommended

21

INITIAL TREATMENT

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

ASPIRIN

Loading

160 – 320mg

Ticagrelor

or

clopidogrel*

O2

NTG / ISDN

2018

M

O

N

A • 180 mg loading dose + 90 mg BID• 300 mg loading dose + 75 mg OD if

ticagrelor is not available or contraindicated

Morphine

sulfate iv

1-5 mg

• Can be repeated per 10 – 30 min, for patient who not responsive

• when SaO2 < 90% or PaO < 60

• If ongoing chest pain by the time admitted at ER

Onset P2Y12 inhibitor

Ticagrelor provide Faster Onset and offset vs high dose clopidogrel

IPA : Inhibition of Platelet Aggregation

Onset

100

90

80

70

60

50

40

30

20

10

0

IPA

%

Ticagrelor (n=54)

Clopidogrel (n=50)

0 0.5 1 2 4 8 24 6 weeks 0 2 4 8 24 48 72 120 168 240

Maintenance OffsetTime (hours))

Loading Dose

TICA 180 mg

CLO 600 mg

*

** * *

‡

†

** †

Last maintenance dose

TICA 90 mg bid

CLOPI 75 mg qd

** * P<0,0001

† P<0,005‡ P<0,05

Time (hours)

Catatan : penelitian ini dilakukan pada pasien CAD yang

mengkonsumsi aspirin tanpa riwayat ACS <1 tahun

Ticagrelor belum mendapatkan persetujuan untuk populasi

pasien ini.

22

Referensi Adapted from Gurbel PA, et al. Circulation. 2009;120:2577–2585.

41% ticagrelorVs.

8% clopidogrel

At 30 minutes

88% ticagrelorVs.

38% clopidogrel

At 2 hours

8

23

Adjunctive treatment in Primary PCI and Fibrinolytic Therapy

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

Primary PCI Fibrinolytic

Antiplatelet • Ticagrelor 180 mg + 90 mg BID• Clopidogrel 600 mg + 75 mg

OD if ticagrelor is not available or contraindicated

• Clopidogrel** If patient undergoing PCI after fibrinolytic may considered to switch to ticagrelor

Anticoagulant • UFH if patient can not received bivalirudin or enoxaparin

• Enoxaparin

• Enoxaparin sc• UFH iv• Fondaparinux bolus + sc for

24 hours - streptokinase

GPIIbIIIa Only for no reflow or thrombotic complication

2018

Ticagrelor 90 mg did not increase TIMI major bleeding at 30 days compared with clopidogrel 1,2

1. Berwanger O et al. JAMA Cardiol 2018 doi:10.1001/jamacardio.2018.0612; 2. Berwanger O et al. JAMA Cardiol 2018

doi:10.1001/jamacardio.2018.0612 Supplementary Appendix

0

0.5

1

1.5

2

2.5

0 3 6

Time (days)

15 18 21 24 279 12 30

Cu

mu

lative

in

cid

en

ce

of p

rim

ary

ou

tco

me

,

TIM

I m

ajo

r b

lee

din

g (

KM

%)

Ticagrelor

Clopidogrel

< 75 years old

P value non inferiority <0.001

28

NSTEMI patients remain at high and persistent risk

of CV events post discharge from hospital1

Vora AN et al. Circ Cardiovasc Qual Outcomes 2016;9:513–522.

2-year rate of MI, stroke or all-cause mortality in NSTEMI and STEMI patients ≥65 years of age.

Both NSTEMI and STEMI patients are at high risk of recurrent CV events, NSTEMI

is associated with greater long-term risk than STEMI

VER

Y H

IGH

RIS

KIN

TER

MED

IATE

H

IGH

RISK

LOW

RISK

• Hemodynamic instability or cardiogenic

shock

• Recurrent or ongoing chest pain

refractory to medical treatment

• Life-threatening arrhythmias or cardiac

arrest

• Mechanical complications of MI

• Acute heart failure

• Recurrent dynamic ST-T wave changes,

particularly with intermittent ST-elevation

• Diabetes mellitus

• Renal insufficiency

(eGFR <60 mL/min/1.73 m²)

• LVEF < 40% or congestive HF

• Early post infarction angina

• Prior PCI

• Prior CABG

• GRACE risk score 109 - 140

• Relevant rise or fall in troponin

• Dynamic ST- or T-wave changes

(symptomatic or silent)

• GRACE Score > 140

• Any characteristics not mentioned above

Risk Criteria Mandating Invasive Strategy

in NSTE-ACS1

Reference: 1. Roffi M et al. Eur Heart J 2016;37(3):267-315

33

Cath lab or later ?

Benefit of early intervention in high risk patients

Mehta, SR et al. N Engl J Med 2009;360:2165-75.

Kaplan–Meier Cumulative Risk of the Primary Outcome (death, myocardial infarction, or stroke), Stratified According to GRACE Risk Score at Baseline.

Aggressive approach recommended in NSTEACS

Patient with HIGH RISK

Reference: 1. Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

Initial Treatment when an ACS diagnosis appears likely based on ESC

NSTEACS Guideline1,2

35

Aspirin Initial dose of 150 – 300 mg non-enteric formulation followed by 75-100 mg/day (I.v. administration is acceptable)

P2Y12 inhibitor Loading dose of ticagrelor or clopidogrel

Anticoagulation Choice between different options depends on strategy:• Fondaparinux 2.5 mg/daily subcutaneously• Enoxaparin 1 mg/kg twice daily subcutaneously• UHF Lv. Bolus 60-70 IU/kg (maximum 5000 IU) followed by infusion of 12-

15 IU/kg/h (maximum 1000 IU/h) titrated to aPTT 1.5 – 2.5 × control• Bivalirudin is indicated only in patients with a planned invasive strategy

Oral β-Blocker If tachycardic or hypertensive without signs of heart failure

P2Y12 inhibitor is recommended in initiation soon after the diagnosis of NSTE-ACS irrespective of

management strategy2

Reference: 1. Hamm CW et al. Eur Heart J. 2011; 32:2999-30354; 2. Roffi M et al. Eur Heart J 2016;37(3):267-315

Is the Debate Over? Routine Thrombus Aspiration in STEMI (From TAPAS to INFUSE-AMI to TASTE to TOTAL)Stefan James

Professor of Cardiology

Uppsala Clinical Research Centre

Uppsala University Uppsala, Sweden

INFUSE-AMI - Primary powered endpoint -

AspirationN=229

No aspirationN=223

Infa

rct siz

e,

%LV

Median [IQR]

17.0%[9.0, 22.8]

Median [IQR]

17.3%[7.1, 25.5]

P=0.51

Stone GW et al. JAMA 2012;307:1817-26

N=452All anterior MISx-hosp <4 hrsTIMI 0-2

TAPAS: 1,071 pts

Vlaar et al. Lancet 2008;371:1915-20

30 days

4.0% vs. 2.1%

P=0.07

Time (days)

Mort

alit

y (

%)

Conventional PCI

Thrombus-Aspiration

0

0 100 200 300 400

2

4

6

8

10

12

1 year

7.6% vs. 4.0%

P=0.04A large confirmatory trial is needed (small trials with

unexpected large effect sizes, need to be replicated)

All-cause mortality

HR up to 1 year 0.94 (0.78 – 1.15), P=0.57

HR up to 30 days 0.94 (0.72 - 1.22), P=0.63

N Engl J Med. 2013 Oct 24;369(17):1587-97 N Engl J Med. 2014 Sep 18;371(12):1111-20

1,071 pts

TAKE HOME MESSAGE

• Gunakan tatalaksana standar dengan benar

• Tatalaksana penanganan ACS dilakukan secepatmungkin

• Pemilihan strategi pengobatan yg tepat

• Pemilihan obat yang tepat

• Teknik intervensi yg sesuai

N-STE ACS ESC 2015

STEMI ESC 2017