rodarohw case-acs dynamics nstemi to stemi management and prognosis
TRANSCRIPT
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R.D. Robi
* ACS ProgressionNSTEMI to STEMI
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CounselorDr. H. A. Fauzi Yahya., Sp. JP. (K), FIHA.
by RD. Robin H Wibowo
*
Case Report Presentation
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*
Case Presentation
Case discussion
Conclusion
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* General information
* A male patient, TW, 59 years old
* Retired go ernment employee
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Clinical History
!mo"ing
Dyslipidemia
#eit$er
C$est pain!%& $istory
C$est pain5 Hourbe'ore
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* Physical Examinat()P 5*+cmH %
H(R -*
Kardiomegali -/
!0 normal, !normal, !+ -/ !1 -/2urmur -/Rales -*3* 03+
4dema -/Warm -*3*
&P 00 36 mmHg,regular $eart rateo' 67 bpm,RR 1 8!a% 97
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* a!oratory "in#in
Hb : 11,1 : 36 #a : 139 ?D! :
Tr : 255000 = : 4,0
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*
Ele$tro$ar#io
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*
Rontgen th
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* %iag
*
NSTEMI& 'illip II* T@2@ 36* ?RAC4 059
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*
Treat
* &R, % + liter3menit, Hepcup* Diet antung @ 05 ""al3$ari, protein 0 gr3"g&&3$ari, =H:> 7 :1* Aspilets loading dose 07 mg, dilan ut"an 08B0 mg po*
Clopidogrel loading dose + mg, dilan ut"an 0865 mg po* @!D# 5 mg !> prn* Heparinisasi dengan 4no8aparin 8 ,7 cc sc* Rencana angiografi $oroner #an a# hoc PCI (early)* "urosemi#e *x+, mg i- target !alance ./,,.0,,, cc1*+ 2am* %ia3epam ,.,./ mg* axa#ine ,.,.0/ mg* Ator-astatin ,.,.+, mg* Peri$sa profil lipi#& G%P& G% *4PP& asam urat* Peri$sa E'G serial1*+ 2am atau !ila nyeri #a#a* Rencana echocar#iografi* Ra5at I6C1I7
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Clinical History
Admisson
nd Day
PersistentC$est Pain
+rd DayC$est Pain
Worsened&reat$lessnes
s
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*
Ele$tro$ar#io@
@@
@@@
5
0
05
5
+
+5
+5
e-els
C'M8
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* Acute 48tensi e Anterior !T42@
=illip @@@
PrimaryPCI
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* Angiogra
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Clinical History
Admisson
+rd Day
PrimaryPC@
6t$ DayDisc$arge
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*
Case Presentation
Case discussion
Conclusion
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* O-e
*
* #CCH=, data 'rom 9/ 00 s$owed t$erewas 5 5 !T42@ patients -+5 , 0761 #!T42@patients - + , and 99
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* %efini
2yocardial in'arction -2@ is deFned in pat$ology AC! spectrum -
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* Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$
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Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$
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* #!T42@ is an unstable coronary conditionprone to isc$emic recurrences and ot$ercomplications
* T$e ?RAC4 study s$owed B/0 o' #!T42@patients will $a e recurrent angina wit$ !Tsegment c$anges on $ospitaliJation.
* Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$
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* Ris$ Stratification for 9A1NS
* @mportant in management* Determines t$e c$oice o' management*
4stimating prognosis* !e eral ris" scores predicting ris" Widely used =illip, T@2@ and ?RAC4 score
* Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patients Wit$
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=illip Classi'ication o' A2@=illip Classi'ication o' A2@
Absence o' !+ gallop rales
Class I
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T@2@ 00&
TIMI Risk Score for UA/ ST!MI
% "/MI/Ur#e$ Re&'sc()'ri*' io$ +s TRS
A$ '$ !M, -AMA 2000.284 83
$e oof
A >
' r
50 ST >
e& A !)
M
4arly Ris" !trati'ication4arly Ris" !trati'ication
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T@2@ 06
TIMI Risk Score for ST!MI
Mor ')i ' 30 7 &s ST!MI TRS
Morro: "A, irc()' io$ 2000.102 203
;is oric')A#e 65 4
> 53"M/;T /A$#i
!='S < 100 ;R > 100 ?@i))i II I+
ei# < 6
rese$ ' io$A$ erior ST
B Ti e o R= >
Risk Score C
4arly Ris" !trati'ication4arly Ris" !trati'ication
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o e$7i( of A?ri7#e7 !S F(i7e)i$es 2008, ?lobal Registry o' Acute Coron
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* In-asi-e -ersus conser-ati-e approach
* 2eta/analysis -&a ry et al E signiFcant ris" reduction 'or all caumortality and non/'atal 2@ 'or an early in asi e approac$ at years wit$out an e8cess o' deat$ and non/'atal 2@ at 0 mont$
* 2eta/analysis -% Donog$ue et al E signiFcant reduction in deat$2@, or re$ospitaliJation wit$ AC! 'or in asi e strategy at 0 year
* 2eta/analysis - o8 et al E re ealed a reduction in rates o' deat$and non/'atal 2@ at 5/year 'ollow/up, wit$ t$e most pronounceddi''erence in $ig$ ris" patients -00,0 .
* &a ry AA, =umb$ani D(, Rassi A#, et al. &eneFt o' early in asi e t$erapy in acute coronary syndromes: a meta/analysis o' contemporary randomiJed clinical trials. ( Am Coll Cardiol7E1B:0+09I0+ 5.
* %ODonog$ue 2, &oden W4, &raunwald 4,et al. 4arly in asi e s conser ati e treatment strategies in women and men wit$ unstable angina and non/!T/segment ele ation myocardialin'arction: a meta/analysis. (A2A BE+ :60IB .
* o8 =A, Clayton TC, Damman P, et al. >ong/term outcome o' a routine ersus selecti e in asi e strategy in patients wit$ non/!T/segment ele ation acute coronary syndrome a meta/analysis o' indi idual pati ent data. ( Am Coll Cardiol 0 E55: 1+5I 115.
6ighlight the role of ris$
strati;cation
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* Timing of angiography an# inter-entio
The TIMACS trial* !igniFcant reduction in deat$, 2@, or stro"e at 7 mont$s
in $ig$ ris" #!T42@ patients -?RAC4 score L01 , wit$ early -K 1 $ compared wit$ a delayed strategy.* Howe er, t$ere was not signiFcant di''erence wasobser ed in patients wit$ a low to intermediate ris"proFle -?RAC4 score K01 .
2e$ta !R, ?ranger C&, &oden W4, et al. 4arly ersus delayed in asi e inter ention in acute coronary syndromes. # 4ngl ( 9E+7 : 075I 065
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Anderson (>, Adams CD, Antman 42, et al. ACC3AHA 6 ?uidelines 'or t$e 2anagement o' Patie
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* STEMI an# NSTEMI& is it #iffe
* 2ortality L !T42@ t$an #!T42@ -6 s.+I5 ,respecti ely , but 7/mont$s mortality rates are erysimilar -0 and 0+ , respecti ely
* Opera registry s$owed comparable result* >ongterm obser ational study 'ound t$at deat$ rates
L#!T42@ t$an wit$ !T42@E 8 at 1 years
e$ RW, !idney !, C$andra 2, et al. Population trends in t$e incidence and outcomes o' acute myocardial in'arction. # 4ng2ed 0 E +7 : 055I 075
2andelJweig >, &attler A, &oy"o ), et al. T$e second 4uro Heart !ur ey on acute coronary syndromes: c$aracteristics,treatment, and outcome o' patients wit$ AC! in 4urope and t$e 2editerranean &asin in 1. 4ur Heart ( 7E 6: B
Ter"elsen C(, >assen ( , #orgaard &>, et al. 2ortality rates in patients wit$ !T/ele ation s.non/!T/ele ation acutem ocardial in'arction: obser ations 'rom an unselected co$ort. 4ur Heart ( 5 7:0BI 7
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?iles, et al. !T42@ and #!T42@ : are t$ey so di''erent %P4RA registry real/world data 'rom t$e 4uropean PubliHealt$ %utcome Researc$ and @ndicators Collection Pro ect. Arc$ @ntern 2ed 0 E06 :BBBIB95
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urman 2@, Dauerman H>, ?oldberg R(, et al. Twenty/two year -0965 to 0996 trends in t$e incidence, in/$ospital anterm case 'atality rates 'rom initial Q/wa e and non/Q/wa e myocardial in'arction: a multi/$ospital, community/wideperspecti e. ( Am Coll Cardiol 0E+6:0560/B
More attentionto NSTEMI
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* Treatm
!c$iele study 'ound 00 N in mortality 30increase in ad$erence to ACC and AHA guidelines
?AP -T$e ?uidelines Applied in Practice study'ound t$at ris" o' deat$ wit$in a year was 5lower a'ter disc$arge i' $ospitals 'ollowed nationalguidelines
!c$iele , 2ene eau #, !eronde 2 , et al. Compliance wit$ guidelines and 0/year mortality in patients wit$ acutmyocardial in'arction: a prospecti e study. 4ur Heart ( 5E 7:B6+/B .
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*
Case Presentation
Case discussion
Conclusion
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* Conc
* We reported a case o' male patient, 2r TW, 59 yo, w$omwas diagnosed as #!T42@ T@2@ ris" 36 grace score 019,=illip @@. During e aluation, $is myocardial in'arction
e ol ed to !T42@. He was treated wit$ primary PC@, wit$good results.
* AC! represent a p$ysiologic continuum spanning o'unstable angina, non/!T ele ation myocardial in'arctionand !T ele ation myocardial in'arction.
* T$e management must begin wit$ ris" strati'ication,'ollowed wit$ t$erapy according to guidelines, and goode aluation during $ospital care and a'ter disc$arge.
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* Ta$e 6ome Messa
?ood prior e aluation ?ood inter ention
!tate o' t$e art monitoring 'ollow up
!a e muscleOs, !a e li es
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Gracias
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