Tatalaksana Awal Sindroma Koroner Akut (SKA )
Siska Suridanda Danny RS Jantung Nasional Harapan Kita Jakarta 2015
[email protected]
Penyakit Arteri Koroner
STEMI
Sindroma Koroner Akut
Angina Stabil
NSTEMI
Unstable Angina
Tata laksana SKA ACS with persistent STEMI ST segment elevation
PROMPT DIAGNOSIS and REVASCULARIZATION offers greatest benefit for myocardial salvage in the first hours of STEMI
O’Connor RE et al. Circulation. 2010;122[suppl ]:S787–S817.)
ACS without persistent UAP/NSTEMI ST segment elevation
EARLY MANAGEMENT and RISK STRATIFICATION reduces adverse events and improves outcome
PROFIL PASIEN Perempuan, 62 tahun Faktor Risiko PJK • Hipertensi > 10 thn, kontrol dan minum obat tidak rutin • Menopause • Riwayat kolesterol tinggi • Diabetes • Obesitas Riwayat Penyakit Sekarang • Sejak + 3 hr terakhir mengeluhkan rasa berat di dada dan ulu hati, hilang timbul, yang dianggap pasien sebagai ‘maag yang kambuh’ • Nyeri dada hebat disertai sesak nafas, mual-muntah dan keringat dingin 4 jam sebelumnya
Algoritma pendekatan terhadap SKA
5
Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054
ANGINA • Sakit dada (sakit, nyeri, rasa tertimpa beban, rasa terbakar) di belakang tulang dada • Dipicu oleh aktivitas atau stres emosional à menghilang dengan istirahat atau nitrat • Dapat menjalar ke punggung, bahu, rahang atau lengan. • Disertai rasa lemah, keringat dingin, rasa cemas dan bahkan bisa pingsan.
Presentasi Angina pada SKA • Angina berat yang timbul saat istirahat dengan durasi lebih dari 20 menit • Angina new onset (dalam 1 bulan terakhir), dengan derajat CCS III (angina muncul dengan aktivitas ringan sehari-hari) • Angina progresif (dirasakan lebih berat, lebih lama, atau dicetuskan oleh aktivitas yang lebih ringan dibandingkan biasanya)
Braunwald, et al. JACC 2000;36:3
ELEKTROKARDIOGRAM • • • •
EKG 12 Sandapan Dalam 10 menit !! Membuat dan menganalisa EKG Tentukan: • Irama • Elevasi segmen ST ? • Depresi segmen ST ? • LBBB (BARU )? • Gelombang Q ? • Non diagnostik/EKG normal • Dapat diulang dalam 3-6 jam atau jika pasien melaporkan keluhan lagi
ELEKTROKARDIOGRAM YANG NORMAL TIDAK MENGEKSKLUSI ADANYA SINDROMA KORONER AKUT
ANGINA TIDAK STABIL (UAP/APTS) ADALAH DIAGNOSIS BERDASARKAN ANAMNESIS
Contoh perlepasan penanda jantung pada pasien NSTE-ACS (ESC 2007)
EKG dan BioMarker
• • • • •
TEST Hs Troponin T
RESULT 585 ug/L (<14 ug/L)
Rhythm ? Segmen ST elevation ? Segmen ST depresssion? LBBB (new )? Q Wave?
REMARKS Elevated consistent with myocardial damage
DIAGNOSIS? TATA LAKSANA?
SINDROMA KORONER AKUT
Non ST Elevasi
ST Elevasi
TATA LAKSANA AWAL YANG HAMPIR SAMA
Validasi diagnosis dan Stratifikasi risiko
Terapi reperfusi secepatnya
Gejala dan Tanda sesuai dengan SKA Pemeriksaan awal • • • • • •
• •
Tanda Vital Akses intravena EKG 12 lead Riwayat penyakit terfokus Pemeriksaan fisik terfokus Ambil sampel darah untuk pemeriksaan biomarker kardiak, ditambah dengan darah rutin, fungsi ginjal dan elektrolit Chest X-Ray(<30 min) Checklist fibrinolitik
Penanganan awal • •
•
• •
Oksigen 4 L/menit jika saturasi <95% Morphine iv jika nyeri dada hebat dan tidak berkurang dengan nitrat Nitroglycerin / Nitrat Sublingual, spray atau IV. Hatihati pada TDS < 90 mmHg Aspirin 160 to 325 mg Clopidogrel 600 mg ATAU Ticagrelor 180 mg
NSTEACS Management strategy
Step 1. initial evaluation
Step 2. Diagnosis validation and risk assessment Step 3. invasive strategy
Step 4. revascularization modalities
Step 5. hospital discharge and post-discharge management Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Risk Stratification is important in NSTE-ACS Management 1
2
CLINICAL CONDITION
TIMI SCORE
Less accurate in predicting events but its simplicity makes it useful and widely accepted
3
GRACE SCORE
recommended as the preferred classification to apply on admission and at discharge in daily clinical routine practice
Hamm W et al. European Heart Journal 2007; 28:1598–1660; Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Clinical condition HIGH RISK PRIMARY • Relevant rise or fall in troponin • Dynamic ST- or T-wave changes (symptomatic or silent) SECONDARY • Diabetes mellitus • Renal insufficiency (eGFR <60 mL/min/1.73 m²) • Reduced LV function (EF <40%) • Early post infarction angina • Recent PCI • Prior CABG • Intermediate to high GRACE risk score
Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
VERY HIGH RISK • Refractory angina • Severe heart failure • Life-threatening ventricular arrhythmias, or Hemodynamic instability
TIMI SCORE Age 65 years or older?
Risk Score
TIMI risk score for developing at least 1 component of the primary end point through 14 days after randomization.1
0-1
4.7%
2
8.3%
3
13.2%
4
19.9%
5
26.2%
6- 7
40.9%
At least 3 risk factors for CAD? Prior coronary stenosis of 50% or more? ST-segment deviation on ECG 0.5mm? Use of aspirin in prior 7 days At least 2 anginal events in prior 24 hours? Elevated serum cardiac markers?
Hamm W et al. European Heart Journal 2007;28:1598–1660
GRACE SCORE Predictor
Score
Age, years
Predictor
Score
Predictor
Systolic Blood Pressure (mmHg)
Score
Killip class
< 40
0
< 80
63
I
0
40 - 49
18
80 – 99
58
II
21
50 - 59
36
100 - 119
47
III
43
60 - 69
55
120 - 139
37
IV
64
70 - 79
73
140 - 159
26
80
91
160 - 199
11
Predictor
Score
> 200
0
Cardiac arrest at admission
43
Elevated cardiac markers
15
ST Segment deviation
30
Predictor
Score
Heart Rate , beats/min
Predictor
Score
Creatinine (µmol/L)
< 70
0
0 - 34
2
70-89
7
35 – 70
5
90-109
13
71 – 105
8
110 - 149
23
106 – 140
11
150 - 199
36
141 – 176
14
> 200
46
177 – 353
23
≥ 354
31
Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30
Risk category (tertile)
GRACE Risk Score
In-hospital death (%)
Low
≤ 108
<1
Intermediate
109 - 140
1-3
High
> 140
>3
Initial Treatment
Initial Therapeutic Measures
Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Checklist of treatments when an ACS diagnosis appears likely
Activated platelets are central to thrombus formation in ACS • Platelets do 3 things that promote thrombus formaton - Adhesion - Activation Activated platelets aggregate - Aggregation and assemble a critical mass
3
2 1
Adherent platelet become activated
Plaque rupture leads to platelet adhesion to the exposed subendothelium
Vorchheimer DA, et al. Mayo Clin Proc. 2006;81:59-68; Davies MJ. Heart. 2000;83:361-366.
of activated, pro-thrombotic platelet membrane at the site of injury
Antiplatelet recommendation in Updated ACS Guidelines Aspirin should be given to all patients without contraindications at an initial loading dose of 150–300 mg, and at a maintenance dose of 75–100 mg daily long-term regardless of treatment strategy. A P2Y12 inhibitor should be added to aspirin as soon as possible and maintained over 12 months, unless there are contraindications such as excessive risk of bleeding.
Clopidogrel
Ticagrelor
1.Kolh P et al. Eur Heart J August 29 2014; DOI:10.1093/eurheart/ehu278 [Epub ahead of print] 2.Steg PG et al. Eur Heart J 2012;33:2569–2619; 3.Hamm CW et al. Eur Heart J 2011;32:2999 – 3054. 4. Amsterdam EA et al. J Am Coll Cardiol Sept 23, 2014 Epub ahead of print. DOI:10.1016/j.jack.2014.09.017
Prasugrel* *Not yet approved and available in Indonesia
Profile P2Y12 inhibitor
*Prasugrel is not yet approved and available in Indonesia Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Metabolism P2Y12 inhibitor (Pro drug vs active drug) Active compound Intermediate metabolite Pro-drug
Ticagrelor (Active Drug) Prasugrel* (Prodrug) Clopidogrel (Prodrug)
No in vivo biotransformation
CYP-dependent oxidation CYP3A4/5 CYP2B6 CYP2C19 CYP2C9 Hydrolysis CYP2D6 by esterase
Binding Platelet
P2Y12 CYP-dependent oxidation CYP1A2 CYP2B6 CYP2C19
*Prasugrel is not yet approved and available in Indonesia Figure adapted from Schömig A (2009). CYP, cytochrome P450. Schömig A. N Engl J Med 2009;361:1108–1111.
CYP-dependent oxidation CYP2C19 CYP3A4/5 CYP2B6
Limitation of clopidogrel • Dual antiplatelet therapy (DAPT) with aspirin & clopidogrel is the current standard treatment in patients with ACS1 - With or without ST segment elevation1 • Poor platelet inhibition response to clopidogrel is seen in approximately 5% - 40% of patients2 - Contribute to residual high risk of recurrent results • Clopidogrel has slow onset of action1 - Prodrug that requires conversion to active metabolite1 • Variable metabolism results in interindividual variability in inhibition of platelet agregation1
1. Bassand JP . European Heart Journal Supplements 2008; 10 : Supplement D, D3–D11; 2. Gurbel PA, Tantry US. Thrombosis Research. 2007;120: 311–321
Cumulative Incidence (%)
Ticagrelor : PLATO study (efficacy) Ticagrelor : PLATO study (efficacy) 13 12 11 10 9 8 7 6 5 4 3 2 1 0
0–30 Days
0–12 Months 11.7 Clopidogrel 9.8 Ticagrelor
Clopidogrel 5.4
4.8 Ticagrelor
ARR=0.6%
ARR=1.9%
RRR=12%
RRR=16%
P=0.045
NNT=54*
HR: 0.88 (95% CI, 0.77−1.00)
P<0.001 HR: 0.84 (95% CI, 0.77–0.92)
0
2
4
6
8
10
12
Months After Randomization
No. at risk Ticagrelor
9,333
8,628
8,460
8,219
6,743
5,161
4,147
Clopidogrel
9,291
8,521
8,362
8,124
6,650
5,096
4,047
Both groups included aspirin. *NNT at one year.
Wallentin L, et al. N Engl J Med. 2009;361:1045–1057.
Ticagrelor : PLATO study (safety)
K-M estimated rate (% per year)
Ticagrelor
Clopidogrel
PLATO bleeding criteria
20
TIMI bleeding criteria
18 16 14 12
HR=1.04 (P=0.43) 11,6
HR=1.05 (P=0.33)
11,2
10
HR=1.03 (P=0.70)
8
5,8
6
5,8
HR=1.03 (P=0.57) HR=0.87 (P=0.6553) 5,3
7,9
11,4 10,9
7,7
5,2
4 2
0 Total Major
Both groups included aspirin
Wallentin L, et al. N Engl J Med. 2009;361:1045–1057.
Major Fatal/LifeThreatening
Other Major
TIMI Major
TIMI Major+Minor
ONSET Ticagrelor vs high dose clopidogrel Last Maintenance Dose 100 90 80
Loading Dose 180 mg 600 mg
*
*
*
90 mg bid 75 mg qd
* *
//
70
IPA %
*
Ticagrelor (n=54)
*
†
Clopidogrel (n=50)
*
P<0.0001 P<0.005 ‡ P<0.05 *
†
60 50
*
//
40
‡
30
†
20 10 0 0
0.5
1
2
4
Onset
Time (Hours) Adapted from Gurbel PA, et al. Circulation. 2009;120:2577–2585.
8
24
//
6 weeks
Maintenance
0
2
4
8
24
48 72 120 168 240
Offset Time (Hours)
ACS PERKI GUIDELINE - NSTEACS
ACS PERKI GUIDELINE - STEMI
P2Y12 Di Dalam Addendum 2 FORNAS 2015
Updated Guidelines 2014
STEMI Primary PCI and NSTEACS PCI1 A P2Y12 inhibitor is recommended in addition to ASA, and maintained over 12 months unless there are contraindications such as excessive risk of bleeding.
NSTE-ACS Early invasive or ischemia-guided strategy2 A P2Y12 inhibitor (either clopidogrel or ticagrelor) in addition to aspirin should be administered for up to 12 months to all patients without contraindications
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1. Windecker S et al. European Heart Journal / doi:10.1093/eurheartj/ehu278; 2. Amsterdam EA et al. J Am Coll Cardiol Sept 23, 2014 Epub ahead of print. DOI: 10.1016/j.jack.2014.09.017
OUR PATIENT:
• Pasien klinis perbaikan dengan pemberian anti platelet, anti iskemia dan anti koagulan
• Dilakukan tindakan PCI pada hari ke-3 perawatan dengan hasil CAD 1 VD dan dipasang 1 stent di LCx
• Pasien pulang pada hari ke-5 dalam kondisi baik, dengan terapi: – Aspirin 1x80 mg – Ticagrelor 2x90 mg – Rosuvastatin 1x20 mg – Ramipril 1x5 mg – Bisoprolol 1x5 mg
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