Nstemi

NSTEMI Sayid Najibullah Dokter muda Bag. Cardiology RSUZA Banda Aceh

Definisi • acut coronary sindrom (ACS) adalah istilah yang digunakan untuk kumpulan simptom yang muncul akibat iskemia miokard akut. ACS yang terjadi akibat infark otot jantung disebut infark miokard. Termasuk di dalam ACS adalah unstable angina pektoris/infark miokard non elevasi segmen ST (NonSTEMI), dan infark miokard elevasi segmen ST (STEMI)

Epidemiologi Menurut WHO pada tahun 2004 infark miokard penyebab kematian utama di dunia sebanyak 7.200.000 (12,2%) kematian terjadi akibat penyakit ini di seluruh dunia. Infark miokard akut adalah penyebab kematian nomor dua pada negaraberpenghasilan rendah, dengan angka mortalitas 2.470.000 (9,4%)

Di Indonesia pada tahun 2002, penyakit infark miokard akut merupakan penyebabkematian pertama, dengan angka mortalitas 220.000 (14%) Direktorat Jendral Yanmedik Indonesia meneliti, bahwa pada tahun 2007 jumlahpasien penyakit jantung yang menjalani rawat inap dan rawat jalan di rumah sakitdi Indonesia adalah 239.548 jiwa. infark miokard akut (13,49%)

STEMI

Nyeri Dada Akut dan elevasi segmen ST persisten (>20 menit)

ACS

NSTEMI/UAP Nyeri Dada Akut depresi segmen ST persisten , atau inversi gelombang T, gelombang T datar.

Patofisiology • ACS occurs when there is an imbalance between myocardial oxygen supply and demand. In NSTEMI, the most common cause for this imbalance is thrombus formation at the site of an atherosclerotic plaque, resulting in incomplete vessel occlusion or transient total occlusion.

• In NSTEMI, this thrombus does not completely occlude the arterial lumen and antegrade flow remains intact. Clumps of activated platelets or components of the disrupted plaques can propagate down the arterial tree. These microemboli may result in myocardial necrosis and are presumed to be responsible for the release of biochemical markers of AMI associated with NSTEMI. Alternate mechanisms for NSTEMI are less common. These include (1) smooth muscle cell spasm with transient obstruction;

Gejala Klinis Gejala khas Tekanan retrosternal yang menjalar ke lengan kiri, leher, atau dagu bertahan dalam beberapa menit.

Gejala Penyerta Diaforesis, Nausea, Nyeri perut, Dispnea dan sinkop

Diagnosa Diferensial Kardiak

Pulmonar

Hematologi

Miokarditis

Emboli paru

Sickle cell crisis Diseksi aorta

Spasme esofageal

Perikarditis

Infrak paru

anemia

Aneurism a aorta

Sofagitis

Penyaki serebrova skular

Ulkus peptik

Kardiomiopati Pleuritis pnemonia Penyakit vaskular Kardiomiopati tako-Tsubo

pnemothoraks

Vaskular

Gastro intestinal

Pakreatitis kolestitis

Pemeriksaan Penunjang Anamnesis dan pemeriksaan fisik. EKG : dilakukan pada 10 menit pertama dan diperiksa EKG 12-lead saat istirahat. Dan ditemuka depresi segmen ST atau perubahan gelombang T. Biomarker : Troponin kardiak untuk membedakan antara NSTEMI dan Angina Tak Stabil. Peningkatan troponin minor membaik dalam 48-72 jam, creatine kinase MB (CK-MB), and myoglobin

diagnosa • when evaluating patients with chest pain or suspected ACS so that an early diagnosis can be made and appropriate care can be initiated, • Berdasarkan EKG, biomarker, dan modalitas pencitraan.

Diagnosa

Terapi 1. Anti-ischemic Agents 0xygen: maintain oxygen saturations above 90% in hypoxic patients. Nitrate : Nitroglycerin is a potent venodilator, reduction in wall stress and myocardial oxygen demand, and with NSTEMI for relief of ongoing chest pain.

Beta-Blockers : decrease myocardial contractility and slow heart rate, which results in decreased myocardial oxygen demand • Calcium Channel Blockers : They are generallyclassifi ed into two groups: dihydropyridine calcium channel antagonists (amlodipine, nifedipine)

and non-dihydropyridine calcium channel antagonists (such as verapamil and diltiazem). Dihydropyridine calcium channel antagonists predominantly have an affect on peripheral smooth muscle relaxation while non-dihydropyridines result in a reduction in myocardial contractility and atrioventricular (AV) nodal conduction. • Morphine Sulfate

2. Antiplatelet Therapy Aspirin : As a result, the ACC/AHA guidelines recommend that all patients with NSTEMI receive aspirin on initial presentation .An initial dose of 162 to 325 mg should be given and continued indefinitely if ASHD is present, ADP Receptor Antagonists, Glycoprotein IIb/IIIa Inhibitors.

3. Antithrombotic Therapy Fondaparinux (2,5 mg subkutan perhari) 4. Additional Medical Therapies • Angiotensin-Converting Enzyme Inhibitors • Statin Therapy 5. Repofusi

Complikasi Kematian Infrak miokard

Prognosa • Dubia ad bonam = vitam jika penganan cepat dan tepat.