Introduction ACS
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Transcript of Introduction ACS
Yeo Hans Cahyadi Yeo Hans Cahyadi MD PhDMD PhD FESC FESC
Born: Jakarta, 24 August 1955Born: Jakarta, 24 August 1955Status: Married, 3 childrenStatus: Married, 3 childrenEducation: High school, Budi Mulia, 1973Education: High school, Budi Mulia, 1973
GP, University of Indonesia, 1980 GP, University of Indonesia, 1980 Cardiologist, Kanazawa Med University, Japan,1991 Cardiologist, Kanazawa Med University, Japan,1991 PhD, Kanazawa Medical University, Japan, 1991PhD, Kanazawa Medical University, Japan, 1991
Fellow of European Society of Cardiology (FESC), 2007Fellow of European Society of Cardiology (FESC), 2007Employment:Employment:
Primary Health Care, Kalimantan 1980-1984Primary Health Care, Kalimantan 1980-1984 GP in Husada Hospital 1984-1986GP in Husada Hospital 1984-1986 Cardiologist, Husada Hospital 1991-now Cardiologist, Husada Hospital 1991-now President Director of Husada Hospital 1999-2005President Director of Husada Hospital 1999-2005 Head of Depart of Cardiology, Husada Hospital 1999-nowHead of Depart of Cardiology, Husada Hospital 1999-now
Kegawatdaruratan Jatung Kegawatdaruratan Jatung Infark Miokard AkutInfark Miokard Akut
Dr. Yeo Hans Cahyadi PhD, SpJP, FIHA, FESCDr. Yeo Hans Cahyadi PhD, SpJP, FIHA, FESC
Normal ECGNormal ECG
VES (Ventricular Extra-Systole)VES (Ventricular Extra-Systole)
VES (Ventricular Extra-systole)pada Old Antero-septal MI
Anterior-inferior STEMI
VT (Ventricular Tachycardia)
Ventricular Fibrillation
Cardiac Arrest
DefibrillatorDefibrillator
ATHEROSCLEROSIS
INTRAPLAGUE THROMBUS
PLAGUE RUPTURE
INTRALUMINAL THROBUS
PLAGUE RUPTURE
PROPAGATION THROMBUS
The Vulnerable Plaque
Plaque Disruption
3434
1990199219941996199820002002
1990ACC/AHA
AMI R.
Gunnar
1994AHCPR/NHLBI
UA E. Braunwald 1996 1999
Rev Upd ACC/AHA AMI T. Ryan
2004 2007 Rev Upd ACC/AHA STEMI E. Antman
2000 2002 2007 Rev Upd RevACC/AHA UA/NSTEMI E. Braunwald; J. Anderson
20042007
Evolution of Guidelines for ACS
2009
2009Upd
ACC/AHA STEMI/PCIF. Kushner
Pathway: Triage and Transfer for PCI (in STEMI)Pathway: Triage and Transfer for PCI (in STEMI)
2009 STEMI Focused Update. Appendix 5
STEMI patient who is acandidate for reperfusion
Initially seen at a PCIcapable facility
Initially seen at a non-PCIcapable facility
Send to Cath Lab for primary PCI(Class I, LOE:A)
Transfer for primary PCI(Class I, LOE:A)
Initial Treatmentwith fibrinolytictherapy (Class 1, LOE:A)
Prep antithrombotic (anticoagulantplus antiplatelet) regimen
Diagnostic angio
Medicaltherapy only
PCI CABG
NOT HIGH RISK
Transfer to a PCI facility may be considered (Class IIb, LOE:C), especially if ischemic symptoms persist and failure to reperfuse is suspected
HIGH RISKTransfer to a PCI facility is reasonable for early diagnostic angio & possible PCI or CABG (Class IIa, LOE:B),
High-risk patients as defined by 2007 STEMI Focused Update should undergo cath (Class 1: LOE B)
At PCI facility, evaluate for timing of diagnostic angio
Mr. SS, 23-03-2011 (9 Ms post PCI)Mr. SS, 23-03-2011 (9 Ms post PCI)
Angina PectorisAngina Pectoris
Cardiogenic shock, BP 85/65 mmHgCardiogenic shock, BP 85/65 mmHg
ECGECG
Mr. SS, ECG pre Primary PCI
Mr. SS, CAG + Primary PCIMr. SS, CAG + Primary PCI
Mr. SS, Primary PCIMr. SS, Primary PCI
Mr. SS, ECG post Primary PCI
Time is MoneyTime is Money
Time is Time is MyocardiumMyocardium
Copyright restrictions may apply.Kim, K. P. et al. Arch Intern Med 2009;169:1188-1194.
Estimated lifetime risk of radiation-induced cancer per 100 000 persons from a single computed tomographic scan to assess coronary artery calcification by age at screening
Copyright restrictions may apply.Kim, K. P. et al. Arch Intern Med 2009;169:1188-1194.
Site-Specific Estimates of the Lifetime Risk of Radiation-Induced Cancer From a Single Coronary Artery Calcification Computed Tomographic Screen at Age 55 Years
Thank youThank you
6666
ACC/AHA 2009 STEMI/PCI Guidelines ACC/AHA 2009 STEMI/PCI Guidelines Focused Update Focused Update
Based on the ACC/AHA Guidelines for the Management of Patients With ST-Elevation
Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI): A Report of the ACC/AHA Task Force on Practice Guidelines
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Class I Benefit >>> Risk
Procedure/ Treatment SHOULD be performed/ administered
Class IIa Benefit >> RiskAdditional studies with focused objectives needed
IT IS REASONABLE to perform procedure/administer treatment
Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful
Procedure/Treatment MAY BE CONSIDERED
Class III Risk ≥ BenefitNo additional studies needed
Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
shouldis recommendedis indicatedis useful/effective/
beneficial
is reasonablecan be useful/effective/
beneficialis probably recommended
or indicated
may/might be consideredmay/might be reasonableusefulness/effectiveness is
unknown /unclear/uncertain or not well established
is not recommendedis not indicatedshould notis not
useful/effective/beneficialmay be harmful
Applying Classification of Recommendations and Level of Evidence
Class I Benefit >>> Risk
Procedure/ Treatment SHOULD be performed/ administered
Class IIa Benefit >> RiskAdditional studies with focused objectives needed
IT IS REASONABLE to perform procedure/administer treatment
Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful
Procedure/Treatment MAY BE CONSIDERED
Class III Risk ≥ BenefitNo additional studies needed
Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Applying Classification of Recommendations and Level of Evidence
Level A: Multiple populations evaluated; Data derived from multiple randomized clinical trials or meta-analyses
Level B: Limited populations evaluated. Data derived from a single randomized trial or non-randomized studies
Level C: Very limited populations evaluated. Only consensus opinion of experts, case studies, or standard-of-care.