Sindrom Koroner Akut

BAB I PENDAHULUANLatar BelakangSindrom koroner akut (SKA) merupakan keadaan darurat jantung dengan manifestasi klinis rasa tidak enak didada atau gejala lain sebagai akibat iskemia miokardium. SKA terdiri atas angina pektoris tidak stabil, infarct myocard acute (IMA) yang disertai elevasi segmen ST. Penderita dengan infark miokardium tanpa elevasi ST. SKA ditetapkan sebagai manifestasi klinis penyakit arteri koroner. Penyakit jantung koroner (PJK) merupakan manifestasi utama proses aterosklerosis. Yaitu suatu fase akut dari APTS yang disertai IMA gelombang Q (IMA-Q) dengan non ST elevasi (NSTEMI) atau tanpa gelombang Q (IMA-TQ) dengan ST elevasi (STEMI) yang terjadi karena adanya trombosis akibat dari ruptur plak aterosklerosis yang tak stabil (Vulnerable). Sindrom ini menggambarkan suatu penyakit yang berat, dengan mortalitas tinggi. Mortalitas tidak tergantung pada besarnya prosentase stenosis (plak) koroner, namun lebih sering ditemukan pada penderita dengan plak kurang dari 5070% yang tidak stabil, yakni fibrous cap dinding (punggung) plak yang tipis dan mudah erosi atau ruptur. Terminologi sindrom koroner akut berkembang selama 10 tahun terakhir dan telah digunakan secara luas. Hal ini berkaitan dengan patofisiologi secara umum yang diketahui berhubungan dengan kebanyakan kasus angina tidak stabil dan infark miokard.1 Angina tidak stabil, infark miokard tanpa gelombang Q, dan infark miokard gelombang Q mempunyai substrat patogenik umum berupa lesi aterosklerosis pada arteri koroner. Istilah Sindrom Koroner Akut (SKA) banyak digunakan saat ini untuk menggambarkan kejadian kegawatan pada pembuluh darah koroner. SKA merupakan satu sindrom yang terdiri dari beberapa penyakit koroner yaitu, angina tak stabil (unstable angina), infark miokard non-elevasi ST, infark miokard dengan elevasi ST, maupun angina pektoris pasca infark atau pasca tindakan intervensi koroner perkutan. Alasan rasional menyatukan semua penyakit itu dalam satu sindrom adalah karena mekanisme patofisiologi yang sama. Semua disebabkan oleh terlepasnya plak yang merangsang terjadinya agregasi trombosit dan trombosis, sehingga pada akhirnya akan menimbulkan stenosis berta atau oklusi pada arteri koroner dengan atau tanpa emboli. Sedangkan letak perbedaan antara angina tak stabil, infark Non-elevasi ST dan dengan elevasi ST adalah dari jenis trombus yang menyertainya. Angina tak stabil dengan trombus mural, Non-elevasi ST dengan thrombus inkomplet/nonklusif, sedangkan pada elevasi ST adalah trobus komplet/oklusif. Proses terjadinya trombus dimulai dengan gangguan pada salah satu dari Trias Virchow. Antara lain akibat kelainan pada pembuluh darah, gangguan endotel, serta aliran darah terganggu. Selanjutnya proses koagulasi berlangsung diawali dengan aterosklerosis, SMF Ilmu Penyakit Dalam RSUD Waled

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inflamasi, terjadi ruptur/fissura dan akhirnya menimbulkan trombus yang akan menghambat pembuluh darah. Apabila pembuluh darah tersumbat 100% maka terjadi infark miokard dengan elevasi ST segmen. Namun bila sumbatan tidak total, tidak terjadi infark, hanya unstable angina atau infark jantung akut tanpa elevasi segmen ST. The American Heart Association memperkirakan bahwa lebih dari 6 juta penduduk Amerika, menderita penyakit jantung koroner (PJK) dan lebih dari 1 juta orang yang diperkirakan mengalami serangan infark miokardium setiap tahun. Kejadiannya lebih sering pada pria dengan umur antara 45 sampai 65 tahun, dan tidak ada perbedaan dengan wanita setelah umur 65 tahun.46 Penyakit jantung koroner juga merupakan penyebab kematian utama (20%) penduduk Amerika. Di Indonesia data lengkap PJK belum ada. Pada survei kesehatan rumah tangga (SKRT) tahun 1992, kematian akibat penyakit kardiovaskuler menempati urutan pertama (16%) untuk umur di atas 40 tahun. SKRT pada tahun 1995 di Pulau Jawa dan Pulau Bali didapatkan kematian akibat penyakit kardiovaskuler tetap menempati urutan pertama dan persentasenya semakin meningkat (25%) dibandingkan dengan SKRT tahun 1992. Di Makassar, didasari data yang dikumpulkan oleh Alkatiri7 diempat rumah sakit (RS) selama 5 tahun (1985 sampai 1989), ternyata penyakit kardiovaskuler menempati urutan ke 5 sampai 6 dengan persentase berkisar antara 7,5 sampai 8,6%. PJK terus-menerus menempati urutan pertama di antara jenis penyakit jantung lainnya. dan angka kesakitannya berkisar antara 30 sampai 36,1%. 2,3.

BAB II PEMBAHASAN

Sindrom Koroner Akut

DefinisiSindrom Koroner Akut (SKA) adalah suatu istilah atau terminologi yang digunakan untuk menggambarkan spektrum keadaan atau kumpulan proses penyakit yang meliputi angina pektoris tidak stabil/APTS (unstable angina/UA), infark miokard gelombang non-Q atau infark miokard tanpa elevasi segmen ST (Non-ST elevation myocardial infarction/ NSTEMI), dan infark miokard gelombang Q atau infark miokard dengan elevasi segmen ST (ST elevation myocardial infarction/STEMI) (Gambar 1). APTS dan NSTEMI mempunyai patogenesis dan presentasi klinik yang sama, hanya berbeda dalam derajatnya. Bila ditemui penanda biokimia nekrosis miokard (peningkatan troponin I, troponin T, atau CK-MB) maka diagnosis adalah NSTEMI; sedangkan bila penanda biokimia ini tidak meninggi, maka diagnosis adalah APTS. Pada APTS dan NSTEMI pembuluh darah terlibat tidak mengalami oklusi total/ oklusi tidak total (patency), sehingga dibutuhkan stabilisasi plak untuk mencegah progresi, trombosis dan vasokonstriksi. Penentuan troponin I/T ciri paling sensitif dan spesifik untuk nekrosis miosit dan penentuan patogenesis dan alur pengobatannya. Sedang kebutuhan miokard tetap dipengaruhi obat-obat yang bekerja terhadap kerja jantung, beban akhir, status inotropik, beban awal untuk mengurangi konsumsi O2 miokard. APTS dan NSTEMI merupakan SKA yang ditandai oleh ketidakseimbangan pasokan dan kebutuhan oksigen miokard. Penyebab utama adalah stenosis koroner akibat trombus non-oklusif yang terjadi pada plak aterosklerosis yang mengalami erosi, fisur, dan/atau ruptur. Angina tidak stabil (UA) dan infark miokard non-ST elevasi (NSTEMI) adalah bagian dari sindrom koroner akut kontinum, di mana plak pecah dan terbentuk trombosis koroner aliran darah ke daerah miokardium. UA dan NSTEMI juga disebut sindrom koroner akut non-ST elevasi, untuk membedakan mereka dari akut infark miokard ST elevasi (STEMI). Dalam UA dan NSTEMI, tidak ditemukan ST elevasi dan gelombang Q patologis pada EKG. Pada pasien dengan MI akut, alasan mengapa gelombang Q atau menjadi oklusi koroner, berhubungan dengan durasi oklusi, sejauh mana daerah infark menjaga kelangsungan hidup selama oklusi, serta letak pembuluh darah yang menentukan ukuran infark. Arteriografi koroner dilakukan pada 60-85% kasus, dalam periode akut NSTEMI menunjukkan bahwa infark arteri yang terkait tidak tersumbat.2-5 Hal ini merupakan alasan terhadap kurangnya kemanjuran fibrinolisis dalam gangguan ini.

EpidemiologiThe American Heart Association memperkirakan bahwa lebih dari 6 juta penduduk Amerika, menderita penyakit jantung koroner (PJK) dan lebih dari 1 juta orang yang SMF Ilmu Penyakit Dalam RSUD Waled 3

diperkirakan mengalami serangan infark miokardium setiap tahun. Kejadiannya lebih sering pada pria dengan umur antara 45 sampai 65 tahun, dan tidak ada perbedaan dengan wanita setelah umur 65 tahun.46 Penyakit jantung koroner juga merupakan penyebab kematian utama (20%) penduduk Amerika. Di Indonesia data lengkap PJK belum ada. Pada survei kesehatan rumah tangga (SKRT) tahun 1992, kematian akibat penyakit kardiovaskuler menempati urutan pertama (16%) untuk umur di atas 40 tahun. SKRT pada tahun 1995 di Pulau Jawa dan Pulau Bali didapatkan kematian akibat penyakit kardiovaskuler tetap menempati urutan pertama dan persentasenya semakin meningkat (25%) dibandingkan dengan SKRT tahun 1992. Di Makassar, didasari data yang dikumpulkan oleh Alkatiri7 diempat rumah sakit (RS) selama 5 tahun (1985 sampai 1989), ternyata penyakit kardiovaskuler menempati urutan ke 5 sampai 6 dengan persentase berkisar antara 7,5 sampai 8,6%. PJK terus-menerus menempati urutan pertama di antara jenis penyakit jantung lainnya. dan angka kesakitannya berkisar antara 30 sampai 36,1%. 2,3 Diagnosis NSTEMI lebih sulit untuk ditegakkan dibanding diagnosis STEMI. Oleh karena itu perkiraan prevalensinya menjadi lebih sulit. Secara keseluruhan, data menunjukkan bahwa kejadian NSTEMI dan UA tahunan lebih tinggi daripada STEMI. Perbandingan antara SKA dan NSTEMI telah berubah seiring waktu, karena laju peningkatan NSTEMI dan UA relatif terhadap STEMI tanpa penjelasan yang jelas mengenai perubahan ini.1,9 Perubahan dalam pola kejadian NSTEMI dan UA mungkin dapat dihubungkan dengan perubahan dalam manajemen serta upaya pencegahan CAD selama 20 tahun terakhir.1,9 Secara keseluruhan, dari berbagai penelitian, didapatkan bahwa kejadian tahunan dari penerimaan rumah sakit untuk NSTEMI dan UA sekitar 3 per 1000 penduduk. Hingga saat ini, tidak ada perkiraan yang jelas untuk Eropa secara keseluruhan, karena tidak adanya statistik kesehatan umum yang terpusat.

PatogenesisSKA merupakan salah satu bentuk manifestasi klinis dari penyakit jantung koroner (PJK), salah satu akibat dari proses aterotrombosis selain strok iskemik serta peripheral

Sindrom Koroner Akut arterial disease (PAD). Aterotrombosis merupakan suatu penyakit kronik dengan proses yang sangat kompleks dan multifaktor serta saling terkait.4 Aterotrombosis terdiri dari aterosklerosis dan trombosis. Aterosklerosis merupakan proses pembentukan plak (plak aterosklerotik) akibat akumulasi beberapa bahan seperti makrofag yang mengandung foam cells, lipid ekstraselular masif dan plak fibrosa yang mengandung sel otot polos dan kolagen. Perkembangan terkini menjelaskan aterosklerosis adalah suatu proses inflamasi atau infeksi, dimana awalnya ditandai dengan adanya kelainan dini pada lapisan endotel, pembentukan sel busa dan fatty streaks, pembentukan fibrous cups dan lesi lebih lanjut, dan proses pecahnya plak aterosklerotik yang tidak stabil. Banyak sekali penelitian yang membuktikan bahwa inflamasi memegang peranan penting dalam proses terjadinya aterosklerosis. Pada penyakit jantung koroner, inflamasi dimulai dari pembentukan awal plak hingga terjadinya ketidakstabilan plak yang akhirnya mengakibatkan terjadinya ruptur plak dan trombosis pada SKA. Perjalanan proses aterosklerosis (inisiasi, progresi, dan komplikasi pada plak aterosklerotik), secara bertahap berjalan dari sejak usia muda bahkan dikatakan juga sejak usia anak-anak sudah terbentuk bercak-bercak garis lemak (fatty streaks) pada permukaan lapis dalam pembuluh darah, dan lambat-laun pada usia tua dapat berkembang menjadi bercak sklerosis (plak atau kerak pada pembuluh darah) sehingga terjadinya penyempitan dan atau penyumbatan pembuluh darah. Kalau plak tadi pecah, robek atau terjadi perdarahan subendotel, mulailah proses trombogenik, yang menyumbat sebagian atau keseluruhan suatu pembuluh koroner. Pada saat inilah muncul berbagai presentasi klinik seperti angina atau infark miokard. Proses aterosklerosis ini dapat stabil, tetapi dapat juga tidak stabil atau progresif. Konsekuensi yang dapat menyebabkan kematian adalah proses aterosklerosis yang bersifat tidak stabil atau progresif yang dikenal juga dengan SKA. 01000900000388ec010000009710010000001610000026060f002220574d46430100000000 00010085ac000000000e000000002000001095010010b50100010000006c0000000000000 0000000002b0100009a00000000000000000000004f2900006415000020454d4600000100 10b501000c00000001000000000000000000000000000000000400005802000069010000d 40000000000000000000000000000001c830500d23a0300460000002c0000002000000045 4d462b014001001c000000100000000210c0db01000000600000006000000046000000ec4 70000e0470000454d462b224004000c000000000000001e4009000c000000000000002440 01000c000000000000003040020010000000040000000000803f214007000c000000000000 0008400005384700002c4700000210c0db010000000000000000000000000000000000000 001000000ffd8ffe000104a46494600010100000100010000fffe003b43524541544f523a206 7642d6a7065672076312e3020287573696e6720494a47204a50454720763632292c2071756 16c697479203d2039300affdb0043000302020302020303030304030304050805050404050 a070706080c0a0c0c0b0a0b0b0d0e12100d0e110e0b0b1016101113141515150c0f1718161 41812141514ffdb00430103040405040509050509140d0b0d1414141414141414141414141 4141414141414141414141414141414141414141414141414141414141414141414141414 14ffc0001108009b012c03012200021101031101ffc4001f000001050101010101010000000 0000000000102030405060708090a0bffc400b5100002010303020403050504040000017d0 1020300041105122131410613516107227114328191a1082342b1c11552d1f024336272820 90a161718191a25262728292a3435363738393a434445464748494a535455565758595a636 SMF Ilmu Penyakit Dalam RSUD Waled 5

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Sindrom Koroner Akut 60d7e8f7fc11e3536d1aefe2edfa344af6fa65b4a0ce48418690fcc476af0f3a972602a4bb7f9a 37a1173a8a2ba9fa83ff000a8fc0bff425f87bff0005507ff1147fc2a2f02ffd097e1dff00c1541ff c45789bfed43aaa75baf0b75c7fc7dca79fca91bf6a4d4d1f61baf0c06c6ec7da25e9ff007cd7e 2bfdbd86fe77f89f67fead663fc8bef3db1be11f8140ff912fc3bff0082a83ff88a07c23f029e9e0 bf0effe0aa0ff00e22be74f1cfed93aa784fc2da86ad12786f5192d5378b58ae650d2720100ede 3ad5af0d7ed877de25f0fe9daaa1f0dd82de42b28b69ef24678f23eeb1da326affb6f0fc9cfceed f327fd5bcc6f6e45f7a3d53c43e0df0ff85fc71a23e8da1699a43cb6774b235859c709701a2e0 95033567e1ffc36f086afe1afb6dff85744bdbb96eeeda4b8b9d3a192473f68939662a493f5af3 1d07e349f1c78f2d9758bfd02d23b5b4945b9b4ba62672c509e58003010f19cf7f5ae43c47fb 5a5ff00c29f07eb773611681ace9fa75d3b5b817722cb74924e49c7cb818dfd79071e95f9f65f 98d3ff005bb195eef9654a9a4f5d5ddf5f983c9b1924b0ea1ef2bb3ea11f08fc0a47fc897e1dff0 0c1541ffc452ffc2a2f02e7fe44bf0f7fe0aa0ffe22bc1342fdaeeff5ed1ecb518cf87ed56eade3b 8fb34b3cccf0865076b10b8246706ada7ed597cea185d7868a9ee669bff0089afbf967b868b6 9cdfe235c3598dafecff13dbcfc23f028e7fe10bf0f1ffb8541ff00c452ff00c2a2f02ffd097e1dff 00c1541ffc457cd9f10ff6dabff027856e35afb3e81ab0864443696f73323be5b0704a76ae874 9fdaea5d634fb5bb8dfc3d6e9711aca2196ea52e9b86769f93a8aafedbc32873b9bb3f527fd5c cc6f6f67f89ee5ff000a8bc0bff425f877ff0005507ff11487e1278147fcc97e1dff00c1541ffc45 78cafed5170d9c5d7870fd269bff0089ae4fe27fedb17fe03f0a36af6f6fa0eaceb32466da2b895 4904e09c95ed4433bc34e4a2a6ff107c3998aff009767b06a5e16d1bc2fe39bc8f46d22c3498e 5d2e36912c6d9210e44926090a064fd6b47e1e7c2df065ff0082345b8b9f08e8371712db23c9 2cba642ceec472492b927debcf3e1b7c4abdf8b9a95f6b935bdac76eb6315ba9b566237ee762 a7760e46e1ce3041ac7d07f68cd43c2ba743a1dc3e8b693e9aa2dde3ba6977640f50083f81afc df28cd2852e2acdaab93d551fc23664acab135d470f4d2728dee8f7c6f849e055ebe0bf0eff00e 0aa0ffe22947c23f029ff00992fc3bff82a83ff0088af993e28fedbba8f80fc32354b58b40d55fe d2901b78e4981c37520e3b57596bfb56dc5cc1148b7fe1a05d41d8659b238fa57e90f3bc3a8a 9f3bb3f52ffd5bcc6f6f667b7ffc2a2f02ff00d097e1effc1541ff00c4535fe127811064f82fc3c0 7fd82a0ffe22bc607ed4f71b49fb77875b1dc19c8fe55c67c51fdb7f51f0168767a85b5b687acf 9b769035bc724d1b6d604ee048f6a54f3cc3d4928c66ff00107c3998ad7d99f4e7fc2a2f02f6f 05f877ff05507ff001149ff000a8bc0bff425f87bff0005507ff115e2b1fed513c917982fbc3e06 d0c40139c703dbde98dfb54ccf1e7fb47410ac3ef049fbfe152f3dc36dceff0011ae1bcc5ffcbb3 a0d7fc3fa5e9163e3ad3ac34db3b2d3fcfc7d92de048e2c34116ef900c73df8e6bd323f847e05f 2d7fe28bf0f1381ff0030a83ff88af927c51fb49685e0af076a4babea035bd535595963b9591a3 591ca851e612a0a6d0a3900e71dabd97f672fda6345f8956567a1de4f241afac7f2493dc24c97 a4724c72285048fee10081eb826be2f856ace8e61994eaa7055aaf341bfb4b952bad4e6c6e5d 89c3c23ed20d72ad4f25ff00829d7c3cf0af87ff00645f11dee97e1ad1f4dbc4bdb20b7167611 45228332838655079afc69f08694bae6b76760f21896e67488c81771504e3206467e99afdb5f f0082a8ff00c99af897febf6c7ff47ad7e2c7c35ff91cb48ffafb8bff004215fd55c12dc9abebabfc 8f93c41763d2f459950c6756915b76d2b68841da32d8f9f9c0209f4a87c8f0f63fd7ea5ff80d1f ff00175dc7803e2e69fe10f0a416171a2dc5eea5632ea3258dcc776b1c20de5ac76f20950c64b 6d11865dacbc920d74d77f1ebc3dabea7aac90fc38d3127beb69ed6d22b3b6b6530bb5d492d b9004182515d232400cfb0648edfaecaad78c9a541b5df9a271a51b6e7924363a15c4a2289f5 49653d112d632c7f0df4f8b4ff000fb185a59f5286195b6895ad536f1d7a3f38cf6af71d33f698 f0f68be32d5f5db8f87c1f54bad7bfb50166b689ad5300181716c08fe3539e083f3293926a58f ed27e1182f6e3ed7f0c34fd474f36f7515bd94f247e5c124a200650a220aac7c972db557fd69d bb702b175f16f45867d35e68fcfee1da3dcf1fd4f44d074c9220d777b3453209229a18232aeb 923232e0f504608ea2a9f91e1eff009f8d47ff0001e3ff00e2ea5d5a0967d27443146f204b3777 SMF Ilmu Penyakit Dalam RSUD Waled

7

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Sindrom Koroner Akut 63094dcb73d63c17f1234af00f866cadeef4797527d52dcc176c93f978b4f3660d1ae3a925b7 60f1944f4aa6bf156d21d3f4236f26b56d77a6adb45f638678c593085f779bb086f9dbae0823 712727a5707addedb5c2d8dbda3492436909884b22853212ece4e32703e6c75ed5984d78d4 b24c2d472af34d4a4db7abf3b68f45a3f23ade2aa25c8b647a97c70f1cd8f8f3c2be1bbbb1b7b a8560b8bd8647ba7c991f6dbb1655dcc107cc06d538e09006715f5ff00fc134bfe4856bdff006 324ff00fa4b6b5f03eaff00f24f349ffb095f7fe8ab4afbdffe09a3ff00242b5eff00b1927ffd25b5 afce78ab0b4f0586861e97c31dafaf566d4e6ea4dca5bb3f3528a28ab330a28a280006bf433fe 093d95d1be38900b1fec38b00753feb2bf3cebf49bfe08d16f25e6aff0015e084a2cb2e9d6c88 6404a825a4c647a57819ec79b2eaa9755faa3b3093f675e137d1a653920bf79937db909f7bea 3b559492e48e20231d3381cd7dfa7e1078b89cff0068787f3ebf6393ff008aa1be1078b58737 da01ff00b7393ff8aafe5dfec3c4aff976ff000ff33fa5e3c7f878ab251fbdff0091f9c7e2b967b3d 0efef6e90c76f0c7963d4819eb815cf5a69da8f8bac34a3f6661a36d59cab101ee003c0c765fd 6bf427e2ff00ecf7e27f16fc36d7b48b8d5743b682eadca3cd0d9c9b9464723e6a9fe17fecf9e2 5f0b780342d26cb5ad1ae2d2d2d5228dee2c5f7b01eb87af5e1925686014941f3f3796d6386b f19e1b11fc471e5ed77f9d8f90bc67e255f12ea76f3695e1887c3d6d1422268a3943195ffbc78 0001d3f0e4d70fe3ad62e6dfc2f7ef7b24f1405409644739c6471ef5fa3aff06fc58579bcf0ec9f 5b3907fecd5e67f1f3f675f16f8c3e176bba303e1db717491a9ba8d24468f1229c8e0fa56183c 9f112c553f6906936afb1a50e31c151c3fd5e1cad2bad5b7f9a3e0e4d3b54f14e95a4442168f4 5891261bdb324fc7cb91d87d6bbbd1e19a3d46d17538da5d2848bf68b7b79c248c9e82bebef 087c09d7b42f04687a63f84347d6e3b4b086dfed514e88f305403710ea304f5ebdeb3755f835 a74395d47e1e6aba728392f6204aa3bf1e5b1fe55c38dcbeb42aca3c8ec9bb68fb9b4388f0988 4d49a6df692bf9595efe87c99f1e6eecb44d2e7bbd2e009a3ac3137d9a39ccbb58e0372738e7 b64d731e11f84f7be334b1bf82ddafa0862172ba6d82348ca300ee71d4f615ebff00b51fc30f0 ee9bf09f579f479f504be1243b34fbb85919c9900e032824f3ef5d2781be0f78c3c3de0bd2ee7 44bc5fb44d6b03cb0c4caac7e504c6e1bd0fa106ba7eadecb2ca753ab934df9596c39e3e2e0a3 49a7cb6b73f57e6ce227b3d6ad34f96f2e74bb9b3b58d70ecf6eca571dc83f7738ac5f8f1e21f 12f87fe145acd75a641fd9f1491a43b605120e4f2ec39c9cf7ebc57d2163e3dbad074eb6b7f10 78667b292df716945bb48b277e7190dce7af7af3efda97e20e85ae7c24b96d3ee60fde5dc2cf1 1521c1de0e08238ebd2be472faf5e59852a7528dfdedfcbfccc31199e3aa28fb48256d9ad527d d33c434cd0f56d4eda1d63fb22edb65a09636b865500606428e719f5f6af1df88571a678d3e2 5785ad2fe03797321581b4e8ee563f25c3643839da49031838c935fa5fe0bf0ee87ac783b4f69 74d49965b28e39b0ea237ca8e4f7fc2b82f16fec5bf0a3c6c96eaba0c7a6f90e37de5836c67cf3 80c3b7eb5785cfa860f133fac41ad5ad3fe1ff0023c3c6e6388c553749a5ba7aaeddcf91fe25fc 42d4bc25a330b8d02eade48ee11089feeed39e78aed62d2bc41e23b6b7bfb1d15ae1e3c3c4b7 12a9e703e6080f6cf535e91fb5cfc38b7b2f827a7430dda84b6bab7b5b732b6e668c31c166ea 4d7a7c7a0da687e18d36142b78d0ac7f69dae55d58a83d7a63158e2f338c72da35e95349ca52 5d7a5bfccf61f1066328ff00134ed647cbdaa68fe3bd3d2292f7447469d77c4aadf36cce3760f2 05705f14f5cbef09f872d6796090dc3dca0292b0c720fa743c57db7e330b69756dac8b2736b2 dbed16eade61900e0b7246dfa57c7bfb564aa7c35a7342675b69350568927653b461b8c0e70 2b4e1ec6fd7330a54e70566ff0043cfab9ce326bde96be866ddeada96a8c8d3e98260b1e523b 86e173c138e327deb90d6be06e99748f777fa049048082df659083c8c8c8e7d6bdfdbc230ea6 96d0accd791f94b2adcc4a415254640e3a0e6b0fc41a2c116bb1cb6f7f34f688a06e8e60c73dd 4a75c0e82ba69e68e95471a2f97d2e7357c64b151e5ad1525e6ae784789fc0da1fc1eb5d3352 83448ee6e6e1f72c93dc799b076e31c1ac6f14f8ff0057f88b7d6497b3adadb45feae2462b1a1 f563ebef5e99f1f6cadee3c3da39fb62dc86bdda62553f2f073d7db1d2b84d7fc3b62da9e97a6 e9ec5ee257540eab839246067f4e7d2bebe8d5856c251c455579b72d7b5bd4f23118aab4e1f5 SMF Ilmu Penyakit Dalam RSUD Waled

9

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Sindrom Koroner Akut 383f6abb8f13dc7c274b6b9d4adae634bdb7c7971b2ca4e48e72326bd16cf56f161b35945ee9 5207b745f27cf1b7ee01c02783c77afa87e2debf1f8afc2c2cf4ef0fea135cfda237c3da28f941e 4e49ae961f15680d6b0acfe18bc7708a1b769c879c7d6b4c4e1f872a65b470f1c6d2bc6527f1 c7adbfbc74c788a2df34f0dbf45ff0c7c4faaea5e35d43458f4e921d2e68620a037da543601edf 3715e0bfb5726a7a9f81345593458ac8dadd468d324e8fe6310de95fa972eade109f993c1d33f f00bda5466b80f8b9e1df0b78af40b6b7d3bc00b35ca5d24a7ccd2a25c28ce7afd6b0c9b0d90 60f1f46b3c752b45dfe38ae9fe21cf3dc3d58b8fd5a49beb73e47f0e6bbe33b1f0c25acde1bb2 b8430058e6765660481d029cfe35e71a87817c497d21797469a0ba2fe6030e303d7e6e99afd 245d1be1dbc2824f0036f0a01c696839fc0d616a1e07f0dea3afc12691e0fb2b6b08add8cb0ea 362a8934858606e04b0e33c8e9e86bc3c4ac97011a989faed2b5f5b4937bf6577d7a1b433ac0 cac9d09dfe47e5e7c72f0beb49e1cd31ee6c63b3c5e85498b8058953c9f4e7ad763fb357ecd1a df8f7c616e2d26fed4bf0409eee2cbda69eb9e6477e8cc39da839cfe75f75fc59f02fc37d534bd 16de7f05e9d657e2fd336b756e1830c7251beeb8fd7d40afa63c3de1fd33c37a64367a469d6b a65a228db05a42b122f1d82802bf50c265f471194e1674aaa941b93bc754d5d6cff0033c3c7e 6d45bbe1e9b5eb6d0f8f3fe0a33e10b1f017ec15a9787f4e5db67a7cd610a12396c4eb963ee49 24fb9afc74f86bff00238e8fff005f717fe855fb4fff000552ff009336f137fd7f58ff00e8f5afc58f 86bff239691ff5f717fe842bf7be078a8a49746fff00493e031327295df536748f87f79aa78566 d7deff004eb0b3124b05bc77d71e5c97724488f2244318255644fbc464b00324e2ba5b3fd9b7 e205da3b1d02780c3706dae239c157818344bf32e327999384dcc33c81c65fe08d2fc7b75f0e 6f0e81e44fa14ad78f3a4f1dbeeb7f2e3816678e4946632cb344a7cb219b0073815daf87adfe3 4de5ceac96d7d045a9974d75acae5ad0c92cd7771110c030c24a648a2210ed618000f9b07f58 ad8baf094b92a53493eaf5471282b2ba6792c3f0abc5d71aa5869d0f87efa6bdbf84dcda40b11 df7110e77a0ea411823d723d455a8fe10788ee359d4749b7b64b9d42c74fb5d45ede162cd22 5c080c4a800cb39fb4c436fa93e95e93a5e9ff1d2c759f0bea705935b6a173a631d2aeee61b34 2d6a8b11dccd200032a980a97f982f97b78c5544f0cfc60d07c6767771ca6c3c57ab3c3a6c20 4d6f1b38b78eda5802be7cb180b0630724a63ae453faf556eded69edfcdd57e960f66bb33cef5 0f83fe36d2d758377e17d4ed868e375f996dd945b0d81f2de8369073e847a8ae3ebd7afbf687f 17c3a578c743d6edad2f353d69de0bcbcb9b70935b1d8b14891aae1532b1aa9c01f74673815 e435eb6167899297d6125b5acf7d35fc4c65cbf64dad63fe49e693ff612beff00d15695f7bffc1 347fe4856bdff006324ff00fa4b6b5f046aff00f24f349ffb095f7fe8ab4afbdffe09a3ff00242b5e ff00b1927ffd25b5afcab8d7e15fd7567750dcfcecf0878bb55f01f89f4df10e8775f62d5f4e985 c5adc6c57f2dc743b58107f115eedff000f0ff8ff00ff0043e37fe0b2d3ff008d57ce3457cde619 16579ace3531f8685571d139453b2f99a42ad4a6ad19347d1dff000f0ff8ff00ff0043e37fe0b2 cfff008d51ff000f0ff8ff00ff0043e37fe0b2d3ff008d57ce345795fea6f0e7fd0052ff00c023fe4 5fd62b7f3bfbcfa3bfe1e1ff1ff00fe87c6ff00c165a7ff001aaed746f0dfc48fdb1f555f10692a9e 32f1145a75b8d55e1786192361941b93e503851d076af8f057e98ffc114cff00c553f137febca d3ff463d7a184c1e5fc27cf9865585a74ea5ad7514ae9b5dacc6aa4eab519c9b479de91fb117c 6fd1356b2d464f87cf74969324e609eea1f2e4da41dad87e871835dbeb9e34f8dfa9cf7d63e23 f0fe87aa4f31beb709bede17862bb8bca9e1530b2e41010e4e5b2839afd38f8b77da8e9df0dfc 4173a542d717d15a3b471c632c78e703b9c66bf39f43f17df689f0afc49e3686359f5d337d96 c4ca322191b39723d457cb677e226354e0aae1a9cdf46d3d3f13edf22c8296674aa55a936b95 a492b5db6655a5bfc7dd3f58bfd62dfc1d610cd7f7f06a12a7da901fdd59b5a6c51e66e00c6c4 e4720f435049f0fbf685f14c1a66b3a7f83e278b4dd6935cb6bb3a8adc949638521547696562 542c638273d7a0c0af32d066f12dddd0bebfd72eeef53924f35e669587cdd78f4afa77e1e7c52 f14dc781358b6b259afb519a396d2748b969b6c6645900eec151d4f7231e95e2d0f126aaafcaf 094b6b68a5e9dcfa5c6702ba1865888d5eaaf73c6b4ed77e2a7877c4167259785747b5b5b2b SMF Ilmu Penyakit Dalam RSUD Waled

11

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13

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15

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17

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19

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Sindrom Koroner Akut 000a000b000a002b000a000b000a000b040a000a000a00b9394f0c300c1008320c1108310c1 0082f0c0f082f081008110c1108120c1108310c1108120c1208110c1108110c1008300c1008 120c1108110c10082f0c2f082f0c0e082f0c0e082e0c0d082f08300c0f08300c0e082e082e0c2 f08300c1008100c100810080f082f0c2f08300c0f0810081108110810082f0c2e082e0c0e083 00c1008300c0f082f0c70145e4ebf5edf5e3c4a91140e08300c0f08300c0e082e0c2d0c0e082e 082e0c2e082f0c0f08300c0f08310c0f08310c1108110c1008300c0f08100c1008310c110831 081108310c110811081008120c1108300c1008120c1208120c10083008701098310a002a04 09002b000a000b000a000b000a002a000a000b000a000b000a000b000a000b000a000b000a 000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a00 0b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b 000a000b000a000a000a000b000a000b000a000b000a000b0409000804fc5e0a000a000a000 a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a00 0a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a0 00a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a 000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000 a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a00 0a000a000a000a000a000a000a000a000a0009000a049835500c1008110810081108100811 080f0810080f0811081108120811081108110811081208120811081108110811080f081008 1108120810082f089114352d562dd2202d086f1014251325701015291529f420f320d21c14 29f424352970140d08583192184e0cb11c562df42450101008310c1008b318352d1329f220 d2201529b3180e08f42014258e149431b43550297f6f552dd21cd21c9014362d90142c08342 9b1184e1012253329d220352d14254f0c0e043008100811081008110810081008100811081 1081108110811081108110811081108110811081008110811081208110810080f08701077 310b00090009000a000a000a000a000a000a0009000a000a000b000a000a000a000a000a00 0a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a0 00a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a 000a000a000a000a000a000a000a000a000a000a000a000a000a000a0009000700fd5e0b000 a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a0 00b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000 b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b0 00a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000 a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a0 00b000a000b000a000b000a000b000a000b000a000b000a000a040a00b9394f0c300c10081 10c1108110c1108100c1008300c1008120c1108120c1108110c1008120c1108120c1108120 c1108100c1008110c10080f08d220df5e3f6b5f6f1f677431542d3f6b9535b639ff623b4a1f67 5a4eb5397f6f1946de5e5b4e8c141f671a46ae18fe5e594abd56f220300c0f0892187e52bd5a5 94e9f7731291f67f8414c101a46ff5e8b10794e9b52574abf77b43539469d5632293f6b12258 e143f6bd739b6391f6337463f677c52bf5ab1184f0c2f0830081008310c110812081108310c1 108110c110c110c1108120c1108110c1108120c1108310c110811081108310c10082f08501 098350a000a0409002b000a000b000a000b040a000a000a002b000a000b000a000b000a000 b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b0 00a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000 a000b000a000b000a000b000a000a000a000b000a000b000a000b000a000b0009002804fd5 e0a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a 000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000 a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a00 SMF Ilmu Penyakit Dalam RSUD Waled

23

0a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a0 00a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a 000a000a000a000a000a000a000a000a000a000a000a000a0009000a009835500c0f0811081 008110c1108110c1008100c1008100c1108120c1108110c1008100c1008110c1108110c110 8110c1008100c1008100c2f0c55317b52502d30291f671846b5391f67cd1cf741de5e0f251f6 3f53df541fd5ecd1c712d5f6f0e217f733846d53d3e6b702d3025f1200d082f0c9014ff66f641 71319f774f2ddc5e16466a10384a1f6330257f732f29ec1c3e67b3353746794e50295f6b1025 8b109f7373315a4edc5a0d219f73594e1946b8390d040e040f0810081108120811081208100 8100c1008110c1008110c1108110c1008110c1108110c1008110810081108100810080f087 01077310a000a000a000a000a000a000b000a000a0009000a000a000a000a000a000a000a00 0a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a0 00a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a 000a000a000a000a000a000a000a000a000a000a000a000a000a000a000a0009000700fd5e0 b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b000a000b0 00a000b000a000b0 Gambar 1. Ilustrasi perjalanan proses aterosklerosis pada plak aterosklerosis5 Sedangkan trombosis merupakan proses pembentukan atau adanya darah beku yang terdapat di dalam pembuluh darah atau kavitas jantung.4 Ada dua macam trombosis, yaitu trombosis arterial (trombus putih) yang ditemukan pada arteri, dimana pada trombus tersebut ditemukan lebih banyak platelet, dan trombosis vena (trombus merah) yang ditemukan pada pembuluh darah vena dan mengandung lebih banyak sel darah merah dan lebih sedikit platelet.6 Komponen-komponen yang berperan dalam proses trombosis adalah dinding pembuluh darah, aliran darah dan darah sendiri yang mencakup platelet, sistem koagulasi, sistem fibrinolitik, dan antikoagulan alamiah.7 Patogenesis terkini SKA menjelaskan bahwa SKA disebabkan oleh obstruksi dan oklusi trombotik pembuluh darah koroner, yang disebabkan oleh plak aterosklerosis yang rentan mengalami erosi, fisur, atau ruptur. Penyebab utama SKA yang dipicu oleh erosi, fisur, atau rupturnya plak aterosklerotik adalah karena terdapatnya kondisi plak aterosklerotik yang tidak stabil dengan karakteristik inti lipid besar, fibrous cups tipis, dan bahu plak penuh dengan aktivitas sel-sel inflamasi seperti limfosit T dan lain sebagainya. Tebalnya plak yang dapat dilihat dengan persentase penyempitan pembuluh koroner pada pemeriksaan angiografi koroner tidak berarti apa-apa selama plak tersebut dalam keadaan stabil. Dengan kata lain, risiko terjadinya ruptur pada plak aterosklerosis bukan ditentukan oleh besarnya plak (derajat penyempitan) tetapi oleh kerentanan plak. 010009000003f45f010000003fc3000000001610000026060f002220574d46430100000000 0001007d8e000000000a000000002000004817010048370100010000006c0000000000000 0000000002b0100006e00000000000000000000004f290000510f000020454d46000001004 83701000c00000001000000000000000000000000000000000400005802000069010000d4 0000000000000000000000000000001c830500d23a0300460000002c00000020000000454

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25

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