dr. Hasanah Mumpuni, Sp.PD, Sp.JP (K)KSM Jantung - Bagian Kardiologi dan Kedoktteran Vaskular RSUP Dr. Sardjito/ FK UGM

ANGINA

Cardiovascular Acute myocardial infarction, Acute coronary ischemia, Aortic

dissection, Cardiac tamponade, Unstable angina, Coronary spasm,

Prinzmetal's angina, Cocaine induced, Pericarditis, Myocarditis, Valvular

heart disease, Aortic stenosis, Mitral valve prolapse, Hypertrophic

cardiomyopathy

Pulmonary Pulmonary embolus, Tension pneumothorax,

Pneumothorax, Mediastinitis,

Pneumonia, Pleuritis, Tumor, Pneumomediastinum

Gastrointestinal Esophageal rupture (Boerhaave), Esophageal tear (Mallory-

Weiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal

reflux, Peptic ulcer, Biliary colic

Musculoskeletal Muscle strain, Rib

fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest wall pain

Neurologic Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic

neuralgia

Other Psychologic, Hyperventilation

Differential Diagnoses Chest Pain

Chest pain

cardiac

Angina /ischemic

Angina stabil /

ACS

Non Angina

Pericarditis

Myocarditis

valvular

Non cardiac

GIT (Gerd, aesophagitis)

Pulmonal, pleuritis

Neurologic

Psycogenic

Epidemiology

• 5% of all ED visits CP

• Approximately 5 million visits per year

Life Threatening Causes of Chest Pain

• Acute Coronary Syndromes

• Pulmonary Embolus

• Tension Pneumothorax

• Aortic Dissection

• Esophageal Rupture

• Pericarditis with Tamponade

What are the key parts of the History Patients in the CP

patient?

What can you get out of the pt in 4 minutes?

History

• Location: Central, left, or right

• Associated symptoms: SOB, sweating, nausea

• Timing: Gradual or sudden onset

• Provocation: What makes worse or better?

• Quality: Visceral vs somatic

• Radiation: Back, neck, arm

• Severity: Scale of 1-10

Objectives

• Establish a differential diagnosis for chest pain

• Know what clues to obtain on history to rule-in or out MI, PE, pneumothorax and aortic dissection

• Identify risk factors for MI

• Know how to do a focused physical exam, identifying features that would distinguish between MI, PE, pneumothorax and aortic dissection.

• Identify investigations required in diagnosing MI

• Outline management strategy in MI

Kasus• Bapak Sumarno, usia 57 th mengeluh nyeri dada yang hilang

timbul. Nyeri dada dirasakan sejak 1 bulan terakhir. Lama nyeri kira-kira 5 menit, timbul apabila beraktifitas sedang seperti jalan cepat atau lari dan saat emosi. Nyeri dada dapat berkurang dengan istirahat. Bapak Sumarno sudah periksa ke dokter, dilakukan pemeriksaan elektrokardiografi dan darah. Oleh dokter disarankan untuk dilakukan pemeriksaan exercise stress test. Dia seorang penderita hipertensi tidak terkontrol dan seorang perokok.

• Sejak 3 jam terakhir nyeri dada dirasakan semakin memberat seperti ditindih beban berat dan nyeri tidak hilang meskipun sudah istirahat, disertai mual dan keringat dingin. Oleh keluarga segera dibawa ke unit gawat darurat. Pada pemeriksaan tekanan darah 150/90 mmHg.

• Bagaimanakah membedakan jenis nyeri dada secara umum?

• Apakah perbedaan tipe nyeri dada yang diderita sebulan sebelumnya dan nyeri dada yg baru saja terjadi?

• Apakah pemeriksaan penunjang yang dipakai untuk menegakkan diagnosis nyeri dada?

• Apakah kemungkinan diagnosisnya?• Bagaimana managemen awal dan lanjut pasien

tersebut?• Bagaimana merujuk pasien tersebut?

Angina

• The term ‘angina’ is from the Latin ‘angere’ meaning to strangle.

• first described by the English physician William Heberden in 1768.

• Angina pectoris refers to the predictable occurrence of pain or pressure in the chest oradjacent areas (jaw, shoulder, arm, back) caused by myocardial ischemia

• Mis - match in the oxygen demand–supply to the myocardium consequently angina.

Cause Of Angina Pectoris

• Ischemia due to obstruction:

- Atherosclerosis

- Coronary vasospasm

- Anomalous coronaries

• Ischemia due to decreased Oxygen Supply:

- Anemia, Hypoxia, Hypotension

• Ischemia due to Increased Oxygen Demand:

- Left ventricular hypertrophy, hypertension, tachycardia

Peningkatan kebutuhan oksigen miokard

Penurunan suplai / pasokan oksigen

Non Kardiak :- Hipertermi- Hiperthyroid- Sympathomimetic toxicity

(penggunaan cocain)- Hipertensi- Anxietas- Fistula arteriovenous

Kardiak- Kardiomiopathi hipertropi- Aorta stenosis- Kardiomiopathi dilatasi- Takikardia : ventrikular ,

supra ventrikular

Non kardiak:- Anemia- Hipoksemia (pneumonia,

asma bronkhial, PPOK, hipertensi pulmonal)

- Sympathomimetic toxicity(penggunaan cocain)

- Hipervskositas (trombositosis, leukimia, polisitemia)

Kardiak :- Stenosis aorta- Kardiomiopathi hipertropi

• Angina that occurs when the coronary arteries do not deliver an adequate amount of oxygen-rich blood to the heart

• Categorized as stable, unstable, and Variant (Prinzmetal’s )

Stable Angina

• Clinical findings of stable angina:

• Substernal , high pressure/heavy feeling

• Duration from 1 – 5 minutes

• Instigated by physical exertion

• Relieved with rest or nitrates

Unstable Angina

• Clinical findings of Unstable Angina:

• Occurs even at rest

• unexpected

• More severe and lasts longer than stable angina, maybe as long as 30 minutes

• May not disappear with rest or use of nitrates

Variant Angina

• Transient coronary vasospasm that is associated with a fixed atherosclerotic lesion (75%)

• Pt tends to be younger and in seemingly good health

• Occurs at rest and and associated with ventrcular dysrhythmias

• Nitrates and CCB’s are often effective

Characteristics of typical angina

Criteria for classification of chest pain

Canadian Cardiovascular Society functional classification of angina (CCS)

Menentukan Pre-Test Probability Kemungkinan seseorang mengalami PJK

PTP rendah (<15%)

• Cari kausa lain, pertimbangkan penyakit koroner fungsional

PTP intermediet (15-85%)

• Tes diagnostik non-invasif

PTP tinggi (>85%)

• Stratifikasi resiko, mulai terapi, dan tawarkan angiografi koroner

PTP (dalam %)

Rest Angina Angina occurring at rest and prolonged, usually > 20 mnt

New onset Angina New onset angina of at least CCS class III severity

Increasing Angina Previously diagnosed angina that has become distinctly more frequent, longer in duration or

lower in threshold (i.e. increased by 1 CCS class to at least CCS class III severity

Three Principal PresentationUnstable Angina

Myocardial ischemia or infarction

• Pressure-type of chest pain

• Generally involves central to left-sided pain with radiation to jaw or arms

• Exacerbated by activity, relieved with rest

• Relieved with nitrogliserida

• Associated with nausea, diaphoresis, syncope, shortness of breath

• Enquire about cardiac risk factors: age, sex, smoking history, diabetes, hypertension, hyperlipidemia, previous myocardial infarction and family history

Physical Examination

Trigerring factors

Vital sign Usually normal

JVP - Right ventricular infarction

Sign of heart failure or cardiogenic shock

Complication (Ventricle Septal Rupture,

Acute Mitral Regurgitation)

Killip klasiffication mortality risk

STEMI

1. ST Elevation with ‘evolution’

- ≥ 1 mVOLT in more than 2 LEAD II,III,aVF dan I - aVL

- ≥ 2 mV in V1-V6

2. New LBBB

NON STEMI

ST depression ≥ 1 mV

Simetrical T wave inversion > 2 mv

Electrocardiography

10 Minutes !!!

Acute Coronary Syndrome

Kasus• Bapak Sumarno, usia 57 th mengeluh nyeri dada yang hilang

timbul. Nyeri dada dirasakan sejak 1 bulan terakhir. Lama nyeri kira-kira 5 menit, timbul apabila beraktifitas sedang seperti jalan cepat atau lari dan saat emosi. Nyeri dada dapat berkurang dengan istirahat. Bapak Sumarno sudah periksa ke dokter, dilakukan pemeriksaan elektrokardiografi dan darah. Oleh dokter disarankan untuk dilakukan pemeriksaan exercise stress test. Dia seorang penderita hipertensi tidak terkontrol dan seorang perokok.

• Sejak 3 jam terakhir nyeri dada dirasakan semakin memberat seperti ditindih beban berat dan nyeri tidak hilang meskipun sudah istirahat, disertai mual dan keringat dingin. Oleh keluarga segera dibawa ke unit gawat darurat. Pada pemeriksaan tekanan darah 150/90 mmHg.

ECG pertama

ECG kedua