Profil

• Dr. Dian Zamroni, SpJP(K), FIHA, FAsCC• Pendidikan :

• Dokter Umum Fakultas Kedokteran UniversitasIndonesia RS Cipto Mangunkusumo Jakarta 2001

• Dokter Spesialis Jantung Fakultas KedokteranUniversitas Indonesia / Pusat Jantung Nasional Harapan Kita Jakarta 2012

• Intensivist dan Interventionalist Cardiology 2015

• Organisasi• Ketua PERKI Cabang Depok• Ketua Departemen Advokasi dan Legislasi

Kebijakan PP PERKI• Pengurus IDI Cabang Depok

1

• Posisi• Staf Pengajar Departemen Kardiologi dan

Kedokteran Vaskular FKUI• Ketua Staf Medik Jantung dan Pembuluh Darah

Rumah Sakit Universitas Indonesia• Staf Divisi Critical Care dan Cardiovascular

Emergency Pusat Jantung Nasional Harapan Kita• Dokter jantung RS Sentra Medika Cisalak Depok

Chest PainHow to Diagnose and Differential Diagnoses

Dian ZamroniDepartemen Kardiologi dan Kedokteran Vaskular Fakultas Kedokteran Universitas Indonesia

RS Jantung dan Pembuluh Darah Haraoan Kita Jakarta

RS Universitas Indonesia Depok

RS Sentra Medika Cisalak Depok

Goal dan obyektif

◼Membedakan Nyeri dada Kardiak dan Non Kardiak

◼Kegawatan Nyeri dada

Scope of the Problem of Chest Pain

• 5 million Emergency Room visits nationwide for Chest Pain• 800,000 experience an MI each year

• 213,000 die from their event

• ½ of those die before reaching the ER

• Data iSTEMI• dari estimasi kasus hanya 1 dari 3 terdiagnosa di fasilitas kesehatan

• Pre-Cardiovascular Care Unit, mortality for MI was >30%• Fell to 15% with Cardiovascular Care Unit

• With current interventions, in hospital mortality of STEMI is 6-7%

Epidemiology of chest pain reflects selection bias

Diagnosis Primary Care: USA Primary Care: Europe

Emergency Department

Musculoskeletal conditions 36% 29% 7%

Gastrointestinal disease 19% 10% 3%

Serious Cardiovascular disease (Infarction, Unstable Angina, PE, HF)

16% 13% 54%

Stable CAD 10% 8% 13%

Unstable CAD 1.5% 13%

Psychosocial or Psychiatric disease 8% 17% 9%

Pulmonary disease (Pneumonia, Pneumothorax, Lung Cancer)

5% 20% 12%

Non-specific chest paiin 16% 11% 15%

Fam Pract. 1994 Apr;38(4):345-52Fam Pract 2001;18: 586-589.

Chest Pain

Misdiagnosed

Fatal

Differential diagnosis sesuai asal dari nyeri dada

Braunwald E : Clinical recognition of acute coronary syndromes. In Theroux P. Acute coronary syndrome: a companion to Braunwald’s Heart Diseases, 2nd ed. Philadelphia, Elsevier Saunders, 2011, pp 99.

RetrostenalNyeri jantung iskemikNyeri pericardiumNyeri esofagusDiseksi aortaLesi-lesi mediastinumEmboli paru

InterscapularNyeri jantung iskemikNyeri otot skeletalNyeri kantong empeduNyeri pankreas

Dada depan kanan bawahNyeri kantong empeduPembengkakan hatiAbses subdiafragmaPneumonia/pleurisyTukak lambung atau duodenumEmboli paruAkut miositisCedera lainnya

Daerah perut atasNyeri jantung iskemikNyeri perikardiumNyeri esofagusNyeri lambung/duodenumNyeri pankreasNyeri kantong empeduPembengkakan hatiPleurisy diafragmaPneumonia

Dada depan kiri bawahNyeri saraf interkostaeEmboli paruMiositisPneumonia/PleurisyInfark limpaSindroma fleksura limpaAbses subdiafragmaSindroma Pericardial catchCedera lainnya

LenganNyeri jantung iskemikNyeri servikal/dorsal spineSindroma Thoracic outlet

BahuNyeri jantung iskemikPerikarditisAbses subdiafragmaPleurisy diafragmaPenyakit spina servikalNyeri otot skeletal akutSindroma Thoracic Outlet

Keluhan tidak nyaman di dada•Onset –saat keluhan dimulainya

•Provocation –

perubahan posisi atau pergerakan ?

Dipengaruhi oleh asupan makanan atau minuman ?

Reaksi terhadap pemberia nitrat

•Quality – kwalitas: viseral atau kutaneous

•Region & radiation – lokasi dan penjalaran

•Severity – skala nyeri

•Time – durasi dan frekwensi

Nyeri kutaneous Nyeri viseral

Kardiak Non kardiak

Iskemik Non iskemik

Otot

Tulang

Kulit

Angina

pektoris stabil

Sindroma

koroner akut

Paru

Traktus GI

Aorta

Mediastinum

Psikiatri

Miokarditis

Kardiomiopati

Perikarditis

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

CARDIAC CHEST PAIN(ANGINA PEKTORIS)

Atherosclerosis –Atherothrombosis A Generalized And Progressive Disease

Adapted from Libby P. Circulation. 2001;104:365-372

Atherosclerosis

Stable angina

Unstable angina

NSTEMI

STEMI

CV death

ACS

Thrombosis

Atherothrombosis

Cardiac Chest Pain Pathophysiology

Angina – Cardiac Chest Pain

CARDIAC CHEST PAIN

• Angina Pectoris

• Retrosternal tightness

• Radiates to neck, jaw , shoulder or arms

• Brought on by:

• Exertion

• Emotion

• Relieved by Nitrat or rest

• EKG: Transient STE or ST depression

Criteria for classification of chest pain - Angina

• Characteristic location, duration and quality

• Provoked by exertion or emotional stress

• Relieved by rest or nitroglycerin

• Typical angina: meets all 3 criteria

• Atypical angina: meets 2 criteria

• Noncardiac pain: meets <2 criteria

Life Threatening Causes of Chest Pain

• Acute Coronary Syndromes

• Pulmonary Embolus

• Aortic Dissection

• Tension Pneumothorax

• Esophageal Rupture

• Pericarditis with Tamponade

SINDROMA KORONER AKUT (ACS)

ANGINA

• Sakit dada (sakit, nyeri, rasa tertimpa beban, rasa terbakar) di belakang tulang dada

• Dipicu oleh aktivitas atau stres emosional →menghilang dengan istirahat atau nitrat

• Dapat menjalar ke punggung, bahu, rahang ataulengan.

• Disertai rasa lemah, keringat dingin, rasa cemasdan bahkan bisa pingsan.

Presentasi Angina pada SKA - Angina Tidak Stabil

• Angina berat yang timbul saat istirahat dengan durasi lebih dari 20 menit

• Angina new onset (dalam 1 bulan terakhir), dengan derajat CCS III

• Angina progresif (dirasakan lebih berat, lebih lama, atau dicetuskan oleh aktivitas yang lebih ringan dibandingkan biasanya)

• Angina paska Infark

Braunwald, et al. JACC 2000;36:3

Presentasi Atipikal pada SKA

• Terkadang gejala angina tidak begitu jelas, namun pasien mengeluhkan nyeri ulu hati, kembung, nyeri dada seperti ditusuk-tusuk, ataupun sesak nafas

• Keluhan atipikal lebih sering dijumpai pada orang tua (usia >75 tahun), wanita, pasien diabetes, Chronic Kidney Disease (CKD), atau demensia

Diagnosis ditegakkan, bila:

( 2 dari 3 indikator )

kriteria WHO terpenuhi, yaitu

• Keluhan klinis → Nyeri dada

• Gambaran khas elektrokardiografi (EKG)

• Peningkatan kadar enzim jantung :

(CK, CKMB dan troponin)

SINDROMA KORONER AKUT

Admission Nyeri Dada

PersistentST-elevation

ST/T -abnormalities

EKGNormal or

undetermined ECG

Diagnosa Kerja Sindroma Koroner Akut

STEMIDiagnosa NSTEMI/ UAP

TroponinRise/fall

Troponin normal

Bio-chemistry

NSTEMIUnstableAngina

Diagnosa STEMI

Atherosclerosis –Atherothrombosis A Generalized And Progressive Disease

Adapted from Libby P. Circulation. 2001;104:365-372

Atherosclerosis

Stable angina

Unstable angina

NSTEMI

STEMI

CV death

ACS

Thrombosis

Atherothrombosis

Unstable Angina STEMINSTEMI

Non occlusive Thrombus

Non specific ECG

Normal cardiac enzymes

Non-occlusive thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/-T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptoms

SKA disertai elevasisegment ST persisten

SKA tanpa elevasi segmen ST

Troponin ↑↑ Troponin dapat ↑ atau tidak

SINDROMA KORONER AKUT

Non ST ElevasiST Elevasi

1. REVASKULARISASI2. Anti trombotik

3. Anti Iskemia

1. Anti Iskemia2. Antitrombotik3. Revaskularisasi

TATA LAKSANA AWAL YANG HAMPIR SAMAMONACO atau MONATICA

• M (MORPHINE,BILA DENGAN PEMBERIAN NITRAT SL/IV TIDAK RESPON

• OXYGEN (BILA SATURASI O2 < 94%)

• NITRAT SL (ISDN 5 MG,DAPAT DIULANG 3X,

KI : (HIPOTENSI,PEMAKAIAN SILDENAFIL,BRADIKARDIA,TAKIKARDIA),

NITRAT IV : DOSIS MULAI 10 MCG/M,DAPAT DINAIKKAN SAMPAI MAX 200 MCG/M )

• ASPIRIN , 160-320 MG (CHEWING)

• CO ,CLOPIDOGREL (LOADING 300 MG)/ TICAgrelor loading 180 mg

STEMI

1. REPERFUSION

2. Anti - Thrombotic

3. Anti - Ischemia

N- STEMI

1. Anti - Ischemia

2. Anti - Thrombotic

3. Revascularization

Victor J. Dzau et al. Circulation. 2006;114:2850-2870

Perjalanan Penyakit KardiovaskularFaskes 1 Kompetensi 3B →rujuk untuk Revaskularisasi

Faskes 1 Kompetensi 3A →rujuk untuk Diagnosis dandefinitive treatment

Faskes 1 Kompetensi 4 → rujukuntuk Diagnosis dantatalaksana lanjut bila kompleks

PencegahanPrimer

PencegahanSekunder

PencegahanSekunder

PencegahanSekunder

PencegahanSekunder

Pulmonary Embolism – Diagnostic Testing

• Sinus Tachycardia is the most frequent EKG finding

• Classic S1,Q3,T3 finding is seen in less than 20%

• ABG plays no role in ruling out PE

• D-Dimer in a low risk patient can be used to rule out PE

Abrupt dyspnea and chest pain

Risk factor for embolism

Aortic Dissection - Pathophysiology

• Intimal tear of the aorta leads to dissection of the layers of the aorta creating a false lumen

• Tearing chest pain radiating to the back

• Risk Factors: HTN, connective tissue disease

• Exam: HTN, pulse differentials, neuro deficits

• Radiology: Wide mediastinum on CXR, CT angio chest, echo

Tension Pneumothorax - Pathophysiology

• Collection of air in the pleural space causes collapse of the ipsilateral lung and then cardiovascular collapse as intrathoracic pressures increase

• Risk factors: COPD; connective tissue disease, trauma, recent instrumentation, positive pressure ventilation

• Absent breath sounds unilaterally, hypotension, distended neck veins, tracheal deviation

Pericarditis with Tamponade

• Inflammation of pericardium

Summary

• The clinical evaluation of patients with chest pain is important

• Misdiagnosed and inappropriate treatment can be fatal

• Acute coronary syndrome is the most presenting chest pain in Emergency Department

ID-0863/Oct 2020