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
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