Chest Pain Angina AMI Kuliah

8/9/2019 Chest Pain Angina AMI Kuliah

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CHEST PAIN

ANGINA PECTORIS

ACUTE CORONARY SYNDROME

Dr. Andreas Arie, SpPD

CARDIOVASCULAR DIVISION INTERNAL MEDICINE DEPARTMENT

MEDICAL FACULTY DIPONEGORO UNIVERSITY


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CHEST PAIN


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Angina is a !inia! s"ndr#$e %ara&eri'ed ("

dis#$)#r& in &%e %es&, *a+, s%#!der, (a-, #r ar$.

T"pia!!" aggraa&ed (" e/er&i#n #r e$#&i#na! s&ress

and re!ieed (" ni&r#g!"erin.

Usa!!" #rs in pa&ien&s +i&% CAD, (& an a!s#

#r in pers#n +i&% a!!ar %ear& disease,

%"per&r#p%i ardi#$"#pa&%", and n#n&r#!!ed

%"per&ensi#n.

A!s# an (e presen& in pa&ien&s +i&% n#r$a! #r#nar"

ar&er" and $"#ardia! is%e$ia re!a&ed spas$ #r

end#&%e!ia! d"s)n&i#n.

And a!s# an (e presen& in pa&ien&s +i&% n#n ardia

#ndi&i#n #) es#p%ags, %es& +a!!, #r !ngs.


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ANGINA PECTORIS


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Grading of Angina Pectorisby the Canadian Cardiovascular Society Classication System


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Guidelines for the Identication of ACS Pati

Chief Complaint

• Chest pain typical of myocardial ischemiaor MI

• Associated : dyspnea nausea and!or

vomiting

diaphoresis

Medical "istory

• CA#G angioplasty CA$ angina on e%ort

or AMI

• &'G use to relieve chest discomfort

• (is) factors

Special Considerations


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"istory

Physical+,G

Chest Pain

S'+MI -A!&S'+MI!"igh (is)

Mod (is) .o/ (is) $enite

&on0Cardiac

Initial Risk Stratification Scheme


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&o S'

+levation

S'

+levation&S'+MI

MyocardialInfarction&1MI-nstable

Angina

1/MI

A&e C#r#nar"

S"ndr#$e

Braunwald E et al. J Am Coll Cardiol 2000; 36:970-1062


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A&e C#r#nar"

S"ndr#$e• S'0segment elevation MI 2S'+MI3

•&on S'0segment elevation MI2&S'+MI3

• -nstable Angina


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Pe$(!% dara% "ang $enga!a$i a&er#s-!er#sis 0 &r#$(#sis


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4oam4oamCellsCells 4atty4attyStrea) Strea) IntermediateIntermediate.esion.esion AtheromaAtheroma 4ibrous4ibrousPla5uePla5ue ComplicatedComplicated.esion!(upture.esion!(upture

+ndothelial+ndothelialdysfunctiondysfunction

Smooth muscleSmooth muscleand collagenand collagen

4rom rst decade4rom rst decade 4rom third decade4rom third decade 4rom fourth decade4rom fourth decade

Gro/th mainly by lipidGro/th mainly by lipidaccumulationaccumulation

Thrombosis,Thrombosis,haematoma haematoma

Adapted from Stary "C et al6Adapted from Stary "C et al6 CirculationCirculation 78898;:7


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INFARCTINFARCT STROKESTROKE GANGRENEGANGRENE ANEURYSMANEURYSM

CLINICAL ORI!ONCLINICAL ORI!ON

CALCIFICATIONCALCIFICATIONCOM"LICATE# LESION$COM"LICATE# LESION$

EMORRAGE% ULCERATION%EMORRAGE% ULCERATION%

TROM&OSISTROM&OSIS

FI&ROUS "LA'UEFI&ROUS "LA'UE

FATTY STREAKFATTY STREAK

A G E

I N Y

E A

R S

A G E

I N Y

E A

R S

()()

*)*)

+)+)

,),)

-)-)

.).)

/)/)

))

+ l ti f th th l ti


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+volution of the atheroscleroticPla5ue

'raditional ris) factors1 $yslipidemia

1 "ypertension1 Smo)ing1 $M

+merging ris) factors1 "omocystein

1 C(P1 4ibrinogen1 etc


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ContractiliContractilityty

"eart rate"eart rate

*all*allstressstress

??;;consumpticonsumpti

onon

@entr@entri0i0

cularcularvoluvolumeme

*all*allthicthic

)0)0nessness

.@.@end0end0

diastoldiastolicic

pressupressurere

??;;supplysupply

??;;transporttransportcapacitycapacity

CoronaryCoronarybloodbloodo/o/

ISC"A+MIISC"A+MIAA

ArterialArterial??;; saturationsaturation

"aematocrit"aematocrit

$iastolic$iastolicaorticaorticpressurepressureCoronaryCoronaryvascularvascular

resistanceresistanceCoronaryCoronary

spasmspasm

?rganic?rganicstenosisstenosis

AnginaAnginapectorispectoris

S'S'segmentsegment

00

depressiondepression 00

ImpairedImpairedperfusionperfusionMetabolicMetabolic

changeschanges

ImpairedImpairedpumppump

functionfunction

Pathophysiology of coronary heartPathophysiology of coronary heartdiseasediseaseMechanisms of myocardial ischaemiaMechanisms of myocardial ischaemia


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non-modifable sia 2se$a-in &a se$a-in $da% $enga!a$iP345 gender 2sia 678 &a%n insidensi pria dgP349+ani&a, na$n dengan $ening-a&n"a sia+ani&a $en*adi !e(i% $da% $enga!a$i P345 gene&i-

modifable $er#-#-dia(e&es $e!!i&s 2DM5

dis!ipide$ia#(esi&as%iper&ensisedentary lie style

s&res

4a

) tor ri

si)

o


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Hypertension

C0# 1isease risk factorsC0# 1isease risk factors

Diabetes

Hyper-cholesterolae

mia

smoking

inactivitystres

obesitas

hipertensi

rokok


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Predisposing (is) 4actorsPredisposing (is) 4actors

O(esi&"O(esi&" ; :MI 9 -g > $; :MI 9 -g > $EE

A(d#$ina! #(esi&"A(d#$ina! #(esi&"

MenMen ; +ais& ir 9


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Conditional (is)Conditional (is)

4actors4actors Trig!"erides 9 == $g > d! Trig!"erides 9 == $g > d!

H#$#"s&eineH#$#"s&eine

S$a!! dense LDLS$a!! dense LDL Pr#&r#$(#&i )ar ; (rin#genPr#&r#$(#&i )ar ; (rin#gen

InJa$ar" Mar-ers CRPInJa$ar" Mar-ers CRP


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PEMERI4SAAN


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EVOLUSI E4G


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Lanjutan ke hal berikutnya


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CLINICAL SUSPICION OF ACS

Physical examination

ECG monitoring, Blood sample

Persistent

ST-elevation No Persistent

ST-elevation

Undetermined

Diagnosis

Thrombolysis

PCI ASA, LMW

Clo!idogrel, betablo"#ers, Nitrate

igh $is# Lo% $is#

Se"ond tro!onin meas&rement

Positive T%i"e negative

Stress testCoronary angiogra!hy

'!IIb(IIIa

Cor)Angiogra!hy

PCI, CABG or edical management


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P(I&CIP.+S '"+(APE ?4 '"(?M#?SIS

#AS+$ ?& PA'"?G+&+SIS

PA'"?G+&+SIS '"+(APE

(IS, 4AC'?(S P(+@+&'I?&

0 P.A'+.+' A$"+SI?&

0P.A'+.+' AGG(+GA'I?&

0#.??$ C?AG-.A'I?& A&'IC?AG-.A&'

0'"(?M#?SIS '"(?M#?.E'IC

A&'IP.A'+.+'


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Al2orithm for e3al4ation an1 mana2ement of 5atients s4s5ecte1 ACS


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Al2orithm for e3al4ation an1 mana2ement of 5atients s4s5ecte1 ACS

SYM"TOMS SUGGESTI0E OF ACS

Definite ACS

N S! ele"atin S! ele"atin

Nn D# EC$

Nr%al initial &eru% 'ardia' %ar(er

S! and)r ! wa"e '*an+e&

,n+in+ ain

/ 'ardia' %ar(er&e%dna%i' anr%alitie&

E"aluatin fr

reerfu&in

t*era

O6ser3e

45 - *: EC$8 'ardia' %ar(er&

Stre&& te&t

N re'urrent ain

- 45 &tudie&

Ne+ati"e

Nni&'*e%i'8 lw ri&(

e'urrent i&'*e%i' ain

/ 45 &tudie&Diagnostic of ACS

confirmed

&iti"e

Diagnostic of ACS confirmed

&&ile ACS

A1mit to hos5ital

Mana2e 3ia

Ac4te ischemic 5ath7a8

Recurrent ischemia and/or


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A'ute &'*e%ia A'ute &'*e%ia

at*waat*wa

Recurrent ischemia and/orST segment shift, or

Deep T-wave inversion, orPositive cardiac markers

AspirinBeta bockers

!itratesAntithrombin regimen

"P ##b/###a inhibitor$onitoring %rh&thm and ischemia'

(ar& conservative strateg&(ar& invasive strateg&

Patient stabii)esRecurrentS&mptoms/ischemia

*eart faiureSerious arrh&thmia

(vauate +unction

( .01 ( 201

Stress Test

!ot ow risk +ow risk

#mmediateangiograph& 34-40 hourangiograph&

oow on$edica R5


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H#spi&a! are

A. Anti Ischemic TherapyBed rest with continuous ECG monitoringSupplemental O to maintain SaO ! "#$

%orphine i&. '(or pain, an)iety, *ulmonary congestion+itrate 'oral or i&.+Betabloc-ers i( no contraindicationon dihydropyridine calcium antagonis 'iltia/emor 0erapamil+ i( Betabloc-ers contraindicated andno se&ere 10 dys(unction.Ace inhibitors (or hypertension 10 dys(unctiona(ter %I


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H#spi&a! are

B. Anti Thrombotic Therapy

*ossible ACS 1i-ely2e(inite ACS 3igh ris- ACS2planned *CI

AspirinAspirin Aspirin 41%53 or

I0 3eparin

Aspirin 41%53 or

I0 3eparin

Aspirin 4 1%53or I0 3eparin 4

G* IIb2IIIa

antagonist


G* IIb2IIIa

antagonist

ClopidogrelClopidogrel

ClopidogrelClopidogrel

4

4


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H#spi&a! are

B. Anti Thrombotic Therapy

3igh ris- ACS2planned *CI


G* IIb2IIIa

antagonist

Clopidogrel4


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Chest Pain Angina AMI Kuliah

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