Profil. Organisasi Ketua PERKI Cabang Depok Ketua Departemen Advokasi dan Legislasi Kebijakan PP PERKI Pengurus IDI Cabang Depok

Profil

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

• Pendidikan :

• Dokter Umum Fakultas Kedokteran Universitas

Indonesia RS Cipto Mangunkusumo Jakarta 2001

• Dokter Spesialis Jantung Fakultas Kedokteran

Universitas 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

Chest Pain

How to Diagnose and Differential Diagnoses

Dian Zamroni

Departemen 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

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):345-52 Fam Pract 2001;18: 586-589.

Chest Pain

Misdiagnosed

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.}

Retrostenal

Nyeri jantung iskemik Nyeri pericardium Nyeri esofagus Diseksi aorta Lesi-lesi mediastinum Emboli paru Interscapular

Nyeri jantung iskemik Nyeri otot skeletal Nyeri kantong empedu Nyeri pankreas

Dada depan kanan bawah

Nyeri kantong empedu Pembengkakan hati Abses subdiafragma Pneumonia/pleurisy

Tukak lambung atau duodenum Emboli paru

Akut miositis Cedera lainnya

Daerah perut atas

Nyeri jantung iskemik Nyeri perikardium Nyeri esofagus

Nyeri lambung/duodenum Nyeri pankreas

Nyeri kantong empedu Pembengkakan hati Pleurisy diafragma Pneumonia

Dada depan kiri bawah

Nyeri saraf interkostae Emboli paru

Miositis

Pneumonia/Pleurisy Infark limpa

Sindroma fleksura limpa Abses subdiafragma Sindroma Pericardial catch Cedera lainnya

Lengan

Nyeri jantung iskemik Nyeri servikal/dorsal spine Sindroma Thoracic outlet

Bahu

Nyeri jantung iskemik Perikarditis

Abses subdiafragma Pleurisy diafragma Penyakit spina servikal Nyeri otot skeletal akut Sindroma 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

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

C

ARDIAC

C

HEST

P

AIN

• Angina Pectoris

• Retrosternal tightness

• Radiates to neck, jaw , shoulder or arms • Brought on by:

• Exertion • Emotion

• Relieved by Nitrat or rest

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

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 atau lengan.

• Disertai rasa lemah, keringat dingin, rasa cemas dan 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

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

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)

Admission _{Nyeri Dada} Persistent ST-elevation ST/T -abnormalities EKG Normal or undetermined ECG

Diagnosa Kerja _{Sindroma Koroner Akut}

STEMI

Diagnosa NSTEMI/ UAP

Troponin Rise/fall Troponin normal Bio-chemistry NSTEMI Unstable Angina 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

NSTEMI

STEMI

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 elevasi segment ST persisten

SKA tanpa elevasi segmen ST

SINDROMA KORONER AKUT Non ST Elevasi ST Elevasi 1. REVASKULARISASI 2. Anti trombotik 3. Anti Iskemia 1. Anti Iskemia 2. Antitrombotik 3. Revaskularisasi

TATA LAKSANA AWAL YANG HAMPIR SAMA

MONACO 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)

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 Kardiovaskular

Faskes 1 Kompetensi 3B → rujuk untuk Revaskularisasi

Faskes 1 Kompetensi 3A → rujuk untuk Diagnosis dan definitive treatment

Faskes 1 Kompetensi 4 → rujuk untuk Diagnosis dan

tatalaksana lanjut bila kompleks Pencegahan Primer Pencegahan Sekunder Pencegahan Sekunder Pencegahan Sekunder Pencegahan Sekunder

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

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

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