1 angina - cdm 2015 ipd
DESCRIPTION
Angina GuidelineTRANSCRIPT
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dr. Hasanah Mumpuni, Sp.PD, Sp.JP (K)KSM Jantung - Bagian Kardiologi dan Kedoktteran Vaskular RSUP Dr. Sardjito/ FK UGM
ANGINA
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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
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Chest pain
cardiac
Angina /ischemic
Angina stabil /
ACS
Non Angina
Pericarditis
Myocarditis
valvular
Non cardiac
GIT (Gerd, aesophagitis)
Pulmonal, pleuritis
Neurologic
Psycogenic
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Epidemiology
• 5% of all ED visits CP
• Approximately 5 million visits per year
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Life Threatening Causes of Chest Pain
• Acute Coronary Syndromes
• Pulmonary Embolus
• Tension Pneumothorax
• Aortic Dissection
• Esophageal Rupture
• Pericarditis with Tamponade
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What are the key parts of the History Patients in the CP
patient?
What can you get out of the pt in 4 minutes?
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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
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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
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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.
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• 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?
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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.
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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
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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
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• 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 )
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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
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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
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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
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Characteristics of typical angina
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Criteria for classification of chest pain
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Canadian Cardiovascular Society functional classification of angina (CCS)
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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
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PTP (dalam %)
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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
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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
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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
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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 !!!
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Acute Coronary Syndrome
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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.
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ECG pertama
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ECG kedua
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