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EIDCP Jakarta 2016

Cardiac Chest Pain

Siska S. Danny, MD

Department of Cardiology and Vascular Medicine


Faculty of Medicine Universitas Indonesia
National Cardiovascular Center Harapan Kita Jakarta
Indonesia

siskadanny@yahoo.com
Chest Pain
Common complaint in Emergency Unit
In the US: 5% of all ED visits or 5 million visits per
year
Wide range of etiologies
Cardiac, Pulmonary, GI, Musculoskeletal
Why does distinguishing these causes matter?
How do you distinguish causes of chest pain?
So
you attend to a 67 yo male complaining of a sudden
pain in the chest and epigastric area. He is also
complaining of shortness of breath and nausea, with
no previous cardiac history but confesses of being a
heavy smoker, had uncontrolled hypertension and
recurrent dyspeptic complaints usually alleviated by
antacids

What are YOU thinking?


Causes of Chest Pain
COULD POTENTIALLY LEADS TO DEATH RELATIVELY MORE BENIGN PAIN
Acute coronary syndrome Musculosceletal
Pulmonary Embolism Esophagitis
Aortic Dissection Bronchitis (CP secondary to
Esophageal Rupture cough)
Pneumothorax Pleuritis
WORKING D/ IN 10 MINUTES!!

History Physical Additiona


taking Exam l tests
DIFFERENTIAL
DIAGNOSIS

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

Onset ANGINA
Provocation VS
Quality ATYPICAL CHEST PAIN

Radiation
Severity
STABLE ANGINA VS
Time UNSTABLE ANGINA/ACS
CHEST PAIN IN ACS
ONSET: Could be sudden or gradual acute chest pain. In
determining onset for STEMI, pinpoint the time of most
severe pain
PROVOCATION: Exercise/physical activity or even occurred
at rest
QUALITY: Diffuse, steady substernal chest pain. Other
sensations include a crushing and squeezing feeling in the
chest
SEVERITY: pain may be severe; not relieved by rest or
sublingual vasodilator therapy, requires opioids.
TIME/DURATION: pain continues for more than 15 minutes
Location: variable, but often pain resides behind upper or
middle third of sternum.
Radiation: pain may radiate to the arms (commonly the
left), and to the shoulders, neck, back, or jaw
Associated manifestations: anxiety, diaphoresis, cool
clammy skin, facial pallor, hypertension or hypotension,
bradycardia or tachycardia, palpitations, dyspnea,
disorientation, confusion, restlessness, fainting, nausea
and vomiting
Atypical presentation of ACS
Sometimes chest pain is not very obvious but
patient complain of epigastric pain or
abdominal distress, dull aching or tingling
sensation, shortness of breath, dyspnea and
extreme fatigue
Atypical presentation is more frequent in old
individuals (>75 yo), female, diabetes, chronic
kidney disease or patients with dementia
Non angina chest pain: Characteristic clues

Chest pain is influenced by breathing and


palpation of the chest wall
Occured only in certain position
Location in central or lower abdomen
Pain could be pinpoint by a single finger
Duration only a few seconds of less
back to our dear patient: Mr X, 67 yo
Chest pain was described as
crushing heavy pain on the
chest and radiated to his jaw
Occured suddenly when he was
yelling at his granddaughter for
running around the house
Very severe (9/10)
Onset 3 hours ago and persisted
for 40 minutes before slightly
subsided
Accompained by nausea,
shortness of breath and
diaphoresis
So Is it ACS?
All chest pain is considered to
be ACS until proven
otherwise!
What is the next step in
diagnosing ACS?
Approach to chest pain

Hamm CW, et al. European Heart Journal (2011) 32, 29993054


12 leads Electrocardiogram has
to be taken in 10 minutes!
ELEKTROKARDIOGRAM YANG NORMAL TIDAK
MENGEKSKLUSI ADANYA SINDROMA KORONER AKUT

ANGINA TIDAK STABIL (UAP/APTS) ADALAH


DIAGNOSIS BERDASARKAN ANAMNESIS

TIDAK PERLU MENUNGGU HASIL ENZIM JANTUNG


UNTUK MULAI MEMBERIKAN TATA LAKSANA PADA
PASIEN DENGAN WD/ ACS
EARLY MANAGEMENT OF ACS
INITIAL ASSESSMENT INITIAL THERAPY
12 lead ECG and monitor Supplemental O2 to Sat >95%
(<10 min)
Aspirin 160 to 325 mg
Focused history and
physical exam
Nitrat SL IV
IV lines. Blood samples for
cardiac enzymes, Morfin if pain persisted
electrolytes, coagulation
study P2Y12 inhibitor: Clopidogrel
Chest X-Ray (<30 min) OR Prasugrel OR Ticagrelor
DIAGNOSIS?

Acute extensive anterior STEMI in non PCI


capable hospital What to do?
ESC guidelines for STEMI 2012
Any contra
indications
present?

NO
Streptokinase 1.5
million units in 100 cc
Dextrose 5% was given Start
over 60ESC
min fibrinolysis
STEMI Guidelines 2008
Chest pain
resolved and ST
segment elevation
almost returned
to baseline

SUCCESSFUL
FIBRINOLYSIS
.so you thought youre done for the day, but
here comes another patient

Mr B, 30 yo, had an ORIF of ankle 2 weeks ago


and now have sudden onset of chest pain

Pleuritic chest pain,


triggered with deep
breaths. Accompanied by
dyspnea and cough
BP 90/60 mmHg, HR 120
bpm, RR 35x/mnt, Sat O2
91% (room air), clear
lungs on auscultation
Working Diagnosis?
Pulmonary Embolism
Risk factors:
Hypercoagulability: Malignancy, pregnancy, estrogen
use, protein C/S deficiency
Venous stasis: prolonged bedrest, recent
hospitalization, long distance travel
Venous injury: recent rauma or surgery
How to confirm diagnosis?
D-dimer
CT scan
.and another one

Mr L, 69 yo, with a history of longstanding


uncontrolled hypertension came with sudden
onset severe ripping and tearing chest pain
radiated to the back
BP 180/110 mmHg (right arm) and 100/60
mmHg (left arm). Diminished pulses on both
legs
ECG: sinus tachycardia with signs of left
ventricular hypertrophy
Working Diagnosis?
Aortic Dissection
Bimodal distribution:
Young: Connective tissue disorder (eg Marfan disease)
or pregnancy
Older: Most commonly > 50 yo
How to confirm diagnosis?
CXR: widened mediastinum, abnormal aortic knob,
pleural effusion
Chest CT scan: very sensitive, risk of kidney injury
Angiography: most reliable
More patients?

TIMES UP
Thank you

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