Curriculum Vitae

Daftar Riwayat Hidup

Nama : Siska Suridanda Danny
Tanggal lahir : 3 November 1978
Alamat : Gudang Peluru V/527, Jakarta Selatan
Pekerjaan
Staf Medik Fungsional pada Instalasi Gawat Darurat, IW
Medikal dan Intensive Cardiovascular Care Unit (ICVCU),
Pusat Jantung Nasional Harapan Kita, Jakarta
Staf Pengajar di Departemen Kardiologi dan Kedokteran
Vaskular, Fakultas Kedokteran Universitas Indonesia,
Jakarta

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 Department
In the US: 5% of all ED visits or 5 million visits per year

Wide range of etiologies

Cardiac, Vascular, Pulmonary, GI, Musculoskeletal

Why does distinguishing these causes matter?

8-10% patients with Acute Coronary Syndrome/ACS are
discharged mistakenly from ED estimated 30-days
mortality of 2%

How do you distinguish causes of chest pain?

So, youre on night duty at the

ED
you attend to a 67 yo male complaining
of sudden pain in the chest and epigastric
area. He is also experiencing shortness of
breath and nausea. No previous cardiac
history but confesses of being a heavy
smoker, had uncontrolled hypertension
and recurrent dyspeptic complaints but
usually alleviated by antacids

What are YOU thinking?

Causes of Chest Pain

POTENTIALLY LEADS TO
DEATH

Acute Coronary
Syndrome
Pulmonary Embolism
Aortic Dissection
Esophageal Rupture
Pneumothorax

RELATIVELY MORE BENIGN

Musculosceletal
Esophagitis
Bronchitis (CP
secondary to cough)
Pleuritis

DIFFERENTIA
L
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,

History matters!
ANGINA
VS
NON ANGINA

STABLE ANGINA
VS
UNSTABLE
ANGINA/ACS

Onset
Provocation
Quality
Radiation
Severity
Time

CHEST PAIN IN ACS

ONSET: 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), shoulders, neck, back, or jaw
Associated manifestations: anxiety, diaphoresis,
cool clammy skin, facial pallor, 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

In patients with acute chest pain,

a-12 leads Electrocardiogram has
to be obtained in 10 minutes!

A Normal ECG do not exclude the

presence of Acute Coronary
Syndrome. (Remember that ACS
consists of STEMI, NSTEMI and UA)
Unstable Angina is a history-based
diagnosis with possibly normal ECG
and no elevation of cardiac markers
Do not wait for cardiac markers results
to start immediate treatment for ACS

Initial Approach
Triage and
vital signs
evaluation

Airway, Breathing,
Circulation
Chest pain pts
with dyspnea or
abnormal
pulse/BP needs IV,
O2, monitor and
ECG right away

Brief history,
ECG and
focused exam

Character of pain,
associated
symptoms, pain
intensity
ECG: ST elevation
or ST depression?
Cardiopulmonary
history

Secondary
exam

Further history,
risk factors,
patients current
medications
Physical exam
Review old
records/previous
ECG

DIAGNOSIS?

Acute extensive anterior STEMI

What to do?

EARLY MANAGEMENT OF ACS

INITIAL ASSESSMENT

INITIAL THERAPY

Supplemental O2 to Sat >95%

12 lead ECG and monitor (<10 min)

Aspirin 160 to 325 mg

Focused history and physical exam

Nitrate SL or IV

IV lines. Blood samples for cardiac enzymes, electrolytes,

coagulation study

Morphine if pain persisted

Chest X-Ray (<30 min)

P2Y12 inhibitor: Clopidogrel OR Prasugrel OR Ticagrelor

ESC guidelines for STEMI 2012

Any
contra
indication
s present?

N
O
Streptokinase 1.5
million units in 100
cc Dextrose 5%
was given over 60
ESC STEMI Guidelines 2008
min

Start
fibrinolysi
s

Chest pain
resolved and ST
segment almost
returned to
baseline

SUCCESSFU
L
FIBRINOLYSI
S

.so you thought youre done for the night,

but here comes another patient
Mr B, 30 yo, had an ankle surgery 2 weeks ago and now
have sudden onset of chest pain

Pleuritic chest pain

triggered by deep breaths.
Also had dyspnea and
cough
BP 90/60 mmHg, HR 120
bpm, RR 35x/mnt, Sat O2
91% (room air), clear
lungs on auscultation
ECG: Sinus tachycardia,
RBBB, non specific ST-T
changes. S1Q3T3 (+)

Working Diagnosis?

Acute 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 trauma or surgery
How to confirm diagnosis?
D-dimer
CT scan

.and came another one

Mr L, 69 yo, with a history of
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 and hypertensive
How to confirm diagnosis?
CXR: widened mediastinum, abnormal aortic
knob, pleural effusion
Chest CT scan: very sensitive, risk of kidney injury
Angiography: most reliable but not always
possible

More patients?

TIMES UP

Take home message

Chest pain is a common complaint in the ED and has a
variable differential diagnosis
Although not 100% accurate, most of the common causes for
chest pain has specific clues to help you build your
diagnosis. Thus history taking is of utmost importance in
determining the cause of chest pain, followed by ECG
Since ACS is the most frequent cause of potentially fatal
chest pain, all chest pain should be considered ACS until
proven otherwise; hence the 10 minutes timeline to do ECG!
Time is muscle in STEMI-ACS. Try to confirm diagnosis and
start therapy as soon as humanly possible
Do not order multiple auxiliary tests blindly to build your
diagnosis. Instead, have a working diagnosis in mind and
order specific tests to confirm it

Thank you

Chest Pain Definitions

Acute Chest Pain:
Acute - sudden or recent onset (usually within minutes to hours), presenting
typically <24 hrs
Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch
Pain noxious uncomfortable sensation
Ache or discomfort

Visceral pain
Often referred
Aching, heaviness, discomfort
Difficult to localize pain

Somatic pain
Sharp, easily localized

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Sesi Tanya Jawab

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