DIAGNOSIS GANGGUAN

KARDIOVASKULER
dr. Abraham Ahmad Ali Firdaus, SpJP

Universitas Nahdlatul Ulama Surabaya

Departemen Ilmu Penyakit Dalam
• Most common challenges in office or emergency
department
• Affecting organs throughout thorax and abdomen
• Potentially serious : acute ischemic heart disease, aortic
dissection, tension pneumothorax, or pulmonary embolism
CAUSES OF CHEST DISCOMFORT

MYOCARDIAL ISCHEMIA AND INJURY

• Oxygen supply not sufficient to meet metabolic needs
• Decrease in oxygen supply, a rise in demand, or both
Angina Pectoris
• Visceral discomfort : described as a heaviness, pressure, or
squeezing
• dyspnea or anxiety
• location usually retrosternal
• radiate to neck, jaw, teeth, arms, or shoulders
• Occasional patients  epigastric distress with ischemic
episodes
• Stable angina  develops gradually with exertion,
emotional excitement, or after heavy meals
• Rest or treatment sublingual nitroglycerin leads to relief
within several minutes
• Can precipitated by any physiologic or psychological stress
that induces tachycardia
Unstable Angina and Myocardial Infarction
• Similar angina pectoris, but more prolonged and severe
• May occur at rest, or awakened from sleep, and sublingual
nitroglycerin may lead to transient or no relief
• Accompanying with diaphoresis, dyspnea, nausea, and ligt-
headedness
• physical examination may be normal
• Murmur of mitral regurgitation suggests ischemic papillary
muscle dysfunction
• Severe episodes of ischemia can lead to pulmonary
congestion and even pulmonary edema
Other Cardiac Causes
• Myocardial ischemia caused by hypertrophic
cardiomyopathy or aortic stenosis leads to angina pectoris
similar to that caused by coronary atherosclerosis
• coronary spasm
• Cardiac syndrome X  angina-like chest pain and ischemic-
appearing ST-segment depression during stress
PERICARDITIS
• Inflammation parietal pleura
• Pericardium insensitive to pain
• Cardiac tamponade  mild or no chest pain
• Parietal pleura receives sensory supply from several sources 
pericarditis pain areas ranging from shoulder and neck to
abdomen and back
• Most retrosternal and aggravated by coughing, deep breaths, or
changes in position (movements pleural surfaces)
• Pain relieved by sitting upright and leaning forward
DISEASES OF THE AORTA
• Aortic dissection  tear in the intima or rupture of the
vasa vasorum within the aortic media
• Causes :
Trauma, including vehicle accidents or medical procedures
Nontraumatic : hypertension and/or conditions
deterioration of elastic or muscular components
Inherited connective tissue diseases : Marfan and
EhlersDanlos syndromes
Half in women younger 40 years during pregnancy
• Acute dissections  severe chest pain
• Reach peak severity immediately, causing collapse from its
intensity
• “ripping” and “tearing”
• Location : site and extent of dissection
• Physical findings :
 loss of a pulse in one or both arms
cerebrovascular accident, or paraplegia
extend proximally : coronary arteries or aortic valve 
acute myocardial infarction or acute aortic insufficiency
• Acute dissections  severe chest pain
• Reach peak severity immediately, causing collapse from its
intensity
• “ripping” and “tearing”
• Location : site and extent of dissection
• Physical findings :
 loss of a pulse in one or both arms
cerebrovascular accident, or paraplegia
extend proximally : coronary arteries or aortic valve 
acute myocardial infarction or acute aortic insufficiency
Thoracic aortic aneurysm
• Frequently asymptomatic
• Can cause chest pain and symptoms  compressing
structures
• Pain : steady, deep, and sometimes severe
PULMONARY EMBOLISM
• Due to distention pulmonary artery or infarction of the lung
adjacent to the pleura
• Substernal pain that suggestive of acute myocardial
infarction
• Associated symptoms :
• Dyspnea
• Hemoptysis
• Tachycardia
• characteristic ECG changes
• Pneumothorax
• Pneumonia or Pleuritis
Gastrointestinal Conditions
• Esophageal pain from acid reflux from the
stomach, spasm, obstruction, or injury
• Deep burning exacerbated by alcohol, aspirin, or
some foods
• relieved by antacid or acid-reducing therapies
 • Esophageal spasm : presence or absence of acid
reflux, squeezing pain
• Prompt relief by antianginal therapies 
promoting confusion
• Chest pain  injury to the esophagus, Mallory-
Weiss tear caused by severe vomiting
• Diseases of the GI tract below diaphragm,
including peptic ulcer disease, biliary disease, and
pancreatitis  typically occurs after meals; acid
production not neutralized by food in stomach
• Neuromusculoskeletal Conditions
 Direct pressure reproduce pain
• Emotional and Psychiatric Conditions
 careful history  depression, prior panic attacks,
somatization, agoraphobia, or other phobias
GUIDELINES FOR ACUTE CHEST DISCOMFORT
• Perform ECG for patients who do not have obvious
noncardiac cause of their pain
• Perform chest x-ray  signs or symptoms congestive heart
failure, valvular heart disease, pericardial disease, or aortic
dissection or aneurysm
• Exercise testing : low-risk, selected intermediate-risk
patients
 screened for high-risk features or indicators hospital
admission
• Rapid identification and treatment patients emergent
reperfusion therapy (Acute Coronary Sysndrome) 
improved outcomes
• Risk stratification
• Shortening lengths of stay in coronary care unit and
hospital
MECHANISMS OF DYSPNEA
• Motor Efferents
• Sensory Afferents
• Integration: Efferent-Reafferent Mismatch
• Anxiety
DIFFERENTIAL DIAGNOSIS
 MECHANISM OF
CARDIOGENIC PULMONARY EDEMA
Distinguishing Cardiogenic from Noncardiogenic
Pulmonary Edema
• History is essential
• Physical examination : increased intracardiac pressures (S3
gallop, elevated jugular venous pulse, peripheral edema),
and rales and/or wheezes
• Chest radiograph : cardiomegaly, vascular redistribution,
interstitial thickening, and perihilar alveolar infiltrates;
pleural effusions
• Hypoxemia responds to supplemental oxygen
CAUSES OF HYPOXIA
• Respiratory Hypoxia
• Hypoxia Secondary to High Altitude
• Right-to-Left Extrapulmonary Shunting
• Anemic Hypoxia
• Carbon Monoxide (CO) Intoxication
• Circulatory disorder
• Specific Organ Hypoxia
• Increased O2 Requirements
• Histotoxic hypoxia
ADAPTATION TO HYPOXIA
• increases ventilation
• Diffuse, systemic vasodilation occurs in generalized hypoxia
raises cardiac output
• chronic hypoxia increase hemoglobin concentration and number
of red blood cells
CYANOSIS
• bluish color of skin and mucous membranes
 reduced hemoglobin, or of hemoglobin derivatives

• lips, nail beds

CLUBBING

Clubbing fingers
CLINICAL CAUSES OF EDEMA
• Obstruction of Venous (and Lymphatic) Drainage of a Limb
• Congestive Heart Failure
• Nephrotic Syndrome and Other Hypoalbuminemic States
• Cirrhosis
• Drug-Induced Edema
• Idiopathic Edema
DIFFERENTIAL DIAGNOSIS
LOCALIZED EDEMA
• Inflammation, venous or lymphatic obstruction
GENERALIZED EDEMA
• Edema of Heart Failure
• Nephrotic Syndrome
• Acute Glomerulonephritis and Other Forms of Renal Failure
• Cirrhosis
• Edema of Nutritional Origin
• Other Causes

Important : DISTRIBUTION OF EDEMA

• Determine if symptom caused by life-threatening arrhythmia
• Association with other symptoms (hemodynamic compromise,
including syncope or lightheadedness)
• Physical examination will help confirm
• ECG used to document arrhythmia
• Holter