Penegakkan Diagnosis dan

Tatalaksana CAD

Chaerul Achmad
Department of Cardiology and Vascular Medicine
Padjadjaran University, Hasan Sadikin General Hospital Bandung
 Disclosure

• I do not have any potential conflicts to disclose.

 Introduction

CAD is pathological process characterized by

atherosclerotic plaque accumulation in the epicardial
arteries, whether obstructive or non-obstructive

Lifestyle, pharmacological, and invasive interventions

Non-invasive functional imaging

for ischaemia may be an option if there
is need to verify the diagnosis
 Sequence of Events in Ischemic
Heart Disease

•Arrythmias
MI •Lost of muscle
•Angina
•Silent Ischemia Remodeling

CAD
Progresif dilatation

Endothelial dysfunction
Heart Failure
Death
Risk Factor
The balance of atherosclerosis
Approach for the initial diagnostic management of patients with angina and
suspected coronary artery disease
 Step 1
Symptoms and signs
 ISCHEMIC CHEST PAIN

TYPICAL ANGINA EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT 2. LOCATION
2. LOCATION 3. INDIGESTION
3. RADIATION 4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS 5. DIAPORESIS
6. SHORTNESS OF BREATH
 STABLE ANGINA DEFINITION

Angina :
• During exertion or emotional stress
• 5 – 15 mnt
• Relieve by rest or nitrat

First-onset angina and crescendo angina

that occur during exertion should not
be consider
CLINICAL CLASSIFICATION OF CHEST PAIN

Typical angina Meets three of the following characteristic

(definite) - Substernal chest discomfort of

characteristic quality and duration

- Parovoked by exertion or emotional stress

- Relief by rest and/or GTN

Atypical angina Meets two of these characteristic

(probable)

Noncardiac chest pain Meets one or none of these characteristic

Fox K et al for The Task Force on the Management of Stable Angina Pectoris of the European Society
of Cardiology 2006
 Stable angina: grading of angina pectoris
Class Canadian Cardiovascular Association functional classification
I Ordinary physical activity, such as walking and climbing stairs,
does not cause angina. Angina with strenuous or rapid or
prolonged exertion at work or recreation
II Slight limitation of ordinary activity. Walking or climbing stairs
rapidly, walking uphill, walking or stair climbing after meals, in
cold, in wind, or when under emotional stress, or only during the
few hours after awakening. Walking more than two blocks on the
level and climbing more than one flight of ordinary stairs at a
normal pace and in normal conditions
III Marked limitation of ordinary physical activity. Walking one to
two blocks on the level and climbing more than one flight in
normal conditions
IV Inability to carry on any physical activity without discomfort —
anginal syndrome may be present at rest
Goldman L et al. Circulation 1981;64:1227
Unstable angina

1. As rest angina, i.e. pain of characteristic

nature and location occurring at rest and for
prolonged periods (>20 min)
2. new-onset angina, i.e. recent (2 months)
onset of moderate-to-severe angina
(Canadian Cardiovascular Society grade II or
III)
3. crescendo angina
Low-risk unstable angina:
- No recurrence of angina
- No signs of HF
- No abnormalities ECG
- No rise in troponin Levels.

non-invasive diagnostic strategy is

recommended.
 Step 2
Comorbidities and other
causes
of symptoms
 Step 3
Basic testing
 Step 4
Assessment of pre-test
probability and clinical
likelihood of coronary artery
disease

Studies have shown that outcomes in

patients classified with the new PTP
<15% is good (annual risk of
cardiovascular death or MI is <1%)
Main diagnostic pathways in symptomatic patients with suspected
obstructive coronary artery disease
Lifestyle management
Pharmacological management
 Treatment Objectives

• Reduce the risk of mortality and morbid events

• Reduce symptoms
• - anginal chest pain or exertional dyspnea;
palpitations or syncope;
• fatigue, edema or orthopnea
❖High clinical likelihood of CAD
❖Symptoms unresponsive to medical
therapy
❖Typical angina at a low level of exercise

Invasive coronary angiography (ICA)

 Conclusion

HIGH-RISK PATIENTS
CORONARY
(regardless of the
REVASCULARIZATION
severity of symptoms)

LOW-RISK PATIENTS
PHARMACOLOGICAL
without serious
MANAGEMENT
symptoms