LEARNING ISSUE

TUTORIAL 1 BLOK 8
Aisha Sabitha Maharani
2208135539
Kelompok 6
CONTENTS
1. Coronary heart disease definitions
2. Risk factors for coronary heart disease
3. The pathophysiology of coronary heart disease
4. Diagnosis for coronary heart disease
5. Differential diagnosis of coronary heart disease
6. Supporting examination of coronary heart disease
7. Early treatment of coronary heart disease
8. Farmacology and non farmacology treament in coronary heart disease
9. Indication to transffered the patient with coronary heart disease
10. Prognosis and prevention of coronary heart disease
 1) Coronary heart
disease definitions
 CHD DEFINITIONS

Coronary heart disease (CHD) is a blood vessel

disease coronary heart due to narrowing,
blockage, or abnormalities other blood
vessels.

This condition can be caused by spasms,

atherosclerosis or a combination of both.

Obstructed flow can cause the supply of

oxygen and nutrients to the myocardium
decrease and causes pain and disruption of
heart function arise.
 CHD DEFINITIONS

Types of CHD 1. Unstable Angina Pectoris (UAP)

Stable Angina Pectoris 2. ST Segmen Elevation

Pain that arises due to myocardial ischemia that occurs Myocardial Infraction (STEMI)
in the chest, substernally or slightly to the left for less
than 20 minutes and can disappear with or without 3. Non ST Segmen Elevation
treatment. Myocardial Infraction (NSTEMI)

Acute Coronary Syndrome

emergency of coronary artery which is a combination of
symptoms indicating acute myocardial ischemia where
there is increasing chest pain,

Richard C. The Netter Collection Cardiovascular System. Elsevier. 2nd

 CHD DEFINITIONS

1) Unstable Angina Pectoris (UAP)

Unstable angina is usually secondary to reduced myocardial perfusion resulting from
coronary artery atherothrombosis. In this event, however, the nonocclusive thrombus
that developed on a disrupted atherosclerotic plaque does not result in any biochemical
evidence of myocardial necrosis.

2) Non ST Segmen Elevation Myocardial Infraction (NSTEMI)

Incomplete or temporary coronary occlusion, or the presence of collateral coronary
arteries that can maintain blood supply to the affected region, can cause myocardial
ischemia and necrosis to a lesser degree, usually limited to the subendocardium. This
situation cannot cause ST segment elevation

Fuster, Walsh, Harrington. Hurst’s The Heart. 13th. Vol 2. 1287 p

 CHD DEFINITIONS

3) ST Segmen Elevation Myocardial Infraction (STEMI)

Complete coronary occlusion sufficient to cause transmural cardiac neknosis, ST
segment elevation occurs

Philip I, Jeremy P. At a Glance Sistem Kardiovaskular. EMS. 3rd. 90 p

 2) Risk factors for
coronary heart disease
 RISK FACTORS FOR CHD

a) Modifable
Dyslipidemia (high LDL, low HDL, TGL)
Tobacco smoking
Hypertension
Diabetes mellitus, metabolic syndrome
Lack of physical activity

Philip I, Jeremy P. At a Glance Sistem Kardiovaskular. EMS. 3rd. 74 p

 RISK FACTORS FOR CHD

b) Non Modifable
Advanced age
Male gender (post menopausal women)
Family history

Philip I, Jeremy P. At a Glance Sistem Kardiovaskular. EMS. 3rd. 74 p

 RISK FACTORS FOR CHD

c) Novel
Homocystein
Lipoprotein (a)
hs-CRP & other inflammatory

Philip I, Jeremy P. At a Glance Sistem Kardiovaskular. EMS. 3rd. 74 p

3) The pathophysiology of
coronary heart disease
 PATHOPHYSIOLOGY OF CHD
Atherosclerosis Time Line

Pepine CJ. Am J Cardiol. 1998;82 (suppl 104)

 PATHOPHYSIOLOGY OF CHD

Elsevier. 2005
 PATHOPHYSIOLOGY OF CHD

Philip I, Jeremy P. At a Glance Sistem Kardiovaskular. EMS. 3rd. 86 p

4) Diagnosis for coronary
heart disease
 DIAGNOSIS FOR CHD

1) ANAMNESIS 2) ECG
Patient identity
Main complaint
History of current illness
Past medical history
Habits and patterns/lifestyle
Family history of illness
Environment
Socioeconomic

.
 DIAGNOSIS FOR CHD

3) BIOMARKER

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 9 p

 DIAGNOSIS FOR CHD

Guideline for the diagnosis and treatment of NSTEMI ACS, ESC Guidelines June 14th, 2007
5) Differential diagnosis of
coronary heart disease
 DIFFERENTIAL DIAGNOSIS

Typical angina (define)

1.Substernal chest discomfort with a characteristic quality and duration that is
2.Provoked by exertion or emotional stress and
3.Relieved by rest or nitroglycerin

Atypical angina ( probable)

Meets 2 of the above characteristics

Noncardiac chest pain

Meets one or none of the typical angina characteristics

.
 DIFFERENTIAL DIAGNOSIS
Class of Angina

Canadian Cardiovascular Society Classification ( CCSC)

 DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
a. Patients with hypertrophic cardiomyopathy or heart valve disease (aortic valve stenosis and
regurgitation) may complain of chest pain accompanied by ECG changes and increased cardiac
markers as occurs in IMA-NEST patients.
b. Myocarditis and pericarditis can cause complaints of chest pain, ECG changes, increased cardiac
biomarkers, and heart wall movement disorders such as IMA-NEST.
c. Stroke can be accompanied by ECG changes, increased cardiac markers, and disturbances in the
movement of the heart walls.
d. Life-threatening non-cardiac differential diagnoses that must always be excluded are pulmonary
embolism and aortic dissection.

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 13 p

6) Supporting examination
of coronary heart disease
 SUPPORTING EXAMINATION OF CHD
.
 SUPPORTING EXAMINATION OF CHD
Richard C. The Netter Collection Cardiovascular System. Elsevier.
 7) Early treatment of
coronary heart disease
 EARLY TREATMENT OF CHD
Therapy given to patients with a working diagnosis of possible ACS or ACS on the
basis of complaints of angina in the emergency room, before there are results of
ECG examination and/or cardiac biomarkers. The initial therapy in question is
Morphine, Oxygen, Nitrate, Aspirin (abbreviated as MONA), which do not have to be
given all or simultaneously
PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 14 p
 EARLY TREATMENT OF CHD
Bed rest
In all patients IMA-EST is recommended to measure peripheral oxygen saturation
Aspirin 160-320 mg is given immediately to all patients with no known aspirin
intolerance
Adenosine diphosphate (ADP) receptor blockers
Nitroglycerin (NTG) sublingual spray/tablet for patients with chest pain that is still
ongoing when arriving at the emergency room
Morphine sulfate 1-5 mg intravenously, can be repeated every 10-30 minutes, for
patients who are unresponsive to therapy with 3 doses of sublingual NTG

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 14 p

 EARLY TREATMENT OF CHD

American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
 EARLY TREATMENT OF CHD

American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
 EARLY TREATMENT OF CHD
UAP and NSTEMI
Complete bed rest
Oxygen 2-4L/min
IVFD installation
Drugs :
- Aspilet 160mg chewable
- Clopidogrel (for those aged <75 years and not regularly taking clopidogrel) give 300 mg or Ticagrelor 180 mg
- Sublingual nitrate 5mg, can be repeated up to 3 (three) times if there are still complaints, followed by IV
nitrate if the complaint is persistent
If the acute phase has not resolved and it is possible to
referred, the patient is immediately referred for treatment
follow-up action.
Heart monitoring

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019

 8) Farmacology and non
farmacology treament in
coronary heart disease
 FARMACOLOGY AND NON FARMACOLOGY
TREAMENT IN CHD
PHARMACOLOGY
1) Anti-Ischemia
Beta blockers: decrease myocardial oxygen consumption. orally
nitrates: venous vasodilation so that myocardial oxygen
consumption is reduced
calcium channel blockers

2) Antiplatelet
Aspirin: should be given to all patients without contraindications

3) Anticoagulants
given together with aspirin

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 28 p

 FARMACOLOGY AND NON FARMACOLOGY
TREAMENT IN CHD
NON FARMAKOLOGI
NON PHARMACOLOGY
changing lifestyle (quitting smoking, dieting)
exercise
benefits of exercise:
Improving Lung Function
Lose weight
Lowers Blood Pressure
Increase Physical Freshness
Hypercholesterolemia Management
Improve Blood Fat Profile Within Normal Limits
 FARMACOLOGY AND NON FARMACOLOGY
TREAMENT IN CHD
Revaskularisasi Miokard
tindakan revaskularisasi pembedahan, bedahpintas koroner
(coronary artery bypass surgery = CABG)

tindakan intervensi perkutan (percutneouscoronary

intervention = PCI).

Fuster, Walsh, Harrington. Hurst’s The Heart. 13th. Vol 2. 1495 p

9) Indication to transffered
the patient with coronary
heart disease
 INDICATION TO TRANSFFERED THE
PATIENT OF CHD
Tingkat Kemampuan 3: mendiagnosis, melakukan
penatalaksanaan awal,dan merujuk

3B. Gawat darurat

Lulusan dokter mampu membuat diagnosis klinik dan
memberikan terapipendahuluan pada keadaan gawat
darurat demi menyelamatkan nyawa ataumencegah
keparahan dan/atau kecacatan pada pasien. Lulusan
dokter mampumenentukan rujukan yang paling tepat
bagi penanganan pasien selanjutnya. Lulusan dokter
juga mampu menindaklanjuti sesudah kembali dari
rujukan

\
Standar Kompetensi Dokter Indonesia
INDICATION TO TRANSFFERED THE
PATIENT OF CHD
REFERENCE CRITERIA
Emergency Referral
Angina during light physical activity
Angina at rest (usually at night)
Progressive angina despite increased intensity of therapy
Early Referral
Patients with a previous history of myocardial infarction, who currently have
angina
Patients who do not respond to therapy
Regular Referrals
To carry out further supporting examinations
Patients with many risk factors and a strong family history of CHD
Patients with significant comorbidities
 10) Prognosis and
prevention of coronary
heart disease
 PROGNOSIS AND PREVENTION OF CHD

PERKI. Panduan Tatalaksana Angina Pektoris Stabil. 2019. 20 p

 PROGNOSIS AND PREVENTION OF CHD

PREVENTION
•Quit smoking
•Control blood pressure (<140/90 mmHg)
•Control blood sugar
•Lowers cholesterol. LDL-C <100 mg/dl.
•Physical activity 5-7 times a week for approximately 30 minutes
•Medication compliance
Thank you