CHEST PAIN

ANGINA PECTORIS
ACUTE CORONARY SYNDROME

Dr. Andreas Arie, SpPD

CARDIOVASCULAR DIVISION INTERNAL MEDICINE DEPARTMENT
MEDICAL FACULTY DIPONEGORO UNIVERSITY

CHEST PAIN

Angina is a clinical syndrome characterized by

discomfort in the chest, jaw, shoulder, back, or arm.
Typically aggravated by exertion or emotional stress
and relieved by nitroglycerin.
Usually occurs in patients with CAD, but can also
occur in person with valvular heart disease,
hypertrophic cardiomyopathy, and uncontrolled
hypertension.
Also can be present in patients with normal coronary
artery and myocardial ischemia related to spasm or
endothelial dysfunction.
And also can be present in patients with non cardiac
condition of esophagus, chest wall, or lungs.

ANGINA PECTORIS

Grading of Angina Pectoris

by the Canadian Cardiovascular Society Classification System

Guidelines for the Identification of ACS Patie

Chief Complaint
Chest pain typical of myocardial ischemia
or MI
Associated : dyspnea, nausea and/or
vomiting
diaphoresis
Medical History
CABG, angioplasty, CAD, angina on effort,
or AMI
NTG use to relieve chest discomfort
Risk factors
Special Considerations

Initial Risk Stratification Scheme

Chest Pain

History,
Physical
EKG

STEMI

UA/NSTEMI/
High Risk

Mod Risk

Definite
Low Risk Non-Cardiac

Acute Coronary
Syndrome
No ST
Elevation

ST
Elevation

NSTEMI

Unstable
Angina

Myocardial
Infarction
NQMI

QwMI

Braunwald E et al. J Am Coll Cardiol 2000; 36:970-1062

Acute Coronary
Syndrome
ST-segment elevation MI (STEMI)
Non ST-segment elevation MI
(NSTEMI)
Unstable Angina

Pembuluh darah yang mengalami aterosklerosis & trombosis

Atherosclerosis Timeline
Foam
Cells

Fatty Intermediate
Fibrous Complicated
Streak
Lesion Atheroma Plaque
Lesion/Rupture

From first decade

Endothelial
dysfunction
From
third decade

Growth mainly by lipid

accumulation

From fourth decade

Smooth muscle
and collagen

Thrombosis,
haematoma

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

70

INFARCT

STROKE

GANGRENE

ANEURYSM

60

AGE IN YEARS

50
CLINICAL HORIZON

40
30

CALCIFICATION
COMPLICATED LESION:
HEMORRHAGE, ULCERATION,
THROMBOSIS
FIBROUS PLAQUE

20
FATTY STREAK
10
0

Evolution of the atherosclerotic

Plaque
Traditional risk factors Emerging risk factors
- Dyslipidemia
- Homocystein
- Hypertension
- CRP
- Smoking
- Fibrinogen
- DM
- etc

Pathophysiology of coronary heart

disease
Mechanisms of
myocardial ischaemia
O2
transport
capacity

Contractili
ty
Heart rate
Wall
stress
Ventr
icular
volu
me

Wall
thic
kness

O2
consumpti
on

O2
supply
Coronary
blood
flow

LV
enddiastol
ISCHAEMI
ic
A
pressu
re
ST
Impaired
Angina
segment
perfusion
pectoris
Metabolic
depression
changes
-

Arterial
O2 saturation
Haematocrit
Diastolic
aortic
pressure
Coronary
vascular
resistance
Coronary
spasm
Organic
stenosis
Impaired
pump
function

F
a
k
t
o
r
r
i
s
i
k
o

non-modifiable
usia (semakin tua semakin mudah mengalami
PJK)
gender (usia <64 tahun insidensi pria dg
PJK>wanita, namun dengan meningkatnya usia
wanita menjadi lebih mudah mengalami PJK)
genetik

modifiable
merokok
diabetes mellitus (DM)
dislipidemia
obesitas
hipertensi
sedentary life style
stres

CVD disease risk factors

rokok
Diabetes

smoking

Hypertension

Hypercholesterolae
mia

hipertensi

obesitas
inactivity

stres

Mayor Independent Risk

Factors

Elevated Blood Presure (JNC VII)

- Hypertension : > 140/90
* Stage I : 140 159 / 90 99
* Stage II : 160 179 / 100 109
* Stage III : > 180 / 110
Dislipidemia (Framingham Criteria)
* Total cholesterol : > 200 mg%
* HDL < 35 mg%
* LDL > 130 mg%
Cigarette Smoking
DM
Advancing Age

Predisposing Risk Factors

Obesity
: BMI > kg / m2
Abdominal obesity
Men : waist circ > 102 cm
Women : waist circ > 88 cm
Physical Inactivity
Family History of Premature CHD
Psychosocial factors

Conditional Risk
Factors

Triglycerides > 200 mg / dl

Homocysteine
Small dense LDL
Protrombotic factor : fibrinogen
Inflamatory Markers CRP

PEMERIKSAAN

EVOLUSI EKG

Lanjutan ke hal berikutnya

Time course of Serum Protein Markers

MB2/MB1
Myoglobin

048

16

24

36

Hour post-AMI

48

Likelihood That Signs and Symptoms

Represent an ACS Secondary to CAD

CLINICAL SUSPICION OF ACS

Physical examination
ECG monitoring, Blood sample
Persistent
ST-elevation

Thrombolysis
PCI

No Persistent
ST-elevation

Undetermined
Diagnosis

ASA, LMWH
Clopidogrel, betablockers, Nitrate

High Risk

Low Risk
Second troponin measurement

GpIIb/IIIa
Cor.Angiography

Positive

PCI, CABG or Medical management

Twice negative
Stress test
Coronary angiography

PRINCIPLES THERAPY OF THROMBOSIS

BASED ON PATHOGENESIS
PATHOGENESIS

THERAPY

RISK FACTORS

PREVENTION

- PLATELET ADHESION
ANTIPLATELET

-PLATELET AGGREGATION

-BLOOD COAGULATION

ANTICOAGULANT

-THROMBOSIS

THROMBOLYTIC

Algorithm for evaluation and management of patients suspected ACS

SYMPTOMS SUGGESTIVE OF ACS
Definite ACS

Possible ACS
No ST elevation
Non Dx ECG
Normal initial serum cardiac marker
Observe
FU 4-8 h: ECG, cardiac markers

ST elevation
ST and/or T wave changes
Ongoing pain
(+) cardiac markers
Hemodynamic abnormalities

Evaluation for
reperfusion
therapy

Recurrent ischemic pain

(+) FU studies
Diagnostic of ACS
confirmed

No recurrent pain
(-) FU studies
Stress test
Negative
Nonischemic, low risk

Positive
Diagnostic of ACS confirmed

Admit to hospital
Manage via
Acute ischemic pathway

Recurrent ischemia and/or

ST segment shift, or
Deep T-wave inversion, or
Positive cardiac markers

Acute Ischemia
Pathway

Aspirin
Beta blockers
Nitrates
Antithrombin regimen
GP IIb/IIIa inhibitor
Monitoring (rhythm and ischemia)

Early invasive strategy

Immediate
angiography

12-24 hour
angiography

Early conservative strategy

Patient stabilizes

Recurrent
Symptoms/ischemia
Heart failure
Serious arrhythmia
Evaluate LV
Function
EF <.40

EF >.40
Stress Test
Not low risk

Low risk
Follow on
Medical Rx

Hospital care
A. Anti Ischemic Therapy
Bed rest with continuous ECG monitoring
Supplemental O2 to maintain SaO2 > 90%
Morphine iv. (for pain, anxiety, Pulmonary congestion)
Nitrate (oral or iv.)
Betablockers if no contraindication
Non dihydropyridine calcium antagonis (Diltiazem
or Verapamil) if Betablockers contraindicated and
no severe LV dysfunction.
Ace inhibitors for hypertension LV dysfunction
after MI

Hospital care
B. Anti Thrombotic Therapy
Possible ACS

Likely/Definite ACS

Aspirin

Aspirin +
LMWH or
IV Heparin

+
Clopidogrel

High risk ACS/planned PCI

Aspirin + LMWH
or IV Heparin +
GP IIb/IIIa
antagonist

+
Clopidogrel

Hospital care
B. Anti Thrombotic Therapy
High risk ACS/planned PCI
Aspirin + LMWH
or IV Heparin +
GP IIb/IIIa
antagonist

+
Clopidogrel