BBDM Nyeri Dada

Arie Bachtiar Dwitaryo Bagian Ilmu Penyakit Dalam, Sub Bagian Kardiologi FK. UNDIP / RS. Dr. Kariadi Semarang

Ilustrasi Kasus

Penderita laki laki usia 55 tahun dengan keluhan nyeri dada kiri leher seperti dicekik. Keringat dingin, berlangsung 5 menit terjadi waktu bermain tenis, reda dengan istirahat. RPD: Hipertensi (+), merokok (+), dislipidemi (+)

Angina Pain

Deep, Poorly Localised chest or arm discomfort. Associated with physical exertion & Emotional stress. Released promptly with rest/NTG (<5 mnt).

Acute Coronary Syndrome

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

DEFINITION
Unstable Angina Pectoris constitutes a clinical syndrome that is usually but not always caused by atherosclerotic CAD and associated with an increased risk of cardiac death and myocardial infarction

Unstable Angina

Anginal Pain Severe + Prolonged Less Exertion Rest Angina Equivalent No CHEST Discomfort Exercise + Stress Related Pain Location JAW, NECK, EAR, ARM, Epigastric Discomfort

ACUTE CORONARY SYNDROME

Acute Coronary Syndrome

No ST Elevation Non ST Elevation MI

ST Elevation

Unstable Angina

Myocardial Infarction Non Qw MI Qw MI

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

UA/NSTEMI THREE PRINCIPAL PRESENTATIONS

Rest Angina New-onset Angina
Angina occurring at rest and prolonged, usually > 20 minutes New-onset angina of at least CCS Class III severity

Increasing Angina

Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by > 1 CCS) class to at least CCS Class III severity.

Differential Diagnosis of Prolonged Chest Pain

AMI Aortic dissection Pericarditis Atypical anginal pain associated with hypertrophic cardiomyopathy Esophageal, other upper gastrointestinal, or biliary tract disease Pulmonary disease Hyperventilation syndrome Chest wall Psychogenic

Features that are not characteristic

Epigastric Discomfort Pleuritic Pain Knife like pain - Cough - Respiratory Movement Pain in the middle or lower abdominal region. Pain that localized at the of one finger (LV Apex) Pain caused by movement + pal pation (chest wall). Constant pain Many hours Episode of pain Few seconds Pain radiates to lower extremites

Atherothrombosis: A Generalized and Progressive Disease

Atherothrombosis

Unstable angina MI

ACS

Ischemic stroke/TIA
Atherosclerosis Critical leg ischemia Intermittent claudication

CV death

Stable angina/Intermittent claudication

MI = Myocardial infarction ACS = Acute coronary syndromes CV = Cardiovascular

Adapted from Libby P. Circulation 2001; 104: 365372

Pathophysiology of coronary heart disease

Mechanisms of myocardial ischaemia
O2 transport capacity Arterial O2 saturation Haematocrit O2 consumption O2 supply Diastolic aortic pressure Coronary vascular resistance Coronary spasm Organic stenosis Impaired pump function

Contractility
Heart rate Wall stress
Ventricular volume Wall thickness LV enddiastolic pressure Coronary blood flow

ISCHAEMIA
ST segment - depression - elevation Impaired perfusion Metabolic changes

Angina pectoris

Guidelines for the Identification of ACS Patients

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 Women Diabetic Elderly patients

Electrocardiogram

Carries diagnostic and prognostic value

Especially valuable if captured during pain

ST-segment depression or transient ST-segment elevation are primary ECG markers of UA/NSTEMI

75% of patients with + CK-MB do not develop Q waves

Differentiation between UA and NSTEMI relies upon positive biomarkers Inverted T-waves suggestive of ischemia, particularly with good chest pain story

Lanjutan ke hal berikutnya

Gambaran elektrokardiogram penderita ST Elevation Myocardial Infarction. (STEMI)

Time course of Serum Protein Markers

MB2/MB1 Myoglobin

048

16

24

36

48

Hour post-AMI

The Estimation of Early Risk at Presentation

Antman et al.
Age > 65 years
More than 3 coronary risk factors
Prior angiographic coronary obstruction ST-segment deviation More than 2 angina events within 24 hours Use of aspirin within 7 days Elevated cardiac markers
0 to 2 points : low-risk stratum 3 to 4 points : intermediate-risk stratum 5 to 7 points : high-risk stratum

NITRATE MECHANISMS
Isosorbide dinitrate Isosorbide mononitrate

Endo

Cytoplasm
Sarcolemma Peroxynitrite

GTP

LIVER
Mononitrate R-ONO2

Physiologic dilators

Cyclic GMP
Lowers Ca2+

Nitrosothiols NO2 ONO SH

Nitroglycer in

ONO2 ONO2 ONO2

EXCESS NITRATES Deplete SH Peroxynitrite

SH

VASODILATION
Opie (2001)

Nitrate tolerance

Effects of nitrates in generating NO and stimulating guanylate cyclase to cause vasodilation.

BETA BLOCKADE EFFECTS ON ISCHEMIC HEART

increased diastolic perfusion

heart rate after load wall stress heart size contractility O2 wastage DEMAND O2 demand O2 supply

less exercise vasoconstriction

more spasm?

collateral flow

SUPPLY

O2 deficit anaerobic metabolism

(Opie, 1990)

Initial Risk Stratification Scheme

Chest Pain

History, Physical EKG

STEMI

UA/NSTEMI/ High Risk

Mod Risk

Low Risk

Definite Non-Cardiac

The Estimation of Early Risk at Presentation

Boersma et al.
Age

Heart rate
Systolic blood pressure ST-segment depression, Signs of heart failure Elevation of cardiac markers