Curriculum Vitae

Daftar Riwayat Hidup

Nama : Siska Suridanda Danny
Tanggal lahir : 3 November 1978
Alamat : Gudang Peluru V/527, Jakarta Selatan

Pekerjaan
Staf Medik Fungsional pada Instalasi Gawat Darurat, IW
Medikal dan Intensive Cardiovascular Care Unit (ICVCU),
Pusat Jantung Nasional Harapan Kita, Jakarta
Staf Pengajar di Departemen Kardiologi dan Kedokteran
Vaskular, Fakultas Kedokteran Universitas Indonesia, Jakarta
EIDCP Jakarta 2016

Cardiac Chest Pain

Siska S. Danny, MD

Department of Cardiology and Vascular Medicine

Faculty of Medicine Universitas Indonesia
National Cardiovascular Center Harapan Kita Jakarta
Indonesia

siskadanny@yahoo.com
Chest Pain
Common complaint in Emergency Department
In the US: 5% of all ED visits or 5 million visits per year
Wide range of etiologies
Cardiac, Vascular, Pulmonary, GI, Musculoskeletal
Why does distinguishing these causes matter?
8-10% patients with Acute Coronary Syndrome/ACS are
discharged mistakenly from ED estimated 30-days
mortality of 2%
How do you distinguish causes of chest pain?
 So, youre on night duty at the ED

you attend to a 67 yo male complaining

of sudden pain in the chest and epigastric
area. He is also experiencing shortness of
breath and nausea. No previous cardiac
history but confesses of being a heavy
smoker, had uncontrolled hypertension and
recurrent dyspeptic complaints but usually
alleviated by antacids

What are YOU thinking?

Causes of Chest Pain
POTENTIALLY LEADS TO DEATH RELATIVELY MORE BENIGN
Acute Coronary Musculosceletal
Syndrome Esophagitis
Pulmonary Embolism Bronchitis (CP secondary
Aortic Dissection to cough)
Esophageal Rupture Pleuritis
Pneumothorax
 DIFFERENTIAL
DIAGNOSIS

Braunwald E : Clinical recognition of acute coronary syndromes. In Theroux P. Acute coronary syndrome: a
companion to Braunwalds Heart Diseases, 2nd ed. Philadelphia, Elsevier Saunders, 2011, pp 99.
 History matters!

ANGINA Onset
VS
NON ANGINA Provocation
Quality
Radiation
STABLE ANGINA VS
UNSTABLE Severity
ANGINA/ACS Time
 CHEST PAIN IN ACS
ONSET: Sudden or gradual acute chest pain. In
determining onset for STEMI, pinpoint the time of
most severe pain
PROVOCATION: Exercise/physical activity or even
occurred at rest
QUALITY: Diffuse, steady substernal chest pain.
Other sensations include a crushing and squeezing
feeling in the chest
SEVERITY: pain may be severe; not relieved by rest
or sublingual vasodilator therapy, requires opioids.
TIME/DURATION: pain continues for more than 15
minutes
 LOCATION: variable, but often pain resides behind
upper or middle third of sternum.
RADIATION: pain may radiate to the arms
(commonly the left), shoulders, neck, back, or jaw

Associated manifestations: anxiety, diaphoresis, cool

clammy skin, facial pallor, palpitations, dyspnea,
disorientation, confusion, restlessness, fainting,
nausea and vomiting
Atypical presentation of ACS

Sometimes chest pain is not very obvious but

patient complain of epigastric pain or abdominal
distress, dull aching or tingling sensation, shortness
of breath, dyspnea and extreme fatigue
Atypical presentation is more frequent in old
individuals (>75 yo), female, diabetes, chronic
kidney disease or patients with dementia
Non angina chest pain: Characteristic
clues
Chest pain is influenced by breathing and palpation
of the chest wall
Occured only in certain position
Location in central or lower abdomen
Pain could be pinpoint by a single finger
Duration only a few seconds of less
back to our dear patient: Mr X, 67 yo

Chest pain was described as

crushing heavy pain on the
chest and radiated to his jaw
Occured suddenly when he
was yelling at his
granddaughter for running
around the house
Very severe (9/10)
Onset 3 hours ago and persisted
for 40 minutes before slightly
subsided
Accompained by nausea,
shortness of breath and
diaphoresis
 So Is it ACS?
All chest pain is considered to
be ACS until proven
otherwise!
What is the next step in
diagnosing ACS?
Approach to chest pain

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

In patients with acute chest pain, a-12
leads Electrocardiogram has to be
obtained in 10 minutes!
 A Normal ECG do not exclude the
presence of Acute Coronary Syndrome.
(Remember that ACS consists of STEMI,
NSTEMI and UA)

Unstable Angina is a history-based

diagnosis with possibly normal ECG and
no elevation of cardiac markers

Do not wait for cardiac markers results

to start immediate treatment for ACS
 Initial Approach

Triage and Brief history,

Secondary
vital signs ECG and
exam
evaluation focused exam

Airway, Breathing, Character of pain, Further history, risk

Circulation associated factors, patients
Chest pain pts with symptoms, pain current
dyspnea or intensity medications
abnormal pulse/BP ECG: ST elevation Physical exam
needs IV, O2, or ST depression? Review old
monitor and ECG Cardiopulmonary records/previous
right away history ECG
 DIAGNOSIS?

Acute extensive anterior STEMI

What to do?
EARLY MANAGEMENT OF ACS

INITIAL ASSESSMENT INITIAL THERAPY

ESC guidelines for STEMI 2012
 Any
contra
indications
present?

N
O
Streptokinase 1.5
million units in 100
cc Dextrose 5% was Start
given over fibrinolysis
ESC60 min
STEMI Guidelines 2008
 Chest pain
resolved and ST
segment almost
returned to
baseline

SUCCESSFUL
FIBRINOLYSIS
 .so you thought youre done for the night,
but here comes another patient

Mr B, 30 yo, had an ankle surgery 2 weeks ago and now have

sudden onset of chest pain

Pleuritic chest pain

triggered by deep breaths.
Also had dyspnea and
cough
BP 90/60 mmHg, HR 120
bpm, RR 35x/mnt, Sat O2
91% (room air), clear lungs
on auscultation
ECG: Sinus tachycardia,
RBBB, non specific ST-T
changes. S1Q3T3 (+)
Working Diagnosis?

Acute Pulmonary Embolism

Risk factors:
Hypercoagulability: Malignancy, pregnancy,
estrogen use, protein C/S deficiency
Venous stasis: prolonged bedrest, recent
hospitalization, long distance travel
Venous injury: recent trauma or surgery

How to confirm diagnosis?

D-dimer
CT scan
 .and came another one

Mr L, 69 yo, with a history of

uncontrolled hypertension
came with sudden onset
severe ripping and tearing
chest pain radiated to the
back
BP 180/110 mmHg (right arm)
and 100/60 mmHg (left arm).
Diminished pulses on both
legs
ECG: sinus tachycardia with
signs of left ventricular
hypertrophy
Working Diagnosis?

Aortic Dissection
Bimodal distribution:
Young: Connective tissue disorder (eg Marfan
disease) or pregnancy
Older: Most commonly > 50 yo and hypertensive
How to confirm diagnosis?
CXR: widened mediastinum, abnormal aortic
knob, pleural effusion
Chest CT scan: very sensitive, risk of kidney injury
Angiography: most reliable but not always possible
More patients?

TIMES UP
Take home message
Chest pain is a common complaint in the ED and has a
variable differential diagnosis
Although not 100% accurate, most of the common
causes for chest pain has specific clues to help you build
your diagnosis. Thus history taking is of utmost importance
in determining the cause of chest pain, followed by ECG
Since ACS is the most frequent cause of potentially fatal
chest pain, all chest pain should be considered ACS until
proven otherwise; hence the 10 minutes timeline to do
ECG!
Time is muscle in STEMI-ACS. Try to confirm diagnosis and
start therapy as soon as humanly possible
Do not order multiple auxiliary tests blindly to build your
diagnosis. Instead, have a working diagnosis in mind and
order specific tests to confirm it
Thank you
Chest Pain Definitions

Acute Chest Pain:

Acute - sudden or recent onset (usually within minutes to hours), presenting
typically <24 hrs
Chest - thorax midaxillary to midaxillary line, xiphoid to suprasternum notch
Pain noxious uncomfortable sensation
Ache or discomfort
Visceral pain
Often referred
Aching, heaviness, discomfort
Difficult to localize pain
Somatic pain
Sharp, easily localized
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