ARIO SOERYO

KUNCORO,MD,CARDIOLOGIST
DIAGNOSTIC TOOL FOR CHEST PAIN SYMPTOM:
WHAT,WHEN AND WHAT TO EXPECT
OUTLINE OF THE SLIDES

▸ what are the tools that commonly used

▸ how to diagnose pts with stable coronary disease

▸ chest pain in clinical practice + ED

▸ management for pts with chest pain: choosing diagnostic tools

▸ principles of diagnostic test : pre test probability

▸ global risk assessment

▸ summary
DIAGNOSTIC TOOL FOR CHEST PAIN

CARDIOVASCULAR IMAGING FOR (SUSPECTED/KNOWN) CORONARY ARTERY DISEASE

TRANSTHORACIC ECHOCARDIOGRAPHY
STRESS ECHOCARDIOGRAPHY Ultrasound base imaging

CORONARY MULTISLICE CT SCAN X ray based imaging

CARDIAC MAGNETIC RESONANCE IMAGING Electromagnetic based imaging

STRESS CMR

nuclear medicine
SPECT tomographic imaging,
STRESS SPECT using gamma rays

+ CARDIAC CATHETERIZATION / X ray based imaging

CORONARY ANGIOGRAPHY
 HOW TO DIAGNOSE PATIENTS WITH SUSPECTED OF CAD ?

RISK STRATIFICATION

‣ LOW RISK —> <1% MORTALITY/YEAR

‣ INTERMEDIATE RISK —> >1 < 3%
‣ HIGH RISK —> >3% MORTALITY/YEAR
DIAGNOSTIC TOOL FOR CHEST PAIN

RISK STRATIFICATION IN SUSPECTED OF CAD

▸ Clinical evaluation

▸ pts demographic, risk factors, comorbidities, resrting ECG, potential

use of biomarker

▸ Assessment of Left ventricular function

▸ Non invasive functional test for ishemia

▸ exercise ECG, stress echocardiography,myocardial perfusion scan

(SPECT), stress cardiac MRI

▸ assessment of coronary anatomy

▸ invasive coronary angiography, coronary CT scan

DIAGNOSTIC TOOL FOR CHEST PAIN

chest pain
ECG
function
malperfusion

coronary flow
reserve

Epicardial coronary
artery
Normal 20% 50% 75% 90% 100%
DIAGNOSTIC TOOL FOR CHEST PAIN

ECG Angina

Regional dysfunction
DIAGNOSTIC TOOL FOR CHEST PAIN

CHEST PAIN IN DAILY PRACTICE

▸ chest pain is most common complain in emergency unit

▸ chest pain has an extensive of differential diagnosis

▸ 8-10% patients with acute coronary syndrome discharged

mistakenly from ED —> estimated 30 days mortality 2%

▸ clinical history taking is critical in establishing pre test

probability for any diagnosis and guide subsequent test
CHEST PAIN IN EMERGENCY DEPARTMENT
MANAGEMENT OF PATIENTS WITH CHEST PAIN
DIAGNOSTIC TOOL FOR CHEST PAIN

PRE TEST PROBABILITY ASSESSMENT FOR RISK STRATIFICATION

DIAGNOSTIC TOOL FOR CHEST PAIN
DIAGNOSTIC TOOL FOR CHEST PAIN

CHARACTERISTICS OF COMMONLY USED DIAGNOSTIC TEST FOR CAD

DIAGNOSTIC TOOL FOR CHEST PAIN

TREADMILL TEST FOR ANGINA PECTORIS OR SUSPECTED OF CAD

▸ clearly positive : very high risk, significant risk, moderate

risk

▸ clearly negative: np ECG abbnormalities, false negative in

20% of cases

▸ borderline : submaximal HR, clinically positive with no

ECG changes, abnormalities at rest/recovery, abnormal
ECG at rest
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SYMPTOMATIC PATIENTS
DIAGNOSTIC TOOL FOR CHEST PAIN

ASYMPTOMATIC PATIENTS
DIAGNOSTIC TOOL FOR CHEST PAIN

GLOBAL ASSESSMENT FOR CHD RISK: FRAMINGHAM RISK SCORE

DIAGNOSTIC TOOL FOR CHEST PAIN

APPROACH FOR DIAGNOSIS OF ACUTE CORONARY SYNDROME IN EMERGENCY UNIT

Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054

DIAGNOSTIC TOOL FOR CHEST PAIN

INITIAL APPROACH IN EMERGENCY DEPARTMENT

TRIAGE AND VITAL BRIEF HISTORY,ECG SECONDARY EXAM

SIGN EVALUATION AND FOUSED EXAM

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

Circulation associated factors, patient’s
• 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
DIAGNOSTIC TOOL FOR CHEST PAIN

In acute phase, when diagnosis in uncertain, emergency

echocardiography may be useful. However if
inconclusive or unavailable and persistent doubt,
emergency angiography should be considered (Class I)
All patients should have an echocardiography for
assessment of infarct size and resting LV function
(Class I)
For patients with multivessel disease, or in whom
revascularization of other vessels is considered, stress
testing or imaging (Class I)
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IMAGING MODALITIES FOR CHEST PAIN ALGORHYTHM

DIAGNOSTIC TOOL FOR CHEST PAIN

BIOMARKER IN CHEST PAIN ALGORITHM

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DIAGNOSTIC TOOL FOR CHEST PAIN

SUMMARY
▸ Diagnostic tools for suspected CAD yield different interpretation

▸ Chest pain need to be treated as a whole or patient centred

approached

▸ Choosing diagnostic modalities based on evidence and

recomendation is important for management

▸ Patients suspected of CAD should have risk stratification and

manage accordingly

▸ Global risk assessment for CVD is mandatory in stable coronary

disease patient