Ronald Chrisbianto Gani

405090223
Faculty of Medicine
Tarumanagara University
EMERGENCY MEDICINE BLOCK
ISCHEMIC HEART
DISEASE
APPROACH TO PATIENT WITH
CHEST PAIN
APPROACH TO PATIENT WITH
CHEST PAIN
Rosens Emergency Medicine 7th Ed
INITIAL ASSESSMENT
Rosens Emergency Medicine 7th Ed
ACS CHEST PAIN
GUIDELINE
Rosens Emergency Medicine 7th Ed
Rosens Emergency Medicine 7th Ed
NON-ACS CHEST PAIN GUIDELINE
Rosens Emergency Medicine 7th Ed
ISCHEMIC HEART DISEASES
ISCHEMIC HEART DISEASE
Ischemic Heart
Disease
Coronary Artery
Disease
Acute Coronary
Syndromes
UA & NSTEMI
STEMI
Harrisons Principle of Internal Medicine 18th Ed
ISCHEMIC HEART DISEASE
Main symptom : Angina Pectoris
Stable : chest/arm discomfort reprudicibly
associated with physical exertion or stress and is
relieved within 5-10mins by rest or sublingual
nutroglycerin
Unstable : at least have one of three features
Occurs at rest, lasting >10mins
Severe and new onset
Crescendo pattern
Harrisons Principle of Internal Medicine 18th Ed
ISCHEMIC HEART DISEASE
Rosens Emergency Medicine 7th Ed
ACUTE CORONARY SYNDROMES
Harrisons Principle of Internal Medicine 18th Ed
UNSTABLE ANGINA & NON-ST-
ELEVATION MYOCARDIAL INFARCTION
PATHPHYSIOLOGY
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CLINICAL PRESENTATION
History & Physical Examination
Chest pain in substernal or epigastrium region
radiates to neck, left arm, left shoulder
Large infarction diaphoresis, pale cool skin,
sinus tachycardia, 3rd and 4th heart sound, basilar
rales, LVD hypotension
ECG
ST : depression or transient elevation
T waves inversion


Harrisons Principle of Internal Medicine 18th Ed
CLINICAL PRESENTATION
Cardiac Biomarkers
CKMB and Troponin, if elevated NSTEMI, if not
elevated UA

Harrisons Principle of Internal Medicine 18th Ed
DIAGNOSTIC EVALUATION AND RISK
STRATIFICATION
Harrisons Principle of Internal Medicine 18th Ed
CLINICAL CLASSIFICATION
DIFFERENTIAL DIAGNOSIS
Rosens Emergency Medicine 7th Ed
MANAGEMENT
Combination of Bed Rest, Nitrates, Beta
Blocker, + Continuous ECG Monitoring
Antithrombotic Therapy (Table)
Long term therapy consist of
Beta Blockers + Statin + ACEi + Aspirin +
Clopidogrel for 12 months
Aspirin continued to prevent thrombosis
Harrisons Principle of Internal Medicine 18th Ed
MANAGEMENT
Drugs
Nitrates
Sublingual or IV
Avoid in hypotension, patients with sildenafil

Beta Blockers
Used in unstable angina
Avoid when : PR interval >0,24s, AV block, HR<60x, BP
<90mmHg, Shock, LV Failure, Airway disease

Harrisons Principle of Internal Medicine 18th Ed
MANAGEMENT
CCB
If both above drugs cannot relieve symptoms
Avoid in Pulmonary Edema and LV dysfunction
Morphine
Analgesics, if pain persist after 3 nitroglycerin
Avoid in hypotension, Respiratory distress, confusion,
obtudantion.
Antithrombotic Agents (Next slide)

Harrisons Principle of Internal Medicine 18th Ed
MANAGEMENT
Harrisons Principle of Internal Medicine 18th Ed
PRINZMETAL ANGINA
A syndrome of ischemic pain that occurs at
rest but not usually with exertion and
associated with transient ST elevation
Caused by focal spasm of coronal artery
severe myocardial infacrtion
Managed by Nitrates and CCB. Avoid aspirin.
Harrisons Principle of Internal Medicine 18th Ed
ST-ELEVATION MYOCARDIAL
INFARCTION
PATHOPHYSIOLOGY
Thrombotic occlusion of Coronary artery with
atherosclerosis Coronary blood flow
Coronary artery thrombus develop rapidly at
vascular injury site
Affected by : Smoking, HT, Lipid accumulation
Atherosclerotic plaque disrupted
thrombogenesis (collagen, ADP, epinefrin,
serotonin) + Thromboxane A2 platelet
active
Harrisons Principle of Internal Medicine 18th Ed
PATHPHYSIOLOGY
Myocardial damage depends on
Territory supplied by affected vessel
Whether or not the vessel become total occluded
Duration of occlusion
Quantity of blood supplied by collateral vessels
Demand of oxygen
Native factors that can produce spontaneous lysis
Adequacy of reperfusion after flow restored
Harrisons Principle of Internal Medicine 18th Ed
CLINICAL PRESENTATION
Precipitating factor
Physical exercise, emotional stress,
medical/surgical illness
Symptoms does not subsides after rest / nitrates
General Appearance
Anxious, distress, chest pain radiates to left arm
and neck and jaw, Levine Sign, weakness,
sweating, nausea, vomiting
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CLINICAL PRESENTATION
Heart Rate
May vary from bradycardia or tachycardia
When in pain tachycardia
Blood Pressure
Uncomplicated normotensive
Systolic Diastolic
When in pain hypertension
LV dysfunction hypotension
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CLINICAL PRESENTATION
Temperature & Respiration
Fever (38
o
C - 39
o
C) in 24-48h, subsides in 4-5days
RR elevated when STEMI occurs
Carotid pulse
Small pulse Reduced Stroke Volume
Sharp Brief mitral regurgitation, ventricular
septum rupture
Pulsus alternans LV dysfunction

Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CLINICAL PRESENTATION
Cardiac Examination
intensity of 1st heart sound
3rd or 4th heart sound may be audible
Murmur or friction rubs

Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CLINICAL PRESENTATION
Laboratory Findings
ECG ST evelation, Evolve Q waves
Cardiac Biomarkers (Table on next slide)
PMN Leukocytosis (12000-15000)
ESR N in 1st and 2nd day, elevated in 4th day
Imaging
Echocardiography : abnormal wall motion
Radionuclide Imaging Techniques
High Resolution MRI + contrast

Harrisons Principle of Internal Medicine 18th Ed
CLINICAL PRESENTATION
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
CARDIAC BIOMARKERS
Rosens Emergency Medicine 7th Ed
Braunwalds Hearts Disease : Textbook of
Cardiovascular Medicine 9th Ed
MANAGEMENT
Initial Management
Prehospital care
Management in Emergency Department
Control of Discomfort
Management strategies
Limitation of Infarc size
Reperfusion (PCI or Fibrinolytic)
Hospital Care Management
Pharmacotherapy
Harrisons Principle of Internal Medicine 18th Ed
PREHOSPITAL CARE
Major elements
Recognition of symptoms
Rapid deployment of EMS
Expeditious transportation
Expeditious implementation of reperfusion

Harrisons Principle of Internal Medicine 18th Ed
MAJOR COMPONENTS OF TIME DELAY
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
STEMI
ALGORYTHM
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
MANAGEMENT IN EMERGENCY
DEPARTMENT
Face mask oxygen
Aspirin 160-235mg chewed
To relief discomfort
Sublingual nitroglycerin : 3x0,4mg /5mins, avoided
when BP <90mmHg
Morphine : analgesic, may cause constriction, AV
block atropine
IV beta blocker metoprolol 3x5mg/2-5mins
Harrisons Principle of Internal Medicine 18th Ed
MANAGEMENT STRATEGY
Braunwalds Hearts Disease : Textbook of Cardiovascular Medicine 9th Ed
LIMITATION OF INFARC SIZE
Rosens Emergency Medicine 7th Ed
REPERFUSION THERAPY
Primary Percutaneous Coronary Intervention
Angioplasty or stenting
More effective than fibrinolysis
Better short and long term outcomes
Preffered when diagnosis in doubt, cardiogenic
shock, bleeding risk, symptoms have been present
for 2-3h
Very expensive
Harrisons Principle of Internal Medicine 18th Ed
REPERFUSION THERAPY
Fibrinolysis
Agents : tPA, streptokinase, TNK, rPA
Initiated within 30mins
Benefits seen if administered in 1-6hrs
More preffered if symptoms still in 1st hour
tPA 15mg bolus 50mg IV / 30mins 35mg IV /
60 mins
Contraindication (next slide)
Harrisons Principle of Internal Medicine 18th Ed
CONTRAINDICATIONS OF FIBRINOLYSIS
CLEAR / ABSOLUTE
History of Cerebrovascular
hemorrhage
Marked Hypertension
Suspicion of aortic disection
Active internal bleeding
RELATIVE
Current use of
antucoagulants
Recent invasive surgical
procedure
Prolonged cardiopulmonary
ressucitation
Known bleeding diathesis,
pregnancy, DM,
hemmorhagic ophtalmic
History of severe HT
Harrisons Principle of Internal Medicine 18th Ed
PHARMACOTHERAPY
Antithrombotic Agents
Aspirin + Clopidogrel
G IIB/IIIA receptor inhibitor
UFH / LMWH, warfarin
Beta Blockers
Acute IV Beta blockers
Long term therapy
Harrisons Principle of Internal Medicine 18th Ed
PHARMACOTHERAPY
ACEi
Reduce ventricular dysfunction
Reduce risk of CHF
Reduce risk of reocclusion
ARB for intolerance patients
Others
Strict control of blood glucose, serum magnesium,
etc
Harrisons Principle of Internal Medicine 18th Ed
REFERENCES
Longo D, Fauci AS, Kasper D, Hauser S, Jameson
JL, Loscalzo J, editors. Harrisons Principle of
Internal Medicine. 18th Ed. New York : McGraw-
Hill, 2011
Bonnow RO, Mann DL, Zipes DP, Libby P.
Braunwalds Heart Disease 9th Ed. Philadelpia :
Elsevier Saunders, 2012
Marx JA, Hockberger RS, Walls RM, Adams JG,
editors. Rosens Emergency Medicine Concepts
and Clinical Practice. 7th Ed. Philadelpia : Mosby
Elsevier, 2010