ANGINA

dr. Hasanah Mumpuni, Sp.PD, Sp.JP (K)

KSM Jantung - Bagian Kardiologi dan Kedoktteran Vaskular
RSUP Dr. Sardjito/ FK UGM

Differential Diagnoses Chest Pain

Cardiovascular

Acute myocardial infarction, Acute coronary ischemia, Aortic

dissection, Cardiac tamponade, Unstable angina, Coronary spasm,
Prinzmetal's angina, Cocaine induced, Pericarditis, Myocarditis, Valvular
heart disease, Aortic stenosis, Mitral valve prolapse, Hypertrophic
cardiomyopathy

Pulmonary

Pulmonary embolus, Tension pneumothorax,

Pneumothorax, Mediastinitis,
Pneumonia, Pleuritis, Tumor, Pneumomediastinum

Gastrointestinal

Esophageal rupture (Boerhaave), Esophageal tear (MalloryWeiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal
reflux, Peptic ulcer, Biliary colic

Musculoskeletal

Muscle strain, Rib

fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest wall pain

Neurologic

Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic

neuralgia

Other

Psychologic, Hyperventilation

Chest pain

cardiac

Angina
/ischemic

Non cardiac

Non
Angina
GIT (Gerd, aesophagitis)

Angina
stabil /

Myocarditis

ACS

valvular

Pericarditis

Pulmonal, pleuritis

Neurologic
Psycogenic

Epidemiology
5% of all ED visits CP
Approximately 5 million visits per year

Life Threatening Causes of Chest Pain

Acute Coronary Syndromes

Pulmonary Embolus
Tension Pneumothorax
Aortic Dissection
Esophageal Rupture
Pericarditis with Tamponade

What are the key parts of the

History Patients in the CP
patient?

What can you get out of the pt in 4 minutes?

History
Location: Central, left, or right
Associated symptoms: SOB, sweating,
nausea
Timing: Gradual or sudden onset
Provocation: What makes worse or better?
Quality: Visceral vs somatic
Radiation: Back, neck, arm
Severity: Scale of 1-10

Objectives
Establish a differential diagnosis for chest pain
Know what clues to obtain on history to rule-in or
out MI, PE, pneumothorax and aortic dissection
Identify risk factors for MI
Know how to do a focused physical exam, identifying
features that would distinguish between MI, PE,
pneumothorax and aortic dissection.
Identify investigations required in diagnosing MI
Outline management strategy in MI

Kasus
Bapak Sumarno, usia 57 th mengeluh nyeri dada yang hilang
timbul. Nyeri dada dirasakan sejak 1 bulan terakhir. Lama
nyeri kira-kira 5 menit, timbul apabila beraktifitas sedang
seperti jalan cepat atau lari dan saat emosi. Nyeri dada dapat
berkurang dengan istirahat. Bapak Sumarno sudah periksa ke
dokter, dilakukan pemeriksaan elektrokardiografi dan darah.
Oleh dokter disarankan untuk dilakukan pemeriksaan exercise
stress test. Dia seorang penderita hipertensi tidak terkontrol
dan seorang perokok.
Sejak 3 jam terakhir nyeri dada dirasakan semakin memberat
seperti ditindih beban berat dan nyeri tidak hilang meskipun
sudah istirahat, disertai mual dan keringat dingin. Oleh
keluarga segera dibawa ke unit gawat darurat. Pada
pemeriksaan tekanan darah 150/90 mmHg.

 Bagaimanakah membedakan jenis nyeri dada secara

umum?
Apakah perbedaan tipe nyeri dada yang diderita
sebulan sebelumnya dan nyeri dada yg baru saja
terjadi?
Apakah pemeriksaan penunjang yang dipakai untuk
menegakkan diagnosis nyeri dada?
Apakah kemungkinan diagnosisnya?
Bagaimana managemen awal dan lanjut pasien
tersebut?
Bagaimana merujuk pasien tersebut?

Angina
The term angina is from the Latin angere
meaning to strangle.
first described by the English physician William
Heberden in 1768.
Angina pectoris refers to the predictable
occurrence of pain or pressure in the chest or
adjacent areas (jaw, shoulder, arm, back) caused
by myocardial ischemia
Mis - match in the oxygen demandsupply to
the myocardium consequently angina.

Cause Of Angina Pectoris

Ischemia due to obstruction:
- Atherosclerosis
- Coronary vasospasm
- Anomalous coronaries
Ischemia due to decreased Oxygen Supply:
- Anemia, Hypoxia, Hypotension
Ischemia due to Increased Oxygen Demand:
- Left ventricular hypertrophy, hypertension,
tachycardia

Peningkatan kebutuhan
oksigen miokard
Non Kardiak :
- Hipertermi
- Hiperthyroid
- Sympathomimetic toxicity
(penggunaan cocain)
- Hipertensi
- Anxietas
- Fistula arteriovenous
Kardiak
- Kardiomiopathi hipertropi
- Aorta stenosis
- Kardiomiopathi dilatasi
- Takikardia : ventrikular ,
supra ventrikular

Penurunan suplai /
pasokan oksigen
Non kardiak:
- Anemia
- Hipoksemia (pneumonia,
asma bronkhial, PPOK,
hipertensi pulmonal)
- Sympathomimetic toxicity
(penggunaan cocain)
- Hipervskositas
(trombositosis, leukimia,
polisitemia)
Kardiak :
- Stenosis aorta
- Kardiomiopathi hipertropi

 Angina that occurs when the coronary

arteries do not deliver an adequate amount of
oxygen-rich blood to the heart
Categorized as stable, unstable, and Variant
(Prinzmetals )

Stable Angina

Clinical findings of stable angina:

Substernal , high pressure/heavy feeling
Duration from 1 5 minutes
Instigated by physical exertion
Relieved with rest or nitrates

Unstable Angina

Clinical findings of Unstable Angina:

Occurs even at rest
unexpected
More severe and lasts longer than stable
angina, maybe as long as 30 minutes
May not disappear with rest or use of nitrates

Variant Angina
Transient coronary vasospasm that is
associated with a fixed atherosclerotic lesion
(75%)
Pt tends to be younger and in seemingly good
health
Occurs at rest and and associated with
ventrcular dysrhythmias
Nitrates and CCBs are often effective

Characteristics of typical angina

Criteria for classification of chest pain

Canadian Cardiovascular Society

functional classification of angina (CCS)

Menentukan Pre-Test Probability

Kemungkinan seseorang mengalami PJK
PTP rendah (<15%)
Cari kausa lain, pertimbangkan penyakit koroner
fungsional

PTP intermediet (15-85%)

Tes diagnostik non-invasif

PTP tinggi (>85%)

Stratifikasi resiko, mulai terapi, dan tawarkan angiografi
koroner

PTP (dalam %)

Three Principal Presentation

Unstable Angina
Rest Angina

Angina occurring at rest

and prolonged, usually > 20 mnt

New onset Angina

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

Myocardial ischemia or infarction

Pressure-type of chest pain
Generally involves central to left-sided pain with radiation to
jaw or arms
Exacerbated by activity, relieved with rest
Relieved with nitrogliserida
Associated with nausea, diaphoresis, syncope, shortness of
breath
Enquire about cardiac risk factors: age, sex, smoking history,
diabetes, hypertension, hyperlipidemia, previous myocardial
infarction and family history

Physical Examination
Trigerring factors

Vital sign Usually normal

JVP - Right ventricular infarction

Sign of heart failure or cardiogenic shock

Complication (Ventricle Septal Rupture,

Acute Mitral Regurgitation)

Killip klasiffication mortality risk

Electrocardiography
10 Minutes !!!

STEMI
1. ST Elevation with evolution
-

1 mVOLT in more than 2 LEAD II,III,aVF dan I - aVL

2 mV in V1-V6

2. New LBBB

NON STEMI
ST depression 1 mV
Simetrical T wave inversion > 2 mv

Acute Coronary Syndrome

Kasus
Bapak Sumarno, usia 57 th mengeluh nyeri dada yang hilang
timbul. Nyeri dada dirasakan sejak 1 bulan terakhir. Lama
nyeri kira-kira 5 menit, timbul apabila beraktifitas sedang
seperti jalan cepat atau lari dan saat emosi. Nyeri dada dapat
berkurang dengan istirahat. Bapak Sumarno sudah periksa ke
dokter, dilakukan pemeriksaan elektrokardiografi dan darah.
Oleh dokter disarankan untuk dilakukan pemeriksaan exercise
stress test. Dia seorang penderita hipertensi tidak terkontrol
dan seorang perokok.
Sejak 3 jam terakhir nyeri dada dirasakan semakin memberat
seperti ditindih beban berat dan nyeri tidak hilang meskipun
sudah istirahat, disertai mual dan keringat dingin. Oleh
keluarga segera dibawa ke unit gawat darurat. Pada
pemeriksaan tekanan darah 150/90 mmHg.

ECG pertama

ECG kedua