This document provides guidance on evaluating and managing patients presenting with chest pain that may indicate acute coronary syndrome (ACS). Key points include differentiating cardiac from non-cardiac chest pain, identifying characteristics of ACS pain, performing a focused physical exam, obtaining an ECG and cardiac enzymes to diagnose STEMI or NSTEMI, and initiating treatments such as oxygen, nitroglycerin, aspirin, and reperfusion therapies accordingly. Education on risk factor modification is also emphasized.
This document provides guidance on evaluating and managing patients presenting with chest pain that may indicate acute coronary syndrome (ACS). Key points include differentiating cardiac from non-cardiac chest pain, identifying characteristics of ACS pain, performing a focused physical exam, obtaining an ECG and cardiac enzymes to diagnose STEMI or NSTEMI, and initiating treatments such as oxygen, nitroglycerin, aspirin, and reperfusion therapies accordingly. Education on risk factor modification is also emphasized.
This document provides guidance on evaluating and managing patients presenting with chest pain that may indicate acute coronary syndrome (ACS). Key points include differentiating cardiac from non-cardiac chest pain, identifying characteristics of ACS pain, performing a focused physical exam, obtaining an ECG and cardiac enzymes to diagnose STEMI or NSTEMI, and initiating treatments such as oxygen, nitroglycerin, aspirin, and reperfusion therapies accordingly. Education on risk factor modification is also emphasized.
This document provides guidance on evaluating and managing patients presenting with chest pain that may indicate acute coronary syndrome (ACS). Key points include differentiating cardiac from non-cardiac chest pain, identifying characteristics of ACS pain, performing a focused physical exam, obtaining an ECG and cardiac enzymes to diagnose STEMI or NSTEMI, and initiating treatments such as oxygen, nitroglycerin, aspirin, and reperfusion therapies accordingly. Education on risk factor modification is also emphasized.
*Note: Patients come with main sign and symptom of Chest pain, therefore must differentiate cardiac or non-cardiac chest pain* ALL CONCEPT MUST BE AT FINGER TIPS
RPS 1. Onset: Acute 2. Location: ACS- dada kiri, substernal, sakit diffuse ke dinding dada (use palm, cannot pinpoint) 3. Characteristic (descripsikan sakit): • Kayak dicengkam, tercekik, diremas, tertindih (overlap), tusuk terbakar, nyeri ulu hati; Deep visceral, heavy, squeezing, crushing, stabbing, burning (STEMI pain) • Nyeri bertahap (crescendo), henti bertahap (decrescendo) 4. Referred Pain: menjalar ke leher, rahang, dan tangan kiri (DD: GERD- tidak menyalar ke tangan.) 5. Duration (onset of pain): Pain < 20 minute = unstable angina pectoris Pain > 20 minute = infarct 6. Accompanying sign and symptom: Sweating, cold, cold sweat, nausea, vomiting (sympathetic activation), cold extremities, weakness 7. Aggravating factor: Vigorous physical activities, emotional stress 8. Relieving factor: Rest, then no pain = stable angina (not ACS) Rest, then still pain = unstable angine pectoris 9. Risk factor: Age, DM, Hypertension, Obesity, dyslipidemia, smoking 10. Other sign and symptom: Unexplained indigestion, belching, epigastric pain RPD: Belum pernah nyeri seperti ini ACS pain is more severe, longer lasting, radiate more widely RPK: Orang tua mempunyai riwayat penyakit jantung. STEMI NSTEMI UAP Total occlusion Partial occlusion Partial occlusion Necrosis Necrosis No necrosis deep and visceral, heavy, Symptom like STEMI but new onset of severe pain squeezy, crushing, stabing, less between 4-6 weeks. burning Frequency of pain increase after 10 weeks. begin during exertion but Symptom like STEMI but does not subside with less cessation Pain sustained > 20 Pain sustained > 20 Angina at rest < 20 minutes. minutes. minutes. PE 1. do ABC if patient in an emergency situation. 2. General Observation: Patient cemas, gelisah, berkeringat, cool, clammy, pale 3. Vital Sign: o Tarchycardia, pulse increase o Tarchypnea or dypnea o Hypertension o Mild fever 4. Patognomonis Test: Jugular Vein Distension [due to acute Heart Failure] normal is usually <3cm. Sit 45 degree, turn head to opposite side.
5. Heart Exam: Inspection
Palpation Percussion Auscultation- murmur and Gallops 6. Lung exam: Auscultation- rales > 50% OF ACS CASE PHYSICAL EXAMINATION IS NORMAL. Unless Large area myocardiac Infarct- has sinus tarchycardia, S3, S4, rales Treatment 1. INITIAL TREATMENT (both STEMI and NSTEMI) *before ECG and cardiac enzyme result* Morphine- IV 2-4mg with increment of IV 2-8mg every 5-15 minutes Oxygen- 4L/ min during 1st 6 hours (maintain SaO2 > 90%) Nitroglycerin-Sublingual 0.4mg every 5 minutes, up to 3 doses * Contraindication: Hypotension especially Right Ventricular infarct 24 hours ago had Phosphodiesterase Bradycardia (<50bpm) Tarchycardia (>100bpm)
Aspirin- Chew 162- 325mg
R/ Tab. Aspirin 80mg no XXVIII S.p.r.n. 1.d.d Tab IV (dikunyah, saat serangan) Clopidogrel initial EMERGENCY dose 300mg Maintainance dose 75mg THREE WAY TO DIAGNOSE: CHEST PAIN ECG CARDIAC ENZYME (2 OUT OF 3 SHOWS S&S= ACS)
Supporting Exam Within 10 Minutes
1. ECG (differentiate STEMI and NSTEMI) STEMI 1. ST elevation with evolution, >0.1 mV in more than 2 Lead (I, II, III, aVF, aVL) >0.2 mV in V1-V6 2. New LBBB NSTEMI/UAP ST depression >0.1 Simetrical T wave inversion >0.2 2. Cardiac Enzyme- Myoglobin (1-4 hours) <110ng/ml CKMB ( 3-8 hours appear, 48-72 hours disappear) 10-13u/L Troponin ( 3-4 hours appear, 10-14 days disappear) T <0.1ng/ml; I <1.5ng/ml 3. ECG with stress test Management After Ecg Result 1. STEMI- remove occlusion (< 12 hours) golden hour Reperfusion- Door To Needle <30 minute= fibrinolytic eg streptokinase, tPA Door To Ballon < 90 minute= Percutaneous Coronary Intervention (PCI) (< 3 hours better to use fibrinolytic then PCI; after 3 hours, both fibrinolytic and PCI SAME efficacy) (> 12 hours)- antithrombin -- Aspirin 2. NSTEMI / UAP – cegah dari tambah berat LMWH Subcutaneous 1mg q12 UFH IV (60-70U/kg, followed by 12-15U/kg/hr) *aPTT-1.5-2.5 times control*
Education 1. Smoking cesation 2. BP control- lifestyle modification or B blocker / RAA inhibitor 3. Physical activity-30 minutes 3-4 days per week 4. Lipid management- Statin 5. Weight control 6. Diabetis 7. Everyday Aspirin
