Early Diagnosis in ACS Patients

Early Diagnosis of ACS: what should GP Know ?
Acute Coronary Syndrome (ACS)
Acute Abrupt Onset
Coronary Arteries which supply blood for the heart muscle
Syndrome A set of medical signs and symptoms that are

correlated to a particular disease
4
Acute thrombosis induced by a ruptured or
eroded atherosclerotic coronary plaque, with or
without concomitant vasoconstriction, causing a
sudden and critical reduction in blood flow
5
Bentzon JF et al. Circ Res. 2014;114:1852-1866
atherosclerosis
6
7
8
9
10
Chest Pain - Angina
Abnormalities of ECG
Elevated Cardiac Marker
11
Chest Pain - Angina Pandie S et al. S Afr Med J 2016;106(3):239-245
Typical Atypical
S ite Retrosternal Epigastric, indigestion,
stabbing, pleuritic
O nset Sudden / Abrupt
C haracter Heaviness/Pressure type
R adiation Arm, Neck or Jaw
A ssociation Sweating, Nausea, dyspnea, syncope,abd pain
T ime > 20 minutes
E xacerbation/Relieving Factor Nitrates
12 S everity New / Progresssive (Class II / III CCS)
Chest Pain - Angina
13
Chest Pain - Angina

Chest Pain - Angina
Modifiable Non-modifiable
• High blood pressure • Age

• High blood • Sex
cholestherol
• Smoking • Family history
• Diabetes • Race
• Overweight / obesity
• Lack of physical
activity
• Unhealthy diet
• Stress
15
Chest Pain - Angina
16
Retrosternal Bahu
Nyeri jantung iskemik Nyeri jantung iskemik
Nyeri pericardium Perikarditis
Nyeri esofagus Abses subdiafragma
Diseksi Aorta Pleurisy diafragma
Lesi-lesi mediastinum Penyakit spina servikal
Emboli paru Nyeri otot skeletal akut
Sindroma Thoracic Outlet
Interscapular Lengan
Nyeri jantung iskemik Nyeri jantung iskemik
Nyeri otot skeletal Nyeri servikal/dorsal
Nyeri kantong empedu spine
Nyeri pankreas Sindroma Thoracic outlet
Dada depan kanan bawah Dada depan kiri bawah

Nyeri kantong empedu Nyeri saraf interkostae
Pembengkakan hati Emboli paru
Abses subdiafragma Daerah perut atas Miositis
Pneumonia/pleurisy Nyeri jantung iskemik Pneumonia/Pleurisy
Tukak lambung atau duodenum Nyeri perikardium Infark limpa
Emboli paru Nyeri esofagus Sindroma fleksura limpa
Akut miositis Nyeri lambung/duodenum Abses subdiafragma
Cedera lainnya Nyeri pankreas Sindroma Pericardial catch
Nyeri kantong empedu Cedera lainnya
Pembengkakan hati
Pleurisy diafragma
Pneumonia
Braunwald E : Clinical recognition of acute coronary syndromes. In Theroux P. Acute coronary syndrome: a companion
to Braunwald’s Heart Diseases, 2nd ed. Philadelphia, Elsevier Saunders, 2011, pp 99.
Chest Pain - Angina
Physical examination is important to identify:

• Sign of heart failure/ haemodynamic
instability and electricity instability ~
quick diagnosis and treatment
• Cardiac auscultation ~ systolic murmur due to
ischemic mitral regurgitation or aorta
stenosis
• Sign of non coronary cause of chest pain or
extra cardiac pathologies
18 Roffi M et al. European Heart Journal. 2016; 37: 267–315

10’
19
20
21
In the absence of LVH and LBBB
New ST elevation at the J point in 2 contiguous leads
with ≥0.2 mV in men (>40 years old) or ≥ 0.15 mV in
women in leads V2-V3 and/or ≥0.1 mV in other leads
22
23
24
Normal ECG in more than 1/3 of patients

Abnormalities
• ST Depression ST depression ≥ 0.05 mV in two
or more contiguous leads
• Transient ST Elevation Transient ST changes (≥0.5 mm
[0.05 mV]) during symptoms at
• T-Wave changes rest
symmetrical precordial T-wave
inversion (≥ 2 mm [0.2 mV])
25
26
28 Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938; Steg G et al. Eur Heart J.
2012;33:2569-619; Roffi M et al. European Heart Journal. 2016; 37: 267–315
A rapid rule-out and rule-in protocol at 0 h and 1 h is

recommended if a high-sensitivity cardiac troponin test
with a validated 0 h/1 h algorithm is available
Additional testing after 3–6 h is indicated if the ﬁrst two
troponin measurements are not conclusive and the clinical
condition is still suggestive of ACS
29
Roffi M et al. European Heart Journal. 2016; 37: 267–315
30
Roffi M et al. European Heart Journal. 2016; 37: 267–315
High likelihood Intermediate likelihood Low likelihood
Any of the following: Absence of high-likelihood features Absence of high- or intermediate-
Feature
and presence of any of the following likelihood features but may have
Chest or left arm pain or discomfort Chest or left arm pain or discomfort Probable ischemic symptoms in
as chief symptom reproducing as chief symptom absence of any of the intermediate
previously documented angina likelihood characteristics
History
Known history of CAD, including MI Age ≥70 y Recent cocaine use
Male sex
Diabetes mellitus
Transient MR murmur, hypotension, Extracardiac vascular disease Chest discomfort reproduced by
palpation
Examination diaphoresis, pulmonary edema, or
rales
New, or presumably new, transient Fixed Q waves T-wave flattening or inversion <1 mm
in leads with dominant R waves
ST-segment deviation (≥1 mm) or T- ST depression of 0.5-1.0 mm or Normal ECG tracing
ECG
wave
inversion in multiple precordial T-wave inversion >1.0 mm
leads
Elevated cardiac TnI, TnT, or CK-MB Normal Normal
Cardiac markers
levels
Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938 32

Laki2, 49 th
Nyeri dada ± 2 jam, RPD : HT
TD 200/160;HR 70 x/’, extrasistole +
Lab :
Hb 15,2
Leko 10.300
Tro 153.000
SK 1,5
OT/PT 24/20
Na 160
K 3,75
Cl 91,7
Trop I 0,6 (negatif < 0,5)

ACS ?
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Early Diagnosis in ACS Patients

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Early Diagnosis of ACS: what should GP Know ?

Acute Coronary Syndrome (ACS)

Acute Abrupt Onset

Coronary Arteries which supply blood for the heart muscle

Syndrome A set of medical signs and symptoms that are

Chest Pain - Angina

Elevated Cardiac Marker

Chest Pain - Angina

• High blood pressure • Age

Dada depan kanan bawah Dada depan kiri bawah

Physical examination is important to identify:

18 Roffi M et al. European Heart Journal. 2016; 37: 267–315

Normal ECG in more than 1/3 of patients

A rapid rule-out and rule-in protocol at 0 h and 1 h is

Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938 32

Trop I 0,6 (negatif < 0,5)

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