6. Endorsed by the American Society of Echocardiography, American College of
Chest Physicians, Society for Academic Emergency Medicine, Society of
Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic
Resonance
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR
Guideline for the Evaluation and Diagnosis of Chest
Pain
7. Figure 1. Take-Home Messages for the
Evaluation and Diagnosis of Chest Pain
7
8. Figure 2. Index of Suspicion That Chest “Pain” Is
Ischemic in Origin on the Basis of Commonly Used
Descriptors.
8
9. Table 3. Chest Pain Characteristics and
Corresponding Causes
9
Nature
Anginal symptoms are perceived as retrosternal chest discomfort (e.g., pain, discomfort, heaviness, tightness, pressure, constriction, squeezing) (Section 1.4.2, Defining
Chest Pain).
Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (e.g., these symptoms usually occur with acute pericarditis).
Onset and duration
Anginal symptoms gradually build in intensity over a few minutes.
Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome.
Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease.
Location and radiation
Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.
10. Anamnesis:
• Onset nyeri (penting untuk STEMI apakah <12 jam)
• Provocation : aktivitas apa yang mencetuskan nyeri dada
• Quality / Deskripsi nyeri: berat di dada, atau tidak khas seperti sesak
• Radiation / Penjalaran nyeri: ke lengan kiri, bahu, punggung,
epigastrium, leher rasa tercekik atau rahang bawah
• Severity : derajat nyeri dada saat ini (skala 1-10)
• Timing / Lama nyeri: lebih dari 20 menit. Pada STEMI tidak hilang
dengan istirahat atau nitrat SL
• Gejala sistemik : mual, muntah, keringat dingin, berdebar
• Faktor risiko PJK : merokok, hipertensi, DM, dislipidemia, riw.keluarga
dengan PJK prematur
Diagnosis Sindroma Koroner Akut
11. Considerations for Older Patients
With Chest Pain
11
Recommendation for Considerations for Older Patients With Chest Pain
COR LOE Recommendation
1 C-LD
1. In patients with chest pain who are >75 years of age, ACS should be
considered when accompanying symptoms such as shortness of breath,
syncope, or acute delirium are present, or when an unexplained fall has
occurred.
12. PEMERIKSAAN FISIK:
• Fisik secara umum normal
• Bila ada komplikasi dapat ditemukan
takipneu, taki/bradikardi, gallop S4, murmur
sistolik (regurgitasi mitral akut/ rupture IVS),
ronkhi basah halus paru, akral dingin
Diagnosis Sindroma Koroner Akut
15. Morris F, Brady WJ. BMJ 2012;324;831-834 15
5- 30 min setelah onset
1-2 jam
2-6 jam setelah
• Resolusi segmen - - anterior hingga 2 minggu;
posterior > 2 minggu
• Gel T resolusi : berbulan-bulan
Evolusi EKG pada STEMI
17. 17
Patients With Acute Chest Pain and Suspected
ACS (Not Including STEMI) (cont..)
1 C-LD
3. To standardize the detection and differentiation of myocardial injury in
patients presenting with acute chest pain and suspected ACS, institutions
should implement a CDP that includes a protocol for troponin sampling based
on their particular assay.
1 C-LD
4. In patients with acute chest pain and suspected ACS, previous testing when
available should be considered and incorporated into CDPs.
2a B-NR
5. For patients with acute chest pain, a normal ECG, and symptoms suggestive
of ACS that began at least 3 hours before ED arrival, a single hs-cTn
concentration that is below the limit of detection on initial measurement (time
zero) is reasonable to exclude myocardial injury.
19. • Seorang laki-laki 61th datang ke UGD dengan keluhan nyeri
dada di bagian tengah seperti ditindih benda berat
• Kesadaran pasien baik TD 80/50, nadi 45x/m,
pernapasan 20x/m, SaO2 96%
• Nyeri dada muncul sekitar 5 jam yll.
• terasa menjalar ke lengan kiri.
• skala nyeri 4/10
• disertai keringat dingin dan pandangan melayang
• Riwayat merokok 1 bungkus sehari, hipertensi, kolesterol
tinggi
• pemeriksaan fisik dalam batas normal
Ilustrasi kasus
26. • Seorang laki-laki 65th datang ke UGD dengan keluhan
nyeri dada kiri disertai rasa sesak
• Kesadaran CM ; TD 140/50, nadi 45x/m,
pernapasan 20x/m, SaO2 96%
• Nyeri dada muncul sekitar 1 jam yll.
• terasa menjalar ke lengan kiri.
• skala nyeri 6/10
• disertai keringat dingin Riwayat stroke NH 2 thn yll
• pemeriksaan fisik dalam batas normal
Ilustrasi kasus
35. 35
Table 7. Warranty Period for Prior Cardiac Testing
Test Modality Result Warranty Period
Anatomic Normal coronary angiogram
CCTA with no stenosis or plaque
2 y
Stress testing Normal stress test (given adequate
stress)
1 y
CCTA indicates coronary computed tomographic angiography.
36. 36
Figure 5. Chest Pain and Cardiac Testing
Considerations.
The choice of imaging depends on the clinical question of importance, to either a) ascertain the diagnosis of CAD and define coronary anatomy or b) assess ischemia severity among patients with an expected higher
likelihood of ischemia with an abnormal resting ECG or those incapable of performing maximal exercise.
ACS indicates acute coronary syndrome; CAC, coronary artery calcium; CAD, coronary artery disease; and ECG, electrocardiogram.
Please refer to Section 4.1.
For risk assessment in acute chest pain: See Figure 9.
For risk assessment in stable chest pain: See Figure 11.
