ACS OSCE

*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