STEMI INFEROPOSTERIOR ET RIGHT VENTRICULAR ONSET 2 HOURS KILLIP I

Presented by:Henry Liemer Wijaya

Supervisor :dr. Khalid Saleh, Sp.PD-KKV, FINASIM

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar2013

PATIENT IDENTITY

Medical Record : 622664 Name : Mr. R Gender : Male Age : 31 years old Address : Maros Date of admission : 13 August 2013

HISTORY TAKING Chief complaint:

Chest Pain

History of Present Illness:

The chest pain began since 2 hours ago before he was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was resting at home. The pain is described like dull heavy feeling on the left chest, radiated to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and tightness sensation. The patient felt nausea and not vomiting. The chest pain felt continuously more than 20 minutes duration, and not relieved by rest.

The patient felt breathlessness while having chest pain, and it was accompanied by palpitation and cold sweat. He never wakes up from her sleep in the night because of breathlessness. He could sleep with 1 pillow only. There was no cought and fever. No history of epigastric pain. Urination and defecation were normal.

HISTORY TAKING History of Past Illness:

History of chest pain before (-)

History of smoking ( + ) 2 packs/day

History of hypertension : denied

History of drinking alcohol (-)

No history of heart disease

No family history of heart disease

History of diabetes mellitus : denied

No history of dyslipidemia

No history of asthma

No history of epigastric pain

RISK FACTOR

Gender: Male

NonModifiable

Smoking (+)Obesity (+)

Modifiable

PHYSICAL EXAMINATION

General StatusModerate illness/obesity 1/composmentis

Vital Signs BP : 130/80 mmHg HR : 70 bpm, regular RR : 22 tpm T : 36.7˚C BW : 82 kg H :170 cm BMI : 28,3 kg/m2

PHYSICAL EXAMINATION Head Examination

Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-) Neck : Lymphadenopathy (-), JVP R+1 cmH2O

Thorax Examination Insp. : Symmetrical R=L, normochest Palp. : Mass (-), tenderness (-), VF R=L Perc. : Sonor Ausc. : Vesicular

Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION

Cardiac Examination Insp. : IC wasn’t visible Palp. : IC wasn’t palpable Perc. : Dull, normal heart size

Right border : Right parasternalis line Left border : Left medioclavicularis

line Ausc. : Pure regular of I/II heart sound, murmur

(-)

PHYSICAL EXAMINATION

Abdominal Examination Insp. : Flat and following breath movement Ausc. : Peristaltic sound (+), normal Palp. : Liver and spleen is unpalpable Perc. : Tympani (+), ascites (-)

Extremities Oedema : Pretibial -/-, Dorsum pedis -/-

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY Interpretation:

Rhythm : Sinus QRS-Rate : HR 75 bpm, reguler P-Wave : 0.08 sec PR-Interval : 0.16 sec QRS Complex : 0.08 sec Axis : 120˚ ST-Segment : ST-elevation

on lead II, III, aVF, V3R, V4R, V5R, V6R, V8, and V9.

T-Wave : Normal

Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardial infarction.

CHEST X-RAY

14 Augusts 2013

Normal pulmonary

CTI: Normal

Result: Normal Pulmo

LABORATORY EXAMINATION

WBC : 23,7 x 103/mm HB : 16,4 gr/dl PLT : 312.000 HCT : 49,7 % GDS : 123 mg/dl Ureum : 15 mg/dl Creatinin : 0,8 mg/d PT : 21,7 (0,8) APTT : 52,4 (26,6)

CK : 281 U/L CKMB : 22 U/L Trop. T : 0,02 Na : 141 mmol/l K : 4,2 mmol/l Cl : 107 mmol/l SGOT : 31 U/L SGPT : 34 U/L Albumin : 4,0 gr/dl

DIAGNOSIS

- STEMI Inferioposterior + Right Ventricular onset 2 hours KILLIP I

INITIAL MANAGEMENT Bed rest

O2 2-4 LPM (via nasal canule)

IVFD NaCl 0,9% loading 500 cc/24 hours

Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-

0-0 Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg)

maintenance 0-1-0

ACEI

Captopril 3 x 6,25 mg

Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)

Trombolitik

— Streptokinase (Streptase 1,5 million units were dissolved in 100 ml of Dextrose 5% in drips for 1 hour)

Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg)

Laxative Laxadin syrup 1 x 2 cth

ELECTROCARDIOGRAPHY Post Trombolitik 1 hour

PLANNING

Echocardiography Coronary angiography

ACUTE CORONARY SYNDROME

DIAGNOSIS OF CHEST PAIN

3 point typical chest painTend to be Stable Angina Pectoris than Acute Coronary

Syndrome

2 point atypical chest painTend to be Acute Coronary Syndrome than Non

Cardiac Chest Pain

1 point or none non cardiac chest pain

Retrosternal or substernal chest pain

1 poin

tIncreased by activity or emotion

1 poin

tRelieved by resting or nitrate SL

1 poin

t

DEFINITION

Acute Coronary Syndrome (ACS) is a term

for situations where the blood supplied to the

heart muscle is suddenly blocked.

describe a group of conditions resulting

from acute myocardial ischemia

(insufficient blood flow to heart muscle)

ranging from unstable angina

(increasing,

unpredictable chest pain) to

myocardial

infarction (heart attack).

CLASSIFICATION

ANATOMY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectoris Thrombosis

Thrombus

Acute coronary syndrome:• Unstable angina• Myocardial infarction :

- Non Q waves- Q waves

PATHOGENESIS

RISK FACTOR

Gender and Age

Men, increased risk after age 45

Women, increased risk after age

55

Family History

Heart disease diagnosed before

age 55 in father or brother

Heart disease diagnosed before

age 65 in mother or sister

Non- Modifiable Modifiable

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

Lack of physical activity

At least 2 of the following:

DIAGNOSIS OF ACS

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

• Prolonged pain (usually >20

minutes) – constricting,

crushing, squeezing

• Usually retrosternal location,

radiating to left chest, left arm;

can be epigastric

• Dyspnea

• Diaphoresis

• Palpitations

• Nausea/vomiting

1. ISCHEMIC SYMPTOMS

2. DIAGNOSTIC ECG CHANGES

ECG CHANGES Timing of myocardial infarction based on ECG

3. SERUM CARDIAC MARKER ELEVATIONS

Troponin T CK-MB

CK Myoglobin

CARDIAC BIOMARKER

No

Yes

YesNo

STEMIAcute Myocardial

Infarction( Q-wave, non-Q wave )

NSTEMI(No ST-Segment Elevation

Myocardial Infarction)

Unstable Angina

Signs of myocardial ischemia

ST segmen elevation ?

Biochemical cardiac markers ?

DIAGNOSIS

ECG

Lab

INITIAL TREATMENT

1. Bed Rest

2. Diet

3. Oxygen (2-4L/mnt)

4. Anti platelet therapy : • Aspirin 160-325 mg chewed immediately and 81-162

mg continued indefinitely.• Clopidogrel 300-600 mg loading dose and 75 mg daily

continued for at least 14 days and up to 12 months

5. Nitroglycerin ISDN 10 mg or 20 mg, 2-3 a day. ISDN 5 mg SL when chest pain.

INITIAL TREATMENT

6. Morphine 2,5-5 mg or pethidin 12,5-25 mg iv

7. ACE I (Captopril 12,5-25 mg )

8. Fibrinolytic therapy:

a) Streptokinase 1.5million units iv

b) Tenecteplase 0.5mg/kg body weight iv.

9. Anticoagulation therapy:

a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI.

10.Statins

Simvastatin 20 mg

THROMBOLYTIC AGENT INDICATIONS

Age < 70 yo Typical chest pain, > 20 minutes,

not relieved by nitrat ST elevation > 0,1 mV, on 2 lead or

more Onset < 12 hours

THROMBOLYTIC AGENT CONTRAINDICATIONS

Absolute:• Previous intracranial

haemorrhage or stroke of unknown origin at any time

• Central nervous system damage or neoplasms

• Recent major trauma/surgery/head injury (within the preceding 3 weeks)

• Gastrointestinal bleeding within the past month

• Known bleeding disorder (excluding menses)

• Aortic dissection

Relative: Transient ischaemic attack in

the preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 week

postpartum Refractory hypertension

(systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg)

Advanced liver disease Infective endocarditis Prolonged or traumatic

resuscitation

PROGNOSISKILLIP CLASSIFICATION

Class

DescriptionMortality Rate (%)

INo clinical signs of heart failure

6

IIRales or crackles in the lungs, an S3, and elevated jugular venous pressure

17

III Acute pulmonary edema 30 - 40

IV

Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

60 – 80

PROGNOSIS – TIMI SCORE

Historical

   Age 65-74        >/= 75

2 points3 points

   DM/HTN or Angina 1 point

Exam

   SBP < 100 3 points

   HR > 100 2 points

   Killip II-IV 2 points

   Weight > 67 kg 1 point

Presentation

   Anterior STE or LBBB 1 point

   Time to treatment > 4 hrs 1 point

 Risk Score = Total (0-14)

Total Score

Risk of Death in 30 days

0 0.8%

1 1.6%

2 2.2%

3 4.4%

4 7.3%

5 12.4%

6 16.1%

7 23.4%

8 26.8%

9-14 35.9%

RIGHT VENTRICEL INFARCTION• RVI is common complication of Inferior Myocard

Infarct.• CORE study 2001 explained that RVI has many

complication, such as shock, tachycardia or fibrilation ventricel and atrioventricular block.

• Inferior Myocardial Infarction + RVI has mortality rate until 25%-30%, and without RVI the rate is 6% only.

• Guidelines ACC/AHA for STEMI 2004 tells that we have to be careful by giving nitrat, because it can decreases preload and can cause moderate hypotension.

• RVI therapy: inhalation nitric oxide, work as pulmonary vasodilator, can recover hemodynamic condition for Shock RVI patient.

MANAGEMENT

Maintaining preload right ventricel by using fluid

Avoid nitrat, diuretik, or morfin. Hypotension & bradycardi atropin

& fluid (50 cc/10 min) Nitric oxide inhalation

THANK YOU