ST SEGMENT ELEVATIONMYOCARDIAL INFARCTION (STEMI)

PRESENTED BY : NUR RAISAH ULFAH- C 111 09382

SUPERVISED BY :Prof. dr. Peter Kabo, PhD, Sp. FK, Sp. JP (K), FIHA, FASCC

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar2014

PATIENT IDENTITY

• ID Number : 651739• Name : MR TP• Age : 68 years old• Gender : Male• Date of Admission : November 14th 2014

HISTORY TAKINGChief complaint : Chest pain

History of present illness Occurred 3 weeks ago before entering the hospital and was advancing in last

couple of days so that patient have been referred to the RSWS from toraja’s hospital cause there was no significant improvement of symptoms.

At the beginning, Chest pain is suddenly felt in a substernal area, pain is like crushed with heavy load. The pain wasn’t radiated. Duration of pain continuously more than 20 minutes with a cold sweating, and not relieved by rest then increased by activity.

There are shortness of breath, nausea and vomiting, and so complain about a heart burn. Patient didint have a fever and no previous history of fever.

Defecation and urination : normal

# Past Ilness historyNo History of HypertensionNo History of DMNo History of high blood cholesterolNo History of previous heart diseaseNo History of epigastric painNo History of asthma# Family historyNo family history of heart disease# Personal history:History of smoking one pack each day for more 30 years.History of drinking alcohol, once in a week.

HISTORY OF DISEASE

Modifiable

- Drink alcohol

- Smoker

Non Modifiable

- Gender : male (+)- Age : 68th years old (+)

RISK FACTOR

PHYSICAL EXAMINATION

General status• Moderate illness/well

nourished/compos mentis

Vital sign• BP: 120 / 90 mmHg• HR: 72 x/min• RR: 28 x/min• T : 36.80 C

REGIONAL STATUS Head Examination

Eyes : anemia (-), icterus (-) Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R+3 cmH2O

Thoracal Examination Inspection : symetric, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : breath sound : bronchovesicular,

there are minimally ronchi in a basal lung, wheezing -/-

Heart Examination Inspection : IC wasn’t visible Palpation : IC wasn’t

palpable Percussion : normal heart

size Upper border: left 2nd ICS Lower border : left 5th ICS Right border : right

parasternalis line Left border : left axillaris

anterior line Auscultation : Regular of I/II

heart sound, murmur (-)

Abdominal Examination Inspection : flat and

following breath movement Auscultation : peristaltic

sound (+) , normal Palpation : liver and

spleen unpalpable Percussion : tympani,

ascites (-)

Extremities Oedema : pretibial (-),

dorsum pedis (-)

REGIONAL STATUS

ELECTROCARDIOGRAPHY (ECG)

INTERPRETATION Rhythm : Sinus Rhythm Heart rate : 84 bpm Regularity : regularly Axis : Normoaxis, 30o

P wave : 0.08 sec PR interval : 0.16 sec QRS complex: duration 0.08 sec,

configuration q patologis at I, aVL ST Segment: ST elevation at V2, V3, V4, V5

ST depresi at II, III, aVF T wave : Normal Conclusion : Sinus Rhythm, NormoAxis, Infark whole anterior wall,

Ischemic inferior, Old miocard infark high lateral.

LABORATORY EXAMINATIONCo

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WBC : 10,3 x 103 HGB : 12,5 g/dlHCT : 36.8 %RBC : 4.04 x 106 /mm3

PLT : 437 x 103 /mm3

Cardiac enzyme • CK : 84 u/L• CK MB : 6,7 u/L • Troponin T : 0,17u/LElectrolyteSodium :142 mmol/lPotassium : 3,6 mmol/lChloride : 111 mmol/l

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GDS : 105 mg/dlSGOT : 30 u/lSGPT : 56 u/lUreum : 18Creatinin : 1,0PT : 10,9APTT : 26,7Total Cholesterol :209mg/dlHDL : 31 mg/dlLDL : 143 mg/dl Triglyseride : 162 mg/dl

Planning

• EKG everyday• Echocardiography• Ro Thorax• Coronary Angiography

WORKING DIAGNOSISRecent STEMI Anterior, KILLIP II

MANAGEMENT• O2 2 LPM (via nasal canule)• Cardiac Diet• IVFD NaCl 0,9% loading 500 cc/24 hours• Anti Koagulan

– Fondaparinux (Arixtra) 2,5 mg every 24 hours subcutan.• Isosorbid Dinitrat

– Farsorbid 10 mg every 8 hours– Farsorbid 5 mg sublingual (pain attack)

Anti Platelet Aggregation– Loading Aspilet 160 mg, maintenance 80 mg every 24 hours– Loading Clopidogrel 300mg, maintenance 75 mg every 24 hours

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

• Diuretik– Furosemide 40 mg every 12 hours intravena.

• Laxative– Laxadin syrup 1 x 2 cth

• Anti Anxietas– Alprazolam 0,5 mg every 24 hours in night.

ACUTE CORONARY SYNDROME ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

DISCUSSION

DEFINITIONAcute Coronary Syndrome (ACS) is a term for situations where the blood supplied to the heart muscle is suddenly blocked.

STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis.

ANATOMY

CAD

ACS

UAP NSTEMI STEMI

Stable Angina Pectoris

PATHOPHYSIOLOGY

Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectorisThrombosis

ThrombusAcute coronary syndrome:• Unstable angina• Myocardial infarction :

- Non Q waves- Q waves

RISK FACTOR FOR ACS

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 point Increased by

activity or emotion

1 point Relieved by

resting or nitrate SL

1 point

At least 2 of the following:

DIAGNOSIS OF ACS

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

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 ?

ECG

Lab

ALGORITMA

INITIAL TREATMENT

Fixing the chest pain and fearness

• Bed rest• Diet• O2 2-4 lpm via nasal prongs or face mask• Sublingual/oral/IV nitroglycerine• Antiplatelet: aspirin and clopidogrel• Morfin/petidine• Diazepam 2-5mg/8 hour

Stabilizing the hemodynamic (blood pressure and peripheral pulse control)• β-blocker if there is no contraindication• Calcium channel blocker (CCB)• ACE-Inhibitor

Reperfusion of the myocard

Initial Treatment

JACC Vol. 61, No. 4, 2013 2013ACCF/AHA STEMI Guideline: Full Text January 29, 2013:e78–140

COMPLICATION

Arrythmia Heart failure Cardiogenic shock

Rupture of ventricle

septum/wall

Rupture of chordae tendineae Pericarditis

Tromboemboli

PrognosisKILLIP CLASSIFICATION

Class Description Mortality Rate (%)

I No 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

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

60 – 80

Prognosis – TIMI SCOREHistorical Age 65-74 >/= 75

2 points3 points

DM/HTN or Angina 1 pointExam SBP < 100 3 points HR > 100 2 points Killip II-IV 2 points Weight > 67 kg 1 pointPresentation 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%