STEMI ANTEROSEPTAL < 12 HOURS ONSET KILLIP III

Presented By :IJMAL

C 111 10 166Supervisor :

dr. Pendrik Tandean, SpPD-KKV. FINASIM

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar2015

CASE REPORT OKTOBER 2015

PATIENT IDENTITY

Name : Mr. SM

Age : 60 years old

Address : Jl. Dirgantara

MR : 727968

Date of Admission : 03 Oktober 2015

HISTORY TAKING

Chief complaint : Chest pain

Present Illness History : Left chest pain felt since five hours before admission. Described as compressed pain and radiating to left arm,

intermittently, duration of pain : > 20 minutes continously Cold sweating since the night before Have dyspnea There was ‘t nausea or vomit One day before chest pain, the patient went to toraja for

death ceremony of his younger brother

HISTORY TAKING

Past Illness History : History of smoking, 2 packs per day since young No history of hypertension No history of Diabetes Mellitus No history of heart attack No history of chest pain before No history alcohol consumption

RISK FACTOR

Modified Risk Factor

• Lack Activity• Smoking

Non-modified risk factor:

• Gender : Male• Age : 60 years

PHYSICAL EXAMINATION General Status

Moderate illness / Normal / Conscious Weight : 70 kg Height : 170 cm BMI : 22,4 kg/m2

Vital Status Blood pressure :170/80 mmHg Heart rate : 88 bpm Respiratory rate : 30 rpm Temperature : 36,7 oC

PHYSICAL EXAMINATION

Head : Anemic (-), icterus (-), cyanosis (-)

Neck : Lymphadenopathy (-), JVP R+2cmH2O

Thorax: Inspection : Symmetry left=right Palpation : Mass (-), tenderness (-), normal

vocal fremitus Percussion : Sonor Auscultation : Vesicular, ronchi diffuse +/+,

wheezing -/-

PHYSICAL EXAMINATION

Heart : Inspection : ictus cordis not visible Palpation : ictus cordis not palpable, thrill (-) Percussion : Dull

Upper border 2nd ICS sinistra Right border 4th ICS linea parasternalis dextra Left border 5th ICS linea axillaris anterior sinistra

Auscultation : heart sound I/II pure, regular, murmur (-)

PHYSICAL EXAMINATION

Abdomen : Inspection : flat and follows breath

movement Auscultation : Peristaltic sound (+),

normal Palpation : Liver and spleen unpalpable Percussion : Tympani (+), ascites (-)

Extremities : Edema (-)

ELECTROCARDIOGRAPHYSinus rhythmHeart rate : 115 bpmAxis : NormoaxisP Wave : 0,08 sPR interval : 0,16 sDuration QRS : 0,08sST segment : ST elevation on lead V1, V2, V3, V4ST Depresi Lead 1, V5, V6

Conclusion :Sinus rhythm, HR 113 bpm, normoaxis, ST elevation on lead , V1-V4 (Anteroseptal myocard infarction)

LABORATORY RESULTSTEST RESULT NORMAL VALUE

WBC 29,8x 103/uL 4.0 – 10.0 x 103

RBC 5,57 x

106/uL

4.0 – 6.0 x 106

HGB 16,1 g/dL 12 – 18

HCT 48,0% 37 – 48

PLT 317 x 103/uL 150 – 400 x 103

PT 9,9 10 - 14

APT

Kol Tot

Triglisrd

LDL

HDL

23,4

211

110

174

42

22,0 - 30,0

200200

< 130>55

TEST RESULT NORMAL VALUE

GDS - mg/dL <140

SGOT 101 u/L <38

SGPT 53 u/L <41

Ureum 33 10-50

Kreatinin 1,48 0,5-1,2

Troponin T <0,05

CK 612,0 <190

CKMB 57,1 <25

Natrium 147 136 - 145

Kalium 5,4 3,5 - 5,1

Klorida 114 97 - 111

Asam Urat 3,4-7,0

CHEST X-RAY

Result :• Cardiomegaly

(CTI index : 0.61)

• Pulmonary edema

DIAGNOSIS

ST Elevation Myocardial Infarction (STEMI) Anteroseptal onset <12

hours, KILLIP III

TREATMENT

Bed rest O2 2-4 lpm via nasal cannula IVFD NaCl 0,9% 500 cc/24 hours/IV Aspilet 80 mg/24 jam/oral Clopidogrel 75 mg/24 jam/oral Farsorbid 1 mg/jam/syringe pump Furosemid 200 mg/ 24 jam/syringe pump Simvastatin 40 mg/ 24 jam/oral Captopril 12,5 mg/8 jam/oral Arixtra / 24 jam/sc

PLANNING

ECHOCARDIOGRAPHYCORONARY ANGIOGRAPHY

DISCUSSION

INTRODUCTIONAcute coronary syndromes (ACS) is a term for situations where the blood supplied to the heart muscle is suddenly blocked.• described as 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).

INTRODUCTION

ANGINA

Typical Angina Substernal chest discomfort of characteristic quality and duration Provokated by exertion or emotional stress Relieved by rest and/or GTN (Nitrogliserin)

Atypical Meet two of thesee characterr

Unstable Angina STEMI

NSTEMI

Non occlusive thrombus

Non specific ECG

Normal cardiac enzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptoms

Pathophysiology

CORONARY ARTERY DISEASE

Pathophysiology

ATHEROSCLEROSIS OF CORONARY ARTERY

RISK FACTORS

Modifiable

Smoking

Hypertension

Diabetes mellitusHypercholesterolem

iaObesity

Psychosocial stressLack of physical

activity

Non-ModifiableGender & Age• Men > 45 years old• Women > 55 years

old

Family history• Heart disease in

biological brother or father > 55 years old

• Heart disease in biological sister or mother > 65 years old

WHO DIAGNOSTIC CRITERIA

•Prolonged chest pain

•Usually retrosternal location

•Dyspnea•Diaphore

sis

Ischemic symptoms

Diagnostic ECG changes

•Troponin-T

•CK-MB•CK•Myoglobi

nSerum cardiac marker

elevations

1. ISCHEMIC SYMPTOMS

2. ECG CHANGES

Hyperacute Phase • Non specific ST-

Elevation• T taller and wider

Complete Evolution• Specific ST-Elevation• T inverted• Q-Pathologic

Old Infarct• Q-Pathologic• ST segment

isoelectric• T normal or inverted

3. Serum Cardiac Marker Elevation

CK CK-MB

Troponin T

CARDIAC BIOMARKERS

Diagnosis

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

GOAL OF TREATMENT

Relieve painHemodyna

mic stabilization

Myocardial reperfusion

Prevent the complicatio

n

INITIAL TREATMENT

Bed rest Oxygen (2-4 lpm) Anti platelet therapy :

Aspirin 162-325mg chewed immediately and 81-162 mg continued indefinitely.

Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14 days and up to 12 months.

Nitroglycerin : 0.4 mg SL tablets every 3-5 min up to 3 times; if

effect is not sustained, can continue with an IV drip of 50mg in 250mL Dextrose 5%.

INITIAL TREATMENT

Morphine 2-5mg iv (can be administered again in 5-30 minutes later)

Fibrinolytic therapy: Streptokinase 1.5million units iv Tenecteplase 0.5mg/kg body weight iv

Anticoagulation therapy: Low Molecular Weight Heparins (Fondaparinux)

2.5mg/24hrs/sc for up to 8 days post-MI. Unfractionated heparin : Bolus 60units/kg body

weight (maximum 4000U), infuse 12units/kg body weight/hour (maximum 1000U/hour)

Anti Hypertension Drugs

Lipid Lowering Agents

COMPLICATIONS

Ventricular dysfunction

Hemodynamic

disturbances

Cardiogenic shock Arrhythmia

PROGNOSIS KILLIP 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

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