PEMBICARAALVIN KWARDI (090100045)TIAH NURBAITI LUBIS (090100028)

PEMBIMBINGDR. ANDIKA SITEPU SP.JPDR. ALI NAFIAH NASUTION SP.JP

Case Report STEMI INFERIOR ONSET 3 hariKILLIP I TIMI RISK 7/14

DefinitionA Spectrum of clinical syndromes due to sudden, significantly compromised coronary circulation.ACS:Q wave Acute MCI (STEMI)Non-Q wave Acute MCI(NSTEMI)Unstable Angina Pectoris (UAP)

These conditions were the further stages of stable angina pectoris.

PathogenesisMostly caused by coronary atherosclerosisRuptured atherosclerosis plaqueFormation of thrombus which occludes blood vessel.The degree of blood vessel occlusion determines the degree of damage to Myocardium.

Risk FactorsUnmodified Risk factors:AgeSexRaceGenetics (Family History)

ModifiedRiskFactors

CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)DYSLIPIDEMIAMyocardial IschemiaplaqueIschemia = oxygen supply and demand imbalance

CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)DYSLIPIDEMIAMyocardial IschemiaCoronary Thrombosis

CADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)DYSLIPIDEMIAMyocardial IschemiaCoronary ThrombosisACS

DIAGNOSIS

HISTORYPRODROMAL SYMPTOMSHistory very valuable to establish D/. Prodoma : chest discomfort unstable angina1/3 symptoms for 1 4 wks20% symptoms for < 24 hrsMalaise, exhaustionNATURE OF PAINMost patients severe prolonged, 30 minutes - hoursConstricting, crushing, oppressing, compressingheavy weight or squeezing in chestChoking, vise-like, heavy pain or stabbing, knife-like, boring or burning discomfortLocation : retrosternal, spreading frequently to both sides of the chest with predilection to the left sideOften pain radiates down ulnar aspect of left arm, producing tingling sensation in left wrist, hand and fingers

NATURE OF PAINSOME INSTANCES : pain begins in epigastrium, and simulates abdominal disorderSometimes pain radiates to shoulders, upper extremities, neck, jaw and interscapular region favoring the left sideElderly : no chest pain but acute left ventricular failure and chest tightness or marked weakness or syncopePain arises from nerve endings in ischemic or injured, but not necrotic, myocardium

OTHER SYMPTOMS50% nausea or vomiting in transmural infarctsOccasionally diarrhea, profound weakness, dizziness, palpitation, cold perspiration, sense of impending doomOccasionally : cerebral embolism or systemic arterial embolism

*Pain Patterns with Myocardial Ischemia

Clinical Classification of Angina Typical angina (definite) substernal chest discomfort with a characteristic quality and durationprovoked by exertion or emotional stress relieved by rest or nitroglycerin

Atypical angina (probable) meets 2 of the above characteristics

Noncardiac chest pain meets

PHYSICAL EXAMINATIONGENERAL APPEARANCEAnxious, considerable distress, restless, fist on chest (Levine sign)LV failure & sympathetic stimulation : cold perspiration, pallor, dyspnea, cough with frothy pink or blood-streaked sputum.Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientationHEART RATEVariable depending on underlying rhythm and degree or ventr. failureMost commonly, HR 100 110/min; > 95% patients : VPBs within first 4 hours

BLOOD PRESSUREMajority normotensive, but syst. BP may decline and diast. BP may rise Half of pts with inferior MI parasympathetic stimulation : hypotension, bradycardia or both (Bezold Jarisch reflex) half of pts with anterior MI, sympathetic excess : hypertension, tachycardia or both

TEMPERATURE AND RESPIRATIONMost pts with extensive MI fever within 24-48 hrs, fever resolves by 4th or 5th hariRespiration due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure

*WORKUP

Electrocardiogram Q-wave Acute Miocard Infarction (STEMI) :

Elevated ST segment 1 mm at 2 (extremities leads)

Or 2 mm at 2 (Precordial leads which represents the same area or close by)

LBBB (new or presumed new)

ECG presentation for NSTEMI(Non-Q wave MCI or UAP) :

ST Segment depression or inverted T wave(1mm) at 2 or more closely positioned lead.ST segment changes from ST depression at the moment of symptom to normal ST segment when symptom is relieved -> UAP

ACS

Heart Biomarker

BIOMARKERTIME OF ELEVATIONPEAKNORMALIZEDCK-MB3 12 hours24 hours48 72 days(cTn)T3 12 hours24 hours5 10 days(cTn)I3 12 hours12 hour s 2 days5 14 days

ACSCoronary ThrombosisMyocardial IschemiaCADAtherosclerosisRisk Factors( , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)DYSLIPIDEMIAArrhythmia andLoss of MuscleRemodelingVentricular DilatationCongestive Heart FailureEnd-stage Heart Disease

ACSACS ALGORITHM

Time from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARB within 24 h of symptom onset)Statin 12 hours 12 hrsStart adjunctive treatmentChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentStart adjunctive treatmentAdmit to monitored bedAssess risk status High risk: early invasive strategy Continue ASA, heparin, ACE-I, statin

Chest discomfort suggestive of ischemia

Time from onset of symptomsReperfusion strategy: PCI (90 min) or fibrinolysis (30 min)ACE-I/ARB within 24 h of symptom onset)Statin 12 hours 12 hrsStart adjunctive treatmentChest discomfort suggestive of ischemiaReview initial 12 lead ECGImmediate ED assessment and immediate ED general treatmentStart adjunctive treatmentAdmit to monitored bedAssess risk status High risk: early invasive strategy Continue ASA, heparin, ACE-I, statin

Adjunctive Therapy Heparin (UFH/LMWH) Glycoprotein IIb/IIIa receptor inhibitors -Adrenoreceptor blockers Clopidogrel

Date of download: 6/3/2013Copyright The American College of Cardiology. All rights reserved.From: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesJ Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. Performance of PCI is dictated by an anatomically appropriate culprit stenosis. *Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. CABG indicates coronary artery bypass graft; DIDO, door-indoor-out; FMC, first medical contact; LOE, Level of Evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.

Figure Legend:

Medication to relieve symptoms and prevent AspirinBeta-blockerACE inhibitorOutpatient CareStop SmokingBody WeightPhysical Activity (based on patients performance, preferably determined by cardiac stress test [treadmill])Diet (Low fat, with LDL target below 100mg/dL)Control BPControl of blood glucose level for patients with DMModification of Risk Factors

Get regular medical checkups.Control your blood pressure.Check your cholesterol.Dont smoke.Exercise regularly.Maintain a healthy weight.Eat a heart-healthy diet.Manage stress.

KILLIP CLASSIFICATIONStage I- No heart failure. No clinical signs of cardiac decompensation;Stage II- Heart failure. Diagnostic criteria include rales, S3 gallop and pulmonary hypertension. Pulmonary congestion with wet rales in the lower half of the lung fields;Stage III- Severe heart failure. Frank pulmonary oedema with rales troughout the lung fields;Stage IV- Cardiogenic shock. Signs include hypotension (SBP

PROGNOSIS

STATUS PASIENNo : 00.55.87.56 Tanggal : 16 Mei 2013 Nama pasien: Saiman Umur : 73th/ 10 bln/4 hr Seks : LKPekerjaan: Wiraswasta Alamat : Jl. Aek Raso Kec. TorgambaAgama: Islam Tlp: - Hp: -

Keluhan utama: Nyeri dadaAnamnesis: Hal ini dialami os 3 hari yang lalu (Senin, 13/5, sekitar pukul 9 pagi) saat os jalan pagi. Nyeri dada dirasakan os seperti terhimpit benda berat. Penjalaran (+) ke bahu dan punggung. Durasi > 30 menit, disertai mual (+), keringat dingin (+), muntah (-). Nyeri dada yang seperti ini merupakan pertama kali dirasakan os. Sesak nafas (-), DOE (+), PND (-), OP (-), kaki bengkak (-).Riwayat nyeri dada sebenarnya telah dirasakan os 1 tahun ini, bersifat hilang timbul. Nyeri dada terutama dirasakan os bila beraktifitas berat, durasi 5-10 menit, menghilang dengan beristirahat. Oleh karena keluhan nyeri dada tersebut, os lalu dibawa keluarga ke RSUD Rantau Prapat dan dirawat oleh SpPD selama 3 hari.

Menurut pengakuan os, saat di IGD RSUD Rantau Prapat, os telah diberikan obat 4 tablet yang dimakan sekaligus dan 2 tablet kunyah, serta dapat obat suntikan di perut sebanyak 2 kali. Kemudian os dirujuk ke RSHAM untuk penanganan selanjutnya.Riwayat hipertensi dan DM disangkal os. Os adalah pasien baru RSHAM, saat di IGD keluhan nyeri dada sudah berkurang. Riwayat merokok (+) 2 bungkus perhari selama >50 tahun.

Faktor Resiko PJK: Laki laki, usia >45 tahun, merokokRiwayat Penyakit Terdahulu: -Riwayat obat: Clopidrogel, Fasorbid, Fluxum, tanapres s, Alovastatin, Ranitidin, Aspilet.

STATUS PRESENSStatus presens:KU: Nyeri dada. Kesadaran: CMTD: 90/70 mmHg Pols:94 x/i, irregulerRR: 24 x/iSuhu: 36,5CSianosis : (-)Ortopnu: (+) Dispnu: (-)Ikterus: (-)Edema (-) pucat (-)BB: 50 kgTB: 158 cmIMT : BB/(TB)2 = 50/(1.58)2 = 20.08 (normoweight)

PEMERIKSAAN FISIKPemeriksaan Fisik:Kepala : sklera ikterik (-/-) konjungtiva palpebra inferior anemis (-/-)Leher: TVJ : R+3 cmH2ODinding toraks: Inspeksi : simetris fusiformisPalpasi : stem fremitus kanan = kiri, kesan normal Perkusi : sonor pada kedua lapangan paru Batas jantung : Atas : ICS III sinistra Kanan : Linea parasternalis dextra Kiri : 1 cm lateral LMCS

AuskultasiJantung: S1 (N) S2 (N) S3 (-) S4 (-) irregular, HR 94x/i irreguler Murmur : (-), Tipe : (-).Paru :suara pernafasan vesikulersuara tambahan : ronki (+) wheezing (-/-)Abdomen: Palpasi Hepar/Lien : tidak teraba Bising Usus (+) Asites (-)Ekstremitas:akral hangatedema (-)

SINUS RHYTM, QRS RATE 96X/MNT, QRS AXIS (N), GEL. P (N), PR INTERVAL 0,16, QRS DURATION 0,08, Q PATOLOGIS DI II, III, AVF, ST DEPRESI DI I, AVL, V2-V6. LVH (-), VES (-), AES (-), (ECG POST: Q PATH DENGAN ST ELEVASI V8-V9/EKG KANAN: ST ELEVASI V3R-V4R.)KESAN EKG: SR + STEMI INFEROPOSTERIOR + RV INFARK

Interpretasi Foto Thorax:

CTR 55%, segmen aorta dilatasi, segmen Po normal, pinggang jantung (+), kongesti(-). Infiltrat(-).Kesan: Cardiomegali + aorta dilatasi

HASIL LABORATORIUMHematologi Hb 15.60 gr% (Ti)RBC 5.22 x 106 /mm3 WBC 14.22 x 103/mm3 PLT 91 x 103/mm3 Ht 44,40 % (Ti)MCHC 35,10 % RDW 14,40 % Kimia KlinikpH 7,451 pO2 181,2 mmHg (Ti)HCO3 15.6 mmol/L (Tu)CO2 16.3 mmol/L (Tu)BE -6,0 mmol/L (Tu)SO2 99,6%

GinjalKreatinin: 1.42 mg/dl Ureum: 110 mg/dL

ElektrolitNatrium : 121 mEq/LKalium : 4,2 mEq/LKlorida : 107 mEq/L

Diagnosa Kerja : STEMI inferoposteriorFungsional : STEMI inferoposterior onset 3 hari KILLIP II TIMI Risk Score 7/14Anatomi : Arteri KoronerEtiologi : AtherosklerosisDifferensial Diagnosa : - STEMI Inferoposterior onset 3 hari KILLIP II TIMI Risk Score 7/14-NSTEMI-UAP

Pengobatan:Bed RestO2 4L/iIVFD NaCl 0,9 % 10 gtt/I (mikro)Inj UFH 600 IU/hour Aspilet 1x80 mgPlavix 1x75 mgISDN 5mg (k/p)Simvastatin 1x40 mgLaxadin 1x1CI

Rencana Pemeriksaan Lanjutan:KGDN/ 2JPP, HbA1cFaal HemostasisLipid profileEchocardiographyAngiography coronerPrognosis : Dubia ad bonam

FOLLOW UP PASIENFOLLOW UP.docxFOLLOW UP (16 Mei 2013 30 Mei 2013)

KesimpulanPembentukan thrombus di daerah plak akan mempersempit oklusi,dan gangguan aliran darah menyebabkan ketidakseimbangan yang nyata antara pemasukan oksigen dan kebutuhan oksigen. Bentuk ACS merupakan hasil yang bergantung dari derajat obstruksi koroner dan berhubungan dengan iskemia. Oklusi thrombus parsial menyebabkan sindrom unstable angina (UAP) dan non-ST Elevation Myocardial Infarction (NSTEMI). Jika thrombus menyumbat arteri koroner secara komplit, maka menyebabkan iskemik yang lebih parah dan nekrosis yang lebih banyak, dikenal sebagai ST Elevation Myocardial Infarction (STEMI).

Pasien datang dengan diagnosa STEMI inferoposterior + RV infark dengan gejala klinis nyeri dada dirasakan os seperti terhimpit benda berat. Penjalaran (+) ke bahu dan punggung. Durasi > 30 menit, disertai mual (+), keringat dingin (+). Dari interpretasi EKG terlihat kesan SR + STEMI inferoposterior + RV infark. Pasien juga telah mendapat penatalaksaanaan awal dengan ace inhibitor, anti platelet, dan antikoagulan.Pada pasien ini di berikan terapi berupa Bed Rest semi fowler, O2 4L/i, IVFD NaCl 0,9 % 10 gtt/I (mikro), Inj UFH 600 IU/hour , Aspilet 1x80 mg, Plavix 1x75 mg, ISDN 5mg (k/p), Simvastatin 1x40 mg dan Laxadin 1x1ci.

TERIMA KASIH

PDKI 2009..\Downloads\Documents\acs-cardiovascular-emergency-jadi.pdfAHA/ACC 2013..\Downloads\Documents\Circulation-2013-O-Gara-529-55.pdfECS 2012STEMI..\Downloads\Documents\Guidelines_AMI_STEMI.pdfNSTEMI..\Downloads\Documents\Guidelines-NSTE-ACS-FT.pdf

Ppt..\Downloads\Documents\Figure.ppt(aha)..\Downloads\Documents\Slide_Set_AMI_STEMI.ppt(ecs)..\Downloads\Documents\guidelines_ACS_NSTE_Slides-2011.ppt(ecs)

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