Myocardial Infarction

Tutorial group #3
 Tutorial group #3: Members
• Presenter: Angeline Maranata (0961050048)
• Slider/time keeper: Alfonsina C. Pentury (0961050090)
• Sources:
– Anastasia Febrianti (0961050001)
– Ayunita Permata (0961050022)
– Irvan R. Amanu (0961050031)
– S. Dian Tanjung (0961050134)
– Michael R. Marampe (0961050144)
– Meylani Bith (0961050125)
– Marsha D. Sari (0961050140)
– Basten J. Siahaan (0961050167)
Case Report
• ♂ 71y.o complained: dyspneau with
chest pain since morning
• History: hypertension (the onset has not
been known yet), smoker, obese,
physical inactivity
• Analysis findings:
– BP: 180/100mmHg
– BW: 80kg
– Glucose plasma: 265mg/dl
– Elevation of CPK, CK-MB, and Troponin T/I
– ECG result: ST elevation
Explain this phenomenone and plan the
management of this case.
Difficult medical terms
• CPK: Creatine Phosphokinase. An enzyme which found in
brain, skeletal muscle, and heart. Non-spesific marker of
cardiology disorder. It rises within 4-8h after infarct and
return to normal after 48-72h post-infarct and also can be
risen by brain injury, convulsion, and myopathy
• CK-MB: one of the isoenzymes of Creatine
Phosphokinase, which is found in cardiac tissues. It is
more spesific than CPK although can be risen by cardiac
surgery, cardioversion, myocarditis.
• Troponin T/I: protein that is restricted in cardiac muscle. It
is most spesific and sensitive marker to identify cardiac
muscle necrosis. It is elevated within 1-3h after infarct and
remain elevated after 7-10 days post-infarct.
• ST elevation: The elevation of segment ST in
electrocardiogram, which indicates the necrosis of cardiac
muscle.
(Harrison’s Principle of Internal Medicine 18th edition)
Hypothesis
Aging, hypertension, obesity,
smoking, and physical inactivity are
risk factors of Coronary Heart Disease
 Mind Mapping
Cardiac muscle Cardiac Heart failure dyspneau
Hypertension
hypertrophy compensation

Aging
Presipitating factors:
muscle spasm,
Smoking thrombus embolism

Obesity Total occlusion Cardiac

Atherosclerosis of coronary muscle Chest pain
artery infarction
Physical

inactivity
ST elevation

CPK enzym >>

CK-MB enzym >>

Troponin T/I >>

Glucose plasma >>

Working Diagnosis
• Accoding to WHO:
– Characteristic chest pain
– Significant elevation of Biochemical
Markers of MI
– ST segment, T wave, and Q wave
abnormalities
2 out of 3: MI (Myocardial Infarction)
Outlines
• Definition of Myocardial Infarction (MI)
• Etiology and Predisposing Factors of MI
• Cardiovascular system changes in
Elderly
• Pathophysiology of MI
• Clinical Manifestations of patient with MI
• Management of patient with MI
• Complications of MI
• Differential diagnosis of MI
• Outcomes of patient with MI
• Prevention to avoid MI
Definition of MI
Myocardial Infarction:
Cell death of cardiac myocytes
caused by ischemia, which is the
result of a perfusion imbalance
between supply and demand.
Universal Definition of Myocardial
Infarction: American Heart
Association. 2007
Etiology and
Predisposing Factors of MI
• Etiology: total occlusion of coronary
artery infarct
• Predisposing factors:
Unmodified factors Modifiable factors

Age Lifestyle

Sex Psychologic stress

Family History Hypertension

Race Hypercholesterolemia
(metabolic syndrome)
Cardiovascular system
changes in Elderly
Pathophysiology of MI
Clinical Manifestations of
patient with MI
Characteristic pain:
• Pressure
Radiates to neck, jaw, back, left
• Tightness arm, or both arm, possible to
epigastrium: visceral pain
• Heaviness
+ palpitation
+ heartburn
+ persistent shortness of breath
+ weakness, dizziness, loss of
consciousness
Management of patient with MI
Goals:
1.Reperfusion of coronary artery
2.Limitation of infarct size
•ER: MONACO (Morphine, Oxygen, Nitroglycerine, Aspirin,
Clopidogrel)
•Fibrinolysis therapy:
– Streptokinase intravenously
– tPA (tissue Plasminogen Activator)
•Intervention therapy:
– Catheterisation*, Balooning, and Stenting
– CABG (Coronary Artery Bypass Grafting)
•Maintenance therapy:
– ECG monitoring
– Tappering down of BP (-20mmHg/-10mmHg)
– Tappering down of glucose plasma*
Management of Patient with MI
Complications of MI
• Reperfusion injury
• Acute heart failure
• Aneurysm of heart
• Cardiac muscle cells rupture
• LBBB or RBBB
• Ventricular arrhytmias:
– Fibrilation
– bradhyarrhytmia
• Cardiogenic shock
• Hypovolemia
 Differential Diagnosis of MI
Symptom: Acute Chest Pain
System Disease Symptoms Key distinguishing
features

Cardiac Pericarditis Sharp, pleuritic pain Pericardial friction rub

aggravated by changes
in position

Gastrointestinal GERD Burning substernal and Aggravated by large meal

(Gastroesophageal epigastric discomfort, 10- and postprandial
Reflux Disease) 60 minutes in duration recumbency; relieved by
antacid

Vascular Pulmonary Embolism Sudden onset of dyspnea Dyspnea, tachypnea,

and pain, usually pleuritic tachycardia, and signs of
with pulmonary infarction right heart failure

Infectious Herpes Zooster Prolonged burning pain in Vesicular rash,

dermatomal distribution dermatomal distribution
Outcomes of Patient with MI
• Dubia et bonam: the treatment has
been completed under the golden
hour
• Dubia et malam: the necrotic area
has been extended heart failure
Prevention to avoid MI
• Primary prevention: Healthy Lifestyle and
do exercise
• Secondary prevention:
– Prevent another heart attack:
• Antithrombotic agents + enteric formulation
• healthy diet for heart:
– Control eating portion
– Eat more vegetables and fruits
– Select whole grains
– Limits unhealthy fats and cholesterol
• Do exercise safely: involves large muscle groups
and maintain regular breathing pattern
– Daily walking in 30mins – 60mins regulary
– Cycling
References
1. Auntman EM. ST elevation Myocardial Infarction.
Braunwald Heart’s Disease. 8th edition. In editor: Libby.
Saunders Elsevier. 2007. p: 1207-24, 1234-1289
2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL,
Loscazio J: Harrison’s Principle of Internal Medicine 18th
edition: www.accessmedicine.com
3. Phibbs, Brendan. Coronary Artery Disease. The Heart: The
Basic Guide to Heart Disease. 2nd edition. In editor: Fran
Destefano. Lippincot William and Wilkins. 2007 p: 42-52
4. Webb RC, Inscho RW. Age-related changes in
Cardiovascular system. Clinical hypertension and Vascular
diseases. In editor: LM Prissant. Springer. 2008 p: 11-21
5. Van Camp SF, Cantwell DJ, Fletcher GF, Smith K,
Thompson PD. Exercise for Patient with Coronary Artery
Disease. American College of Sports Medicine. 1994.
downloaded from:
http://www.healthsystem.virginia.edu/pub/renal-
services/exercise/position-stand-on-exercise-and-cad.pdf
on November 10, 2012