STEMI EXTENSIVE ANTERIOR ONSET > 12 HOURS KILLIP 2

Presented by: A. Idfa Muidah

Supervisor : Dr.dr.Idar Mappangara, SpPD, Sp JP.FIHA.FINASIM ,FICA

Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

PATIENT IDENTITY
Medical Name Gender Age Address Date

Record

of admission

: 623936 : Mr.AW : Male : 49 years old : Malengkeri : August 21th 2013

HISTORY TAKING

Chief complaint: Chest Pain

History of Present Illness: The chest pain began since 2 days before she was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was riding motorcycle. The pain is described like dull heavy feeling on the chest, radiated to his back. The chest pain felt continuously more than 20 minutes duration, and not relieved by rest. The chest pain was accompanied with cold sweat and unconscious, and felt nausea and vomitting . There is no short of breathness . Urination and defecation were normal.

HISTORY TAKING

History of Past Illness:

History of chest pain (+) about 3 weeks ago, relieved by rest History of hypertension (+) since 10 years ago No history of heart disease, there is a family history of heart disease, his brother History of diabetes mellitus (+) No history of dyslipidemia No history of asthma History of epigastric pain (+) since 3 years ago

Life style :

History of smoking ( +) 3 packs / day History of drinking alcohol (+) since 10 years ago

RISK FACTOR
Non Modifiable Gender: Male Age: 49 yo
Modifiable
Hypertension (+)
DM (+) Obesity (+)

Smoking

PHYSICAL EXAMINATION

General Status Moderate illness/obesity/conscious Vital Signs

BP HR RR T BW H

: 170/100 mmHg : 80 bpm, regular : 24 tpm : 36.7C : 75 kg : 168 cm

PHYSICAL EXAMINATION

Head Examination

Eyes Lips Neck

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

Thorax Examination

Insp. Palp. Perc. Ausc.

: Symmetrical R=L, normochest : Mass (-), tenderness (-), VF R=L : Sonor : Bronchovesicular Ronchi +/+, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac
Insp. Palp.

Examination
: IC wasnt visible : IC wasnt palpable : Dull
: Right parasternalis line : 2 Fingers after midclavicularis line

Perc.

Right border Left border

Ausc.

: Pure regular of I/II heart sound, murmur (-)

PHYSICAL EXAMINATION

Abdominal Examination

Insp. Ausc. Palp. Perc.

: Flat and following breath movement : Peristaltic sound (+), normal : Liver and spleen is unpalpable : Tympani (+), ascites (-)

Extremities

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

ELECTROCARDIOGRAPHY ECG

Interpretation
Sinus Rhythm Heart Rate :89x/I P Wave : 0.08 PR interval :0.12 QRS complex

:0.08 Axis : normoaxis ST elevated at V1-V6, AVL Conclusion: Myocard Infarct Extensive Anterior

LABORATORY EXAMINATION
WBC

: 15.80 HB : 16,7 gr/dl PLT : 288.000 HCT : 45,6 % GDS : 183 mg/dl Ureum : 22 mg/dl Creatinin : 0,9 mg/d

CK CKMB Trop. T Na K Cl SGOT SGPT

: 2708 U/L : 200 U/L : 0,89 : 146mmol/l : 4,19mmol/ : 105mmol/l : 118 U/L : 39 U/L

Echocardiography
LV

systolic function & diastolik decreased left ventricle CEF 38% Akinetic septal & apilkal, hipokinetik lateral

DIAGNOSIS
-

STEMI Extensive anterior, onset >12 hours KILLIP II

INITIAL MANAGEMENT

Bed rest O2 2-4 LPM (via nasal canule) Heart Diet IVFD NaCl 0,9% loading 500 cc/24 hours 140/90 mmHg 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 Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) Anti coagulant Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC Diuretiic Furosemide 40 mg 2x1 Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth Anti hypertension Ace-inhibitor (Captopril) 3x12,5 mg

PLANNING
Echocardiography Coronary

angiography

ACUTE CORONARY SYNDROME

DIAGNOSIS OF CHEST PAIN

1 point
Retrosternal or substernal chest pain

1 point

Increased by activity or emotion

1 point

Relieved by resting or nitrate SL

3 point typical chest pain 2 point atypical chest pain 1 point or none non cardiac chest pain

Tend to be Stable Angina Pectoris than Acute Coronary Syndrome

Tend to be Acute Coronary Syndrome than Non Cardiac Chest Pain

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

PATHOPHYSIOLOGY

Vulnerable Plaque Thrombosis Vasospasme Plaque disruption and thrombosis that result in complete coronary artery occlusion leads to transmural ischemia and necrosis, the hallmark of ST-segment elevation myocardial infarction (STEMI)

PATHOGENESIS
Lipid transport disorder Inflamation Plaque deposition

Stable plaque
Thrombus

Erosion

Plaque rupture

Acute coronary syndrome: Unstable angina Myocardial infarction : - Non Q waves - Q waves

Stable angina pectoris

Thrombosis

RISK FACTOR
Non- Modifiable
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

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity

Heart disease diagnosed before

age 65 in mother or sister

Lack of physical activity

At least 2 of the following:

1. Ischemic symptoms 2. Diagnostic ECG changes 3. Serum cardiac marker elevations

DIAGNOSIS OF ACS

CLINICAL FEATURES
Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain ,pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. more intense and persistent.

Not fully relieved by rest or nitroglycerine

Often accompanied by systemic symptoms: nausea, vomiting, SOB, palpitation, fatigue, cold sweat, light headness

2. DIAGNOSTIC ECG CHANGES

3. SERUM CARDIAC MARKER ELEVATIONS

Troponin T CK-MB CK

SGOT

LDH

Myoglobin

DIAGNOSIS

INITIAL MANAGEMENT

Fixing the chest pain and fearness Bed rest Diet O2 2-4 lpm Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5% Antiplatelet : Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months. Morphine 2-5 mg IV every 5-30 minutes Pethidine 12,5 mg/IV Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker Calcium channel blocker (CCB) ACE-Inhibitor Reperfusion of the myocard Thrombolytic: streptokinase 1,5 million units/IV

PROGNOSIS KILLIP CLASSIFICATION

Class I II III Description No clinical signs of heart failure Rales or crackles in the lungs, an S3, and elevated jugular venous pressure Acute pulmonary edema Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction Mortality Rate (%) 6 17 30 - 40

IV

60 80

THANK YOU