Slide 1
ST Elevation Myocardial Infarction (STEMI) anteroseptal
wallONSET >24 HOURSKILLIP II
Case Report
Cardiology DepartmentMedical FacultyHasanuddin UniversitySekar
Tiarin SC 111 09 807Supervisor: dr. Pendrik Tandean, SpPD-KKV.
FINASIMHASANUDDIN UNIVERSITYMAKASSAR2015NameMr. IBGenderMaleAge62
years oldAddressMakassarMedical Record No.555485Date of
Admission15-6- 2015Patients IdentityChief complain : Chest pain on
left sidePresent illness history : The chest pain felt about 5 days
before he was admitted to Wahidin Sudirohusodo hospital, occurred
suddenly and lasted for approximately 30 minutes. The pain is
described like dull heavy feeling on the chest and radiates to the
left hand. The chest pain didnt relieve by taking a rest.
ANAMNESISNausea (-), vomiting (-) Cold Sweat (+)Cough ( - ),
Shortness of breath ( - ), Palpitation ( - )Dizziness (-), headache
(-) Urination = normalDefecation = normal
PREVIOUS ILLNESS HISTORYHistory of heart disease ( - )History of
hypertension (-)History of diabetes melitus is unknownHistory of
smoking (+) since 10 years oldFamily history of heart disease
(-)RISK FACTORModified Risk FactorHistory of smoking (+) since 10
years oldNon-modified risk factor:Gender : maleAge : 62 year
old
General status:Moderate illness/well nourished/composmentis
Vital StatusTekanan darah: 120/80 mmHgNadi: 60
x/menitPernapasan: 20 x/menitSuhu: 36,6C
Physical ExaminationHead:NormochepalicEye:Anemis (-), Icteric
(-)Pupil:Equal, round, diameter 2,5 mm, reactive to
lightNares:Appearent is normalMouth:No cyanosisNeck:JVP R+2 cmH20,
no lymphadenopathy, no thyroid enlargementLungInspection: Equal
expension bilaterallyPalpation: No tenderness, no mass
palpablePercussion: Normal resonance bilaterallyAuscultation:Breath
Sounds: VesicularAdventitious breath sound: Ronchi -/- , wheezing
-/-
Physical ExaminationPhysical ExaminationCardiac
ExaminationInspection: Ictus cordis was invisiblePalpation : Ictus
cordis was palpable in ICS V about 1 finger from lateral of
medioclavicularis sinistra line, Thrill (-)Percussion: Right heart
border in right parasternalis line, left heart border in left
midclavicle line ICS V.Auscultation : Heart Sound I/II pure
regular, murmur(-). Abdominal Inspection: Flat, following breath
movementAuscultation: Peristaltic sound (+), normalPalpation: Liver
and spleen are unpalpablePercussion: shifting dullness
(-)Extremities Oedema pretibial -/-Oedema dorsum pedis -/- Cyanosis
(-), Clubbing finggers (-)Physical ExaminationECG
Rhythm : sinus, regulerQRS Rate : Heart rate 55 bpm Axis :
NormoaxisP Wave : normalPR Interval : normalQRS Complex :
menyempitST Segment: ST elevasi V1-V3T Wave: T nverted V1-V3
Conclusion : HR 55 bpm STEMI anteroseptal
ECG INTERPRETATIONFoto thoraxKesan
Cardiomegaly disertai dilatatio et elongatio aortaeTanda2
bendungan paruAtherosclerosis aortae
Laboratory FindingsHasilNilai NormalRBC6.32.106/mm3(4,5 -
6,5).106/mm3HGB19,2 g/dL14 - 18 g/dLWBC16,47.103/mm3(4 -
10).103/mm3PLT248.103/mm3(150 - 500).103/mm3PT12,2 kontrol
11,410-14INR1,17APTT24,422-30GDS75 mg/dl< 200 mg/dLCK121,00
U/L< 190 U/LCK-MB29,7 U/L< 25 U/LTroponin I55u/dlLDL87 u/dl24
Jam KILLIP IITherapyO2 2-4 L/menit/nasalIVFD NaCl 0,9%/500 cc/24
jamArixtra 2,5 mg/24jam/scAnti platelet: Clopidogrel 75 mg loading
1x4 tab, maintenance 0-0-1, Aspilet 80 mg loading 1 x 2 tab,
maintenance 0-1-0Anti kolesterol : Simvastatin 20 mg 0 - 0
1Farsorbid 10 mg/24 jam/oralRamipril 5mg 0-2-0Nitrat 0,5 mg (bila
nyeri dada)Bisoprolol 1,25 mg/24 jamLaxadin syr 0-0-2 C
ManagementPlanningECHOCARDIOGRAPHYACUTE CORONARY
SYndromeDEFINITIONSAcute coronary syndromes (ACS) is an umbrella
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).
Acute CoronarySyndromeTextUnstable
AnginaTextTextNSTEMITextSTEMICLASSIFICATIONANATOMY
American Heart Association:
http://watchlearnlive.heart.orgPATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
Unstable AnginaSTEMI NSTEMINon 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 symptomsGender and Age Men, increased risk after age
45 Women, increased risk after age 55Family History CAD diagnosed
before age 55 in father or brother CAD disease diagnosed before age
65 in mother or sisterNon- Modifiable
Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack
of physical activityRISK FACTORSDIAGNOSIS OF ACSAt least 2 of the
following Ischemic symptoms Diagnostic ECG changes Serum cardiac
marker elevations
DIAGNOSIS OF ACSIschemic symptoms Prolonged pain (usually >20
mins) constricting, crushing, squeezing Usually retrosternal
location, radiating to left chest, left arm; can be epigastric
Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness
Sense of impending doom
DIAGNOSIS OF ACS
At least 2 of the following Ischemic symptoms Diagnostic ECG
changes Serum cardiac marker elevations
At least 2 of the following Ischemic symptoms Diagnostic ECG
changes Serum cardiac marker elevations
Troponin T CK-MB CK Myoglobin
DIAGNOSIS OF ACSRISK SCORE FOR ACSTIMI Risk Score for
STEMIHistorical Age 65-74 >/= 752 points3 points DM/HTN or
Angina1 pointExam SBP < 1003 points HR > 1002 points Killip
II-IV2 points Weight < 67 kg1 pointPresentation Anterior STE or
LBBB1 point Time to rx > 4 hrs1 point Risk Score =
Total(0-14)Risk ScoreOdds of death by 30D*00.1 (0.1-0.2)10.3
(0.2-0.3)20.4 (0.3-0.5)30.7 (0.6-0.9)41.2 (1.0-1.5)52.2
(1.9-2.6)63.0 (2.5-3.6)74.8 (3.8-6.1)85.8 (4.2-7.8)>88.8
(6.3-12)* referenced to average mortality (95% confidence
intervals)Bed RestDietOxygen (2-4L/mnt)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 monthsNitroglycerin 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 2013 ACC/AHA Guideline STEMI37Morphine 2-5mg
iv Q5-30minFibrinolytic therapy:a) Streptokinase 1.5million units
iv b) Tenecteplase 0.5mg/kg body weight ivAnticoagulation
therapy:a) Low Molecular Weight Heparins ( Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.StatinsSimvastatin 20mg
qdInitial Treatment 2013 ACC/AHA Guideline
STEMI38ClassDescriptionMortality Rate (%)INo clinical signs of
heart failure6IIRales or crackles in the lungs, an S3, and elevated
jugular venous pressure17IIIAcute pulmonary edema30 -
40IVCardiogenic shock or hypotension (systolic BP < 90 mmHg),
and evidence of peripheral vasoconstriction60 80KILLIP
CLASSIFICATIONPROGNOSIS Smoking cessation Blood pressure control
(less than 140/90 mmHg, or less than 130/80 mmHg in patients with
diabetes or chronic kidney disease) Lipid management (LDL-C level
substantially less than 100 mg per dL; nonHDL-C level less than 130
mg per dL in patients with triglyceride levels 200 mg per dL or
greater) Physical activity (30 minutes at least five days per
week)SECONDARY PREVENTIONS FOR PATIENTS WITH STEMI Weight
management (BMI 18.5 to 24.9 kg per m2; waist circumference less
than 40 inches in men, less than 35 inches in women) Diabetes
management (A1C less than 7 percent) Antiplatelet and anticoagulant
therapy Renin-angiotensin-aldosterone system blocker
therapySECONDARY PREVENTIONS FOR PATIENTS WITH STEMI
THANK YOU DISCUSSIONACUTE CORONARY SYNDROME(ST SEGMENT
ElevationMyocardial Infarction)Definition Acute myocardial
infarction (AMI) is an irreversible necrosis of heart muscle due to
prolonged ischemia, which is suddenly happened.Imbalance in oxygen
supply and demand, which is most often caused by plaque rupture
with thrombus formation in a coronary vessel, resulting in an acute
reduction of blood supply to a portion of the myocardium.
PATHOPHYSIOLOGY
Occurs when coronary blood flow decreases abruptly after a
thrombotic occlusion of a coronary artery previously affected by
atherosclerosis.
In most cases, infarction occurs when an atherosclerotic plaque
fissures, ruptures, or ulcerates
PATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association:
http://watchlearnlive.heart.orgGender and Age Men, increased risk
> age 45 Women, increased risk > age 55Family History CAD
diagnosed before age 55 in father or brother CAD disease diagnosed
before age 65 in mother or sisterNon-Modifiable
Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack
of physical activityRISK FACTORS53
MANAGEMENT
5757KILLIP CLASSIFICATION
ClassDescriptionMortality Rate (%)Ino clinical signs of heart
failure6IIrales or crackles in the lungs, an S3, and elevated
jugular venous pressure17IIIacute pulmonary edema30 -
40IVcardiogenic shock or hypotension (systolic BP < 90 mmHg),
and evidence of peripheral vasoconstriction60 80THANK YOU
