Stemi Inferoposterior et RV Onset 3 Hours Killip I

Presented by: Muh. Ayyub Primadi Supervisor : dr. Abdul Hakim Alkatiri, Sp.JP, FIHA
Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

PATIENT IDENTITY
Medical Record Name Gender Age Address Date of admission : 622664 : Mr. R : Male : 31 years old : Maros : 13 Agustus 2013

HISTORY TAKING
Chief complaint: Chest Pain History of Present Illness: The chest pain began since 3 hours ago before he was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was resting at home. The pain is described like dull heavy feeling on the left chest, radiated to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and tightness sensation. The patient felt nausea and not vomiting. The chest pain felt continuously more than 20 minutes duration, and not relieved by rest. The patient felt breathlessness while having chest pain, and it was accompanied by palpitation and cold sweat. He never wakes up from her sleep in the night because of breathlessness. He could sleep with 1 pillow only. There was no cought and fever. No history of epigastric pain. Urination and defecation were normal.

HISTORY TAKING
History of Past Illness:
History of chest pain before (-)
History of smoking ( + ) 2 packs/day History of hypertension : denied History of drinking alcohol (-) No history of heart disease No family history of heart disease History of diabetes mellitus : denied

No history of dyslipidemia
No history of asthma No history of epigastric pain

RISK FACTOR

Non Modifiable Gender: Male

Modifiable
Smoking (+) Obesitas (+)

PHYSICAL EXAMINATION
General Status Moderate illness/obes 1/conscious Vital Signs
BP HR RR T BW H : 130/80 mmHg : 70 bpm, regular : 22 tpm : 36.7C : 82 kg :170 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 : Vesicular Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination
Insp. : IC wasnt visible Palp. : IC wasnt palpable Perc. : Dull, normal heart size
Right border Left border : Right parasternalis line : Left medioclavicularis line

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

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY
Interpretation:
Rhythm QRS-Rate P-Wave PR-Interval QRS Complex Axis ST-Segment : Sinus : HR 75 bpm, reguler : 0.08 sec : 0.16 sec : 0.08 sec : 120 : ST-elevation on lead II, III, aVF, V3R, V4R, V5R, V6R, V8, and V9. ST-depretion on lead V2, V3, V4, V5, and V6 : Normal

T-Wave

Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardial infarction, whole anterior ischaemic.

CHEST X-RAY
14 Agustus 2013

Normal pulmonary CTI: Normal

Result: Normal Pulmo

LABORATORY EXAMINATION

WBC HB PLT HCT GDS Ureum Creatinin

: 23,7 x 103/mm : 16,4 gr/dl : 312.000 : 49,7 % : 123 mg/dl : 15 mg/dl : 0,8 mg/d

PT APTT

: 21,7 (0,8) : 52,4 (26,6)

CK CKMB Trop. T Na K Cl SGOT SGPT Albumin

: 281 U/L : 22 U/L : 0,02 : 141 mmol/l : 4,2 mmol/l : 107 mmol/l : 31 U/L : 34 U/L : 4,0 gr/dl

DIAGNOSIS
- STEMI Inferioposterior + Right Ventricular onset 3 hours KILLIP I

INITIAL MANAGEMENT
Bed rest O2 2-4 LPM (via nasal canule) IVFD NaCl 0,9% loading 500 cc/24 hours 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) Trombolitik Streptokinase (Streptase 1,5 million units were dissolved in 100 ml of Dextrose 5% in drips for 1 hour) Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth

ELECTROCARDIOGRAPHY Post Trombolitik

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

Tend to be Stable Angina Pectoris than Acute Coronary Syndrome

2 point atypical chest pain

Tend to be Acute Coronary Syndrome than Non Cardiac Chest Pain

1 point or none 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

DIAGNOSIS OF ACS
At least 2 of the following:
1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

1. ISCHEMIC SYMPTOMS
Prolonged pain (usually >20 minutes) constricting, crushing, squeezing

Usually retrosternal location,

radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting

2. DIAGNOSTIC ECG CHANGES

ECG CHANGES
Timing of myocardial infarction based on ECG

3. SERUM CARDIAC MARKER ELEVATIONS

Troponin T CK-MB CK

SGOT

LDH

Myoglobin

CARDIAC BIOMARKER

DIAGNOSIS
Signs of myocardial ischemia ECG

Yes
ST segmen elevation ?

Acute Myocardial Infarction ( Q-wave, non-Q wave )

STEMI

No

Lab

Yes

Biochemical cardiac markers ?

NSTEMI (No ST-Segment Elevation Myocardial Infarction)

No

Unstable Angina

MYOCARDIAL INFARCTION

DEFINITION

Myocardial infarction (MI) is rapid development of myocardial necrosis caused by imbalance oxygen supply and demand of the myocardium.

It results from plaque rupture with thrombus

formation in a coronary vessels, resulting in an acute reduction of blood supply to a part of the myocardium.

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)

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 Heart disease diagnosed before age 65 in mother or sister

Modifiable
Smoking
Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack of physical activity

WHO DIAGNOSTIC CRITERIA

Clinical history of ischaemic type chest pain lasting >20 minutes

Changes in serial ECG tracings

Rise of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

CLINICAL HISTORY
Duration : variable, often more than 30 minutes. Quality : Feels squeezing, pressurelike, tightness, heaviness, and burning. Location : Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms frequently on left. Associated features : Not relieve with rest or nitrat

ECG CHANGES
Timing of myocardial infarction based on ECG

CARDIAC BIOMARKER

DIAGNOSIS

THROMBOLYTIC AGENT
INDICATIONS
Age < 70 yo Typical chest pain, > 20 minutes, not relieved by nitrat ST elevation > 0,1 mV, on 2 lead or more Onset < 12 hours

THROMBOLYTIC AGENT
CONTRAINDICATIONS

Absolute:
Previous intracranial haemorrhage or stroke of unknown origin at any time Central nervous system damage or neoplasms Recent major trauma/surgery/head injury (within the preceding 3 weeks) Gastrointestinal bleeding within the past month Known bleeding disorder (excluding menses) Aortic dissection

Relative:
Transient ischaemic attack in the preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 week postpartum Refractory hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg) Advanced liver disease Infective endocarditis Prolonged or traumatic resuscitation

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

PROGNOSIS TIMI SCORE

Historical
Age 65-74 >/= 75 DM/HTN or Angina Exam SBP < 100 HR > 100 Killip II-IV Weight > 67 kg Presentation Anterior STE or LBBB 1 point 3 points 2 points 2 points 1 point 2 points 3 points 1 point

Total Score
0 1 2 3 4 5 6 7 8 9-14

Risk of Death in 30 days

0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

Time to treatment > 4 hrs

Risk Score = Total

1 point
(0-14)

THANK YOU