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Infarction (STEMI)
Inferior
By :
Anom Partha Jaya (C11112131)
Supervisor :
dr. Pendrik Tandean, Sp.PD-KKV, FINASIM
Cardiology Department
Medical Faculty of Hasanuddin
University
PATIENTS IDENTITY
Name
: Mr. S
Gender
: Male
Age
: 48 years old
Registration no.
: 760995
History Taking
Chief Complaint:
Chest pain
Guided Anamnesis:
Occured about 6 hours before admitted to the hospital. The chest pain
was felt suddenly during rest. The pain was felt at the left side of the
chest and it feels like compressed pain, radiated to the left arm and also
radiated to the back associated with cold sweat. The duration of the chest
pain occurs about 30 minutes and relieved by the time past. The history
of chest pain before is denied. Short of breathness during laying down is
denied, no history of coughing, fever, nausea and vomiting or epigastric
pain. Defecation and urination are normal.
Risk Factors
Non-Modified Risk Factor :
Gender
Age
Clinical Examination
GENERAL STATE
Moderate illness/ non obese/ compos mentis (GCS E4M6V5)
VITAL SIGN
Blood pressure
: 100/70 mmHg
Pulse
: 80 bpm
Breathing
: 22 times/min
Temperature
: 36,7C (Axilla)
Head Examination
Eyes
: anemic -/-, icterus -/-, cyanosis -/
Neck : tumor mass (-), tenderness (-),
JVP R+3 cmH2O, trachea deviation (-)
Chest Examination
Inspection
Palpation
Percussion
: symmetrical R=L
: mass (-), tenderness (-)
: sonor R=L
lung-hepar border = right ICS IV
Right back lung border = right CV th VIII
Left back lung border = left CV th IX
Auscultation
: breath sound : bronchovesicular
additional sound : ronchi -/- wheezing -/-
Cardiac Examination
Inspection
: heart apex was not visible
Palpation
: heart apex was not palpable
Percussion
: normal heart size
Auscultation
: Regular of I/II heart sound,
murmur (-)
Abdominal Examination
Inspection
: flat and following breath movement
Auscultation : peristaltic sound (+), normal
Palpation
: liver and spleen unpalpable
Percussion
: tympani (+), ascites (-)
Extremities
- Oedema
ELECTROCARDIOGRAM
Rhythm
HR
: 83
Regularity
P wave
PR interval
Axis
: sinus rhtym
bpm
: regular
: 0.08 sec
: 0.16 sec
: Normal axis
Duration of QRS
ST segment :
: 0.08 sec
ELECTROCARDIOGRAM
INTERPRETATION
Rhythm
: sinus rhtym
HR
: 83 bpm
Regularity : regular
P wave
: 0.08 sec
PR interval : 0.16 sec
Axis
: Normal axis
Duration of QRS
ST segment :
: 0.08 sec
Conclusion :
LABORATORY FINDINGS
TEST
RESULT
NORMAL
TEST
RESULT
NORMAL
VALUE
VALUE
8,6 x 103/uL
4.0 10.0 x
Tot.Choles
196 mg/dl
200
RBC
5.60 x 106/uL
103
4.0 6.0 x 106
HDL
36 mg/dl
>59
HGB
16.2
12 18
LDL
156 mg/dl
<130
HCT
46
37 48
Triglycerides
119 mg/dl
200
PLT
198 x 103/uL
150 400 x
Ureum
15
10-50
1,26
<1,3
PT
10,4
10
10 - 14
Creatinin
Troponin I
1,48
<0,01
APTT
23,1
22,0 - 30,0
CK
392
<190
INR
1,00
CKMB
50,4
<25
Blood
127 mg/dl
< 200
Sodium
141
136 - 145
Glucose
140
SGOT
106
40 u/L
<38
potassium
4,1
3,5 - 5,1
SGPT
17 u/L
<41
chloride
113
97 - 111
Uric acid
7,0
3,4-7,0
WBC
CHEST X-RAY
WORKING DIAGNOSIS
ST
THERAPY
1. O2
2. IVFD
3. Lovevox
4. Miniaspi
80mg/24 hr/oral
5. Clopidogrel
75 mg/24 hr/oral
6. Atrovastatin
7. Alprazolam
8. Laxative
0,5mg/24 hr/oral
9. Dobutamin
10.
40 mg/24 hr/oral
Resume
Laboratory result SGOT 40, Trop 1,48, HDL 36 mg/dl, LDL 156
mg/dl, CKMB 50,4 , CK 392
INTRODUCTION
Acute coronary
syndromes (ACS) is a
term for situations where
the blood supplied to the
heart muscle is suddenly
blocked.
described as 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
Inferior
II, III, aVF
Anterior /
Septal
V1-V4
Diagnosis
Unstabl
e
Non
Angina
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes
Occluding
NSTEMI
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes
STEMI
Complete thrombus
occlusion
ST elevations on
ECG
Elevated cardiac
enzymes
More severe
symptoms
PATOPHYSIOLOGY
Atherosklerosis, trombosis at coronary
arteries
Decrease the blood flow into the heart
Decrease the supply of oxygen and
nutrition
Ischemia myocard
Necrosis
Imbalance supply and consumption of the
oxygen into the heart
Myocardial infarction
RISK FACTORS
Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical activity
NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years
old
Family history
Heart
Heart disease
disease in
in biological
biological
brother
or
father
brother or father >
> 55
55 years
years
old
old
Heart
Heart disease
disease in
in biological
biological
sister
or
mother
>
sister or mother > 65
65 years
years
old
old
Troponin-T
CK-MB
CK
Myoglobin
ISCHEMIC SYMPTOMS
ECG CHANGES
Hyperacute
Phase
Complete
Evolution
Specific STElevation
T inverted
Q-Pathologic
Old Infarct
Q-Pathologic
ST segment
isoelectric
T normal or inverted
GOAL OF TREATMENT
Relieve pain
Hemodynamic
stabilization
Myocardial
reperfusion
Prevent the
complication
Treatment
Yes
STEMI
Primary PCI
Emergent PCI
available within
90 min ?
No
Fibrinolitic
Theraphy
INITIAL TREATMENT
Bed rest
Clopidogrel
Nitroglycerin :
0.4
INITIAL TREATMENT
Fibrinolytic therapy:
Streptokinase
Tenecteplase
1.5million units iv
Anticoagulation therapy:
Low
Unfractionated
heparin
Complication
2. Heart Failure
4. Cardiogenik Syok
5. Arrhythmia
7. Pericarditis
Prognosis
KILLIP CLASSIFICATION
Class
I
II
III
IV
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
http://en.wikipedia.org/wiki/Killip_class
Mortality Rate
(%)
6
17
30 - 40
60 80
THANK YOU