STEMI EXTENSIVE ANTERIOR ONSET 4 HOURS KILLIP I

By:

Andi Fauziah Armayani

(C111 07 070)

Supervisor:

dr. Khalid Saleh, Sp.PD- KKV, FINASIM

CARDIOLOGY DEPARTMENT

FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

WAHIDIN SUDIROHUSODO HOSPITAL

2013

PATIENT’S IDENTITY

Name : Mr. KGender : Male Age : June 16, 1986Registration no : 601336Date of Admission : March 28, 2013

HISTORY TAKING

Chief Complain :• Chest Pain

Present illness history:• Chest pain was felt since 4 hours

before admitted to the hospital. This pain was felt continue and described as a squeezing sensation. Pain was felt on the left side of chest and radiated to the neck, shoulder, his left arm and the back.

• Cold Sweat (+) while chest pain occurred• Palpitation (+)• Nausea (+), vomiting (-) , epigastric pain (-)• Short of breathness (-), history of short of

breathness (-)• Cough (-) ,mucus (-)• Dizziness (-), headache (-) .• Urination = normal• Defecation = normal

PREVIOUS ILLNESS HISTORY

History of hypertension (-) History of Diabetes mellitus (-) History of heart disease (-) History of smoking (+) 2 packs/day since 10 years

ago

RISK FACTOR

Modified Risk Factor

• Smoking 2 packs/day

Non-modified risk factor:• Gender : man

PHYSICAL EXAMINATION

• moderate illness/well-nourished/conscious

General appearan

ce • BP : 120/80 mmHg• P : 72 x/min• R : 20 x/min• T :36.8oC

Vital Sign

• Anemi (-) , icterus (-)Head

• JVP R - 2 cm H20Neck

CONT…• I : symmetric R=L, normochest

• P : mass (-), tenderness (-), VF R=L

• P : sonor• A : breath

sound :bronchovesicular additional sound : ronchi -/- , wh -/-

Chest Examinati

on

• I : ictus cordis unseen• P : ictus cordis

unpalpable• P : dull, left heart border

left midclavicular line ICS V.

• A : HS I/II pure regular, murmur(-)

Cor

CONT…

Abdomen :• Inspection : flat and correspond with

breathing movement• Auscultation : peristaltic sound (+) ,

normal• Palpation : liver and spleen unpalpable• Percussion: tympani, ascites (-)

Extremitas :• edem -/-

ELECTROCARDIOGRAPHY FINDINGS

ECG Interpretation Sinus Rhythm Heart Rate :60

x/IP Wave : 0.06 ’PR interval : 0.12

’QRS

complex :0.08 ’Axis :

normoaxis ST-elevated : V1-

V6, L1 & aVL

CONCLUSIONSinus Rhythm, heart rate :60 x/minute, normoaxis,

ST elevated at V1, V2, V3, V4, V5, V6 + L1 and AVL

LABORATORIUM FINDING

Test Result Normal value

WBC 21.1 x 103/ul 4.0 – 10.0 x 103

RBC 5.00 x 106/µl 4.0 – 6.0 x 106

HGB 14.8 gr/dl 12 – 16

HCT 46.4 % 37 – 48

PLT 283 x 103 /µl 150 – 400 x 103

Complete blood count

Blood ChemistryTest Result Normal value

GDS 112 mg/dl <140

Ureum 25 mg/dl 10 – 50

Creatinine 1.0 mgr/dl < 1.3

SGOT 24 u/l <38

SGPT 15 u/l <41

Total CholHDL CholLDL Chol

129 mg/dl 37 mg/dl54 mg/dl

<200> 55 < 130

TG 91 mg/dl <200

Test Result Normal value

CK 419 U/L <167

CK-MB 16 U/L <25

Troponin-T >2.0 Negative

Cardiac Enzymes

Electrolyte

Test Result Normal value

Na 145 mmol/l 136-145

K 3.9 mmol/l 3.5-5.1

Cl 109 mmol/l 97-111

DIAGNOSIS

ST Elevation Myocardial Infarction

(STEMI)Extensive Anterior 4

Hours KILLIP I

MANAGEMENT O2 2-4 lpm IVFD NaCl 0,9% 500cc/12h Anti platelet Aspilet 80mg 1x1 Anti platelet Clopidogrel 1 x 75mg Anti Thrombolytic Streptokinase 1.5 million IU

in 60 minutes Anti coagulant Fondaparinux Sodium 2.5

mg/24 h/ S ACE Inhibitor Captopril 12.5 mg ½-0- ½ Statin simvastatin 20 mg 0-0-1 Lactulosa Laxadyn syr Benzodiazepine Alprazolam 0.5 mg 0-0-1

PLANNING Echocardiography Angiography

ST ELEVATION MYOCARDIAL INFARCTION

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

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from

unstable angina to myocardial infarction.

CLASSIFICATION

RISK FACTOR

Modifiable

• Smoking• Hypertension• Obesity• Diabetes

Mellitus• Dyslipidemia• Low HDL < 40• Elevated LDL /

TG

Non-modifiable

• Gender and age:• male after

age 45 y.o• woman after

age 55 y.o

• Family History in first degree relative > 55 y.o for male/ 65 y.o for woman

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-T

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

ECG IN AMI

• Non Specific ST-Elevation• T taller and wider

Hyperacute Phase

• Specific ST-Elevation• T inverted• Q – Phatologic

Complete Evolution

• Q- Phatologic• ST segmen isoelectric• T normal or inverted

Old Infarct

HOW TO DIAGNOSIS

No

Yes

Yes

No

Acute Myocardial Infarction (STEMI)

NSTEMI( Non ST-Elevation

Myocardial Infarction )

Unstable Angina

Signs of myocardial ischemia

↑ Biochemical cardiac markers ?

ECG

Lab

ST segmen elevation ?

MANAGEMENT

Fixing the chest pain and fearness• Bed rest• Heart Diet • O2 • Nitrat sublingual/oral/IV• Antiplatelet : aspirin and clopidogrel• Morfin/petidine• Diazepam

Stabilizing the hemodynamic ( blood pressure and pheripheral pulse controlβ-blockerCalcium chanel blocker (CCB)ACE-InhibitorReperfusion of the myocard

TIMI PROGNOSIS IN STEMI

Risk Factor Score

Age > 65 years old 2

Age > 75 years old 3

History of angina/hypertension/D

M1/1/1

Systolic BP <100 3

Heart rate > 100 2

Killip II-IV 2

Weight > 67kg 1

Anterior MI or LBBB 1

Delay treatment >4hours

1

Total Score Risk of Death in 30 days

0 0.8%1 1.6%2 2.2%3 4.4%4 7.3%5 12.4%6 16.1%7 23.4%8 26.8%

9-16 35.9%

PROGNOSIS KILLIP CLASSIFICATION

Class Description Mortality Rate (%)

I no clinical signs of heart failure

6

II rales or crackles in the lungs, an S3, and elevated jugular venous pressure

17

III acute pulmonary edema 30 - 40

IV cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

60 – 80

Thank you