Stemi Anterolateral

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Anterolateral wall ST ElevationMyocard Infarction (STEMI) , ONSET>12 H ,KILLIP II

BY:Muh. Kemal Putra

C 111 07 096

SUPERVISOR:

Dr. Khalid Saleh, Sp.Pd

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN KARDIOLOGY

FAKULTAS KEDOKTERAN

UNIVERSITAS HASANUDDIN

MAKASSAR

2012

CASE PRESENTATION


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PATIENT IDENTITY

Name : Mr. N

Gender : Male

Age : 52 years old

Address : Sidrap

Registration no. : 554712

Date of admission : 19th June 2012


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ANAMNESIS

Chief complain : Chest pain

History of present illness :

His chest pain begin + 1 day prior to admission at Wahidin

Sudirohusodo hospital. The pain is felt at the substernal area,

with continuous, stabbing sensation spreading to the back

accompanied with cold sweat. Pain does not subside with rest.


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ANAMNESIS

Nausea ( - ), vomiting ( - )

Cough ( - ), Shortness of breath ( - ), Palpitation ( - )

Dizziness ( - ), Headache ( - ) , Fever ( - )

Urination = normal

Defecation = normal


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ANAMNESIS

HISTORY OF PREVIOUS ILLNESS

History of heart disease ( - )

History of hypertension is ( - )

History of diabetes melitus ( - )

History of dyslipidemia is unknown

History of smoking ( - )


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PHYSICAL EXAMINATION

General appearance : Moderate illness/well nourished/

composmentis

Vital Signs:

BP : 110/70 mmHg RR : 26 x/min

HR : 76x/min T : 36,8 (afebris)

Head :Anemia ( - ) , Icterus ( - )

Neck : JVP R+2cm H20


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Lung : Bronchovesicular, Rhonchi +/+ basal , Wheezing -/-

Cor : I : Ictus cordis not visible

P : Ictus cordis not palpable

P : Dull, normal heart size

-Upper border : left 2nd ICS

-Right border : right parasternalis line

-Left border : left medioclavicular line

A : Heart Sound I/II pure regular, murmur(-)


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Abdomen :

Inspection : flat and following breath movement

Auscultation : peristaltic sound (+) , normal

Palpation : liver and spleen unpalpable

Percussion : tympani, ascites (-)

Extremities : Edema -/-


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ECG FINDINGS


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ECG INTERPRETATION

Sinus Rhythm

QRS Rate : 90 x/minutes

P Wave : 0.08

PR interval : 0.16

QRS complex : 0.08

Axis : +65

ST segment : ST elevation V3-V5, I, aVL,


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Rhythm Sinus

Heart rate 90 x/ minute

Anterolateral Myocardial Infarction

ECG CONCLUSION


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ECHOCARDIOGRAPHY


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ECHOCARDIOGRAPHY

CONCLUSION :

LV systolic & dystolic dysfunction, EF 46%

Dilated LA, LVH (+)

MV prolaps

Hypokinetic inferolateral septal

PH-TR severe


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CHEST X-RAY

CONCLUSION :

Cardiomegaly and pulmonary edema


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Complete blood count

WBC :17.93x103/ul

RBC : 5.95X10^6/ul

HGB : 16.6 gr/dl

HCT : 51.9%

PLT : 271 x 103/l

Enzymes

CK : 4118 U/L

CK-MB : 319 U/L

Trop T : >2.0

Blood chemistry

Blood glucose :138

Ureum : 26 mg/dl

Creatinine : 1.0 mg/dl

SGOT : 407 u/dl

SGPT : 87 u/ dl

Total Cholesterol : 236 u/dl

HDL : 137 u/dl

LDL : 44 u/dl

Trigliseride : 209 u/dl

LABORATORIUM FINDINGS


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DIAGNOSIS

Anterolateral wall STEMI onset >12 hours, Killip II


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INITIAL MANAGEMENT

Bed rest

O2 2-4 lpm ( via nasal canule )

IVFD NaCl 0,9% 10 dpm

Cedocard 10mg/ min/iv/SP

Amiodarone 600mg/24 hrs/SP

Arixtra 2,5mg/24hrs/SC

Fargoxin 0,5mg/iv/bolus(slowly)

CPG 75 mg 0-1-0/ oral

Aspilet 80 mg 1-0-0/oral

Captopril 6.25mg 1-1-1

Simvastatin 20mg 0-0-1

Alprazolam 0.5mg 0-0-1/ oral

Laxadyne syr 0-0-2tbsp / oral


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ADVISE

Coronary Angiography


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DISCUSSION


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DEFINITION

Myocardial infarction (MI) rapid

development of myocardial necrosis

caused by a critical imbalance

between the oxygen supply anddemand of the myocardium.

This usually results from plaquerupture with thrombus formation in

a coronary vessels, resulting in an

acute reduction of blood supply to a

portion of the myocardium.


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PaTHOPHYSIOLOGY

Occurs when coronaryblood flow decreasesabruptly after athrombotic occlusion of

a coronary arterypreviously affected byatherosclerosis.

In most cases,infarction occurs whenan atheroscleroticplaque fissures,ruptures, or ulcerates.


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CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from

unstable angina to myocardial infarction.


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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

Risk factors

Non- Modifiable Modifiable

Smoking

Hypertension

Diabetis Mellitus

Dyslipidemia

Obesity

Lack of physical activity


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WHO DIAGNOSTIC CRITERIA

1. Clinical history of ischaemic type chest pain lasting

>20 minutes

2. Changes in serial ECG tracings

3. Rise of serum cardiac biomarkers such as

creatinine kinase-MB fraction and troponin-T


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CLINICAL FEATURES

Chest pain, >30 minutes

Usually tight, crushing, and band

likeLocation in retrosternal

May radiate to left arm, throat, and

jawAssociated features includingpalpitation, sweating,

breathlessness, and nausea.


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ECS CHANGES IN AMI

ST segment elevation

over area of damage

ST depression in leadsopposite infarction

Pathological Q waves

Reduced R waves

Inverted T waves

w v


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Leads with st elevation in

mi


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Cardiac biomarkers


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DIAGNOSIS

No

Yes

YesNo

Acute Myocardial Infarction

( Q-wave, non-Q wave )

NSTEMI( No ST-Segment

ElevationMyocardial Infarction )

Unstable Angina

Signs of myocardial

ischemia

ST segmen elevation ?

Biochemical cardiac markers ?

Diagnose

ECG

Lab


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Manage chest pain and bad feeling/stress

Oxygen 4 lpm ( increase the supply of oxygen)

Give nitrat oral/IV (for the angina)

Give antiplatelet

Give morphine or petidine (for infark pain)

Give diazepam 2/5mg (for make the patient relax)

Therapy


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Hemodanamic stabilization

Fasting first 8 hours after attack then eat soft food

Give laxadyn

Bed rest until 24 hours free from angina

Blood pressure and heart rate is control with

-Beta blocker

-Ace inhibitor

Therapy


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Myocardiac reprofusion as soon as possible

Thrombolitic - streptokinase and t-PA

Plaque stabilization

Simvastatin

Therapy


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PROGNOSIS

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

KILLIP CLASSIFICATION


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COMPLICATION

Congestive heart failure

Myocardial rupture

Arrhythmia

Pericarditis

Cardiogenic shock


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RISK SCORE FOR ACS

TIMI Risk Score for STEMIHistorical

Age 65-74

>/= 75

2 points

3 points

DM/HTN or Angina 1 point

Exam

SBP < 100 3 pointsHR > 100 2 points

Killip II-IV 2 points

Weight < 67 kg 1 point

Presentation

Anterior STE or

LBBB

1 point

Time to rx > 4 hrs 1 point

Risk Score = Total (0-14)

Risk Score Odds of death by

30D*

0 0.1 (0.1-0.2)

1 0.3 (0.2-0.3)

2 0.4 (0.3-0.5)

3 0.7 (0.6-0.9)

4 1.2 (1.0-1.5)

5 2.2 (1.9-2.6)

6 3.0 (2.5-3.6)

7 4.8 (3.8-6.1)

8 5.8 (4.2-7.8)

>8 8.8 (6.3-12)

* referenced to average mortality (95%

confidence intervals)


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RISK SCORE FOR ACSTIMI RISK SCORE FOR NSTEMI/UA

Historical

Age 65 years

Presence of at least three risk

factors for CAD

Known coronary stenosis of 50 % Use of aspirin in past seven days

Presentation

Recent ( 0.5mm

Calculated

TIMI RiskScore

Risk of >1

Primary EndPoint* in


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Stemi Anterolateral

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