Stemi Extensive Anterior Lbh 24 Hour Onset Killip i

7/27/2019 Stemi Extensive Anterior Lbh 24 Hour Onset Killip i

1/35

STEMI EXTENSIVE ANTERIOR

> 24 HOUR ONSET KILLIP I

Presented by:

Andi Ita Maghfirah

Supervisor :Dr.dr.Idar Mappangara, Sp.PD, Sp.JP, FIHA,

FINASIM, FICA

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University

Makassar

2013


2/35

PATIENT IDENTITY

Medical Record : 621999

Name : Mr. LH

Gender : Male

Age : 58 years old Address : Rajawali

Date of admission : August 9th

2013


3/35

HISTORY TAKING

Chief complaint:

Chest Pain

History of Present Illness:

The chest pain began since 7 days before he was admitted to Wahidin

Sudirohusodo Hospital. Damning since 5 days ago. The sensation of chest pain

suddenly appeared when the patient was working. The pain is described like dull

heavy feeling on the left part of the chest, not spreading . The chest pain felt

continuously more than 20 minutes duration, and not relieved by rest. The chest

pain was accompanied with cold sweat and feeling nauseated. Theres no historyof any chest pain before. Theres also have hystory of hypertension since 10 years

ago, no history of fever and diabetes. History of any heart disease in the family

denied. Patient been smoking for almost 30 years with 12 cigarette each days .

Patient has history of epigastric pain. Urination and defecation were normal.


4/35

HISTORY TAKING

History of Past Illness: History of chest pain (-)

History of smoking (+ ) for 30 years

History of hypertension (+) for 10 years

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

History of epigastric pain (+)


5/35

RISK FACTOR

Gender: Male

Age: 58 yo

Non

Modifiable

Smoking (+)

Hypertension (+)

Obesity (+)

Modifiable


6/35

PHYSICAL EXAMINATION

General Status

Moderate illness/normal weight/conscious

Vital Signs

BP : 140/90 mmHg

HR : 98 bpm, regular

RR : 20 tpm

Temp : 36.6CWeight : 64 kg

Height : 158 cm


7/35


Head Examination

Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-)

Neck : Lymphadenopathy (-), JVP R+0 cmH2O

Thorax Examination

Insp. : Symmetrical R=L , normochest Palp. : Mass (-), tenderness (-), Vocal Fremitus

R=L

Perc. : Sonor

Ausc. : Vesicular

Ronchi -/-,Wheezing -/-


8/35


Cardiac Examination Insp. : IC not visible

Palp. : IC not palpable

Perc. : Dull

Right border : Right

parasternalis line

Left border : ICS 5midclavicularis line

Ausc. : Pure regular of I/II heart sound, murmur (-)


9/35


10/35

ELECTROCARDIOGRAPHY


11/35

ELECTROCARDIOGRAPHY

Interpretation:

Rhythm : Sinus ritme QRS-Rate : HR 100 bpm, reguler

P-Wave : 0.12 sec

PR-Interval : 0.20 sec

QRS Complex : 0.11 sec on v1

Axis : Normal axis 50 ST-Segment : ST-elevation on lead I, aVL, V2-V6

T-Wave : Normal

Conclusion: Sinus Rythmn, HR 100 bpm, normoaxis .ST-elevation on lead I ,aVL and lead V2-V6. complexQRS widen normal on v1, Acute Extensive MyocardiacInfarct


12/35

LABORATORY EXAMINATION

WBC : 14.9

HB : 14,5 gr/dl

PLT : 258.000 HCT : 45,3 %

GDS : 108 mg/dl

Ureum : 38 mg/dl

Creatinin : 14 mg/dl

Uric acid : 6,1 mg/dl

CK : 398 U/L

CKMB : 26 U/L

Trop. T : >2.0

Na : 145 mmol/l K : 3,69 mmol/l

Cl : 107 mmol/l

SGOT : 163 U/L

SGPT : 398 U/L

PT : 12,4 control 10,5

APTT : 24,2 control 23,4


13/35

DIAGNOSIS

- STEMI Extensive Anterior with >24

hour onset Killip I


14/35

INITIAL MANAGEMENT

Bed rest

O2 2-4 LPM (via nasal canule)

Heart Diet

IVFD NaCl 0,9% loading 500 cc/24 hours

Anti Platelet Aggregation

ASA (Aspilet) loading dose 80 mg (2 x 80 mg)

maintenance 1-0-0

Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0

Anti cholesterol

HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1

Anti coagulant

Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 hr/SC

Anxiolytic

Benzodiazepin (Alprazolam 1 x 0,5 mg)

Laxative

Laxadin syrup 1 x 2 cth

Anti hypertension

Ace-inhibitor (Captopril) 3 x 12,5 mg


15/35

PLANNING

Echocardiography

Coronary angiography


16/35

ACUTE CORONARY

SYNDROME


17/35

DIAGNOSIS OF CHEST PAIN

3 point typical chest painTend to be Stable Angina Pectoris than Acute CoronarySyndrome

2 point atypical chest painTend to be Acute Coronary Syndrome than NonCardiac Chest Pain

1 point or none non cardiac chestpain

Retrosternalor substernalchest pain

1point Increased by

activity oremotion

1point Relieved by

resting ornitrate SL

1point


18/35

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).


19/35

CLASSIFICATION


20/35

PATHOPHYSIOLOGY

Vulnerable Plaque

Thrombosis

Vasospasme

Plaque disruption andthrombosis that result in

complete coronary

artery occlusion leads

to transmural ischemiaand necrosis, the

hallmark of ST-segment

elevation myocardial

infarction (STEMI)


21/35

Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectorisThrombosis

Thrombus

Acute coronary syndrome:

Unstable angina

Myocardial infarction :

- Non Q waves

- Q waves

PATHOGENESIS


22/35


23/35

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


24/35

At least 2 of the following:

DIAGNOSIS OF ACS

1. Ischemic

symptoms

2. Diagnostic ECGchanges

3. Serum cardiacmarker elevations


25/35

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

1. ISCHEMIC SYMPTOMS


26/35


27/35

2. DIAGNOSTIC ECG CHANGES


28/35

ECG CHANGESTiming of myocardial infarction based on ECG


29/35

3. SERUM CARDIAC MARKER

ELEVATIONS

TroponinT CK-MB CK

SGOT LDH Myoglobin


30/35

CARDIAC BIOMARKER


31/35

DIAGNOSIS


32/35

WHO DIAGNOSTIC CRITERIA

Clinical history of ischaemictype chest pain lasting >20minutes

Changes in serial ECG tracings

Rise of serum cardiacbiomarkers such as creatininekinase-MB fraction and troponin


33/35

INITIAL MANAGEMENT

Fixing the chest pain and fearness Bed rest

Diet

O2 2-4 lpm

Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not

sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5%

Antiplatelet :

Aspirin: 162-325 mg chewed immediately and 81-162 mg continued

indefinetely

Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least

14 days and up to 12 months.

Morphine 2-5 mg IV every 5-30 minutes

Pethidine 12,5 mg/IV

Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and pheripheral pulse control)

-blocker

Calcium channel blocker (CCB)

ACE-Inhibitor

Reperfusion of the myocard

Thrombolytic: streptokinase 1,5 million units/IV


34/35

PROGNOSIS

KILLIP CLASSIFICATION

Class Description Mortality Rate (%)

I No clinical signs of heart failure 6

IIRales or crackles in the lungs, an S3,

and elevated jugular venous pressure17

III Acute pulmonary edema 30 - 40

IV

Cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and

evidence of peripheral vasoconstriction

60 80


35/35

THANK YOU

Stemi Extensive Anterior Lbh 24 Hour Onset Killip i

Documents

Transcript of Stemi Extensive Anterior Lbh 24 Hour Onset Killip i