CASE PRESENTATION

Anterolateral wall ST Elevation Myocard 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

PATIENT IDENTITY
Name
Gender Age Address Registration no. : Male : 52 years old : Sidrap : 554712

: Mr. N

Date of admission : 19th June 2012

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.

ANAMNESIS
Nausea ( - ), vomiting ( - ) Cough ( - ), Shortness of breath ( - ), Palpitation ( - )

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

Urination = normal Defecation = normal

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 ( - )

PHYSICAL EXAMINATION
General appearance : Moderate illness/well nourished/

composmentis
Vital Signs:

BP : 110/70 mmHg HR : 76x/min

RR : 26 x/min T : 36,8 (afebris)

Head : Anemia ( - ) , Icterus ( - )

Neck : JVP R+2cm H20

PHYSICAL EXAMINATION
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(-)

PHYSICAL EXAMINATION
Abdomen :

Inspection Auscultation Palpation Percussion

: flat and following breath movement : peristaltic sound (+) , normal : liver and spleen unpalpable : tympani, ascites (-)

Extremities : Edema -/-

ECG FINDINGS

ECG INTERPRETATION
Sinus Rhythm QRS Rate P Wave PR interval QRS complex Axis ST segment

: 90 x/minutes : 0.08

: 0.16
: 0.08 : +65 : ST elevation V3-V5, I, aVL,

ECG CONCLUSION
Rhythm Sinus Heart rate 90 x/ minute Anterolateral Myocardial Infarction

ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY
CONCLUSION :
LV systolic & dystolic dysfunction, EF 46% Dilated LA, LVH (+) MV prolaps Hypokinetic inferolateral septal PH-TR severe

CHEST X-RAY
CONCLUSION :

Cardiomegaly and pulmonary edema

LABORATORIUM FINDINGS
Complete blood count
WBC
RBC HGB HCT PLT

Blood chemistry
Blood glucose
Ureum Creatinine

:17.93x103/ul
: 5.95X10^6/ul : 16.6 gr/dl : 51.9% : 271 x 103/l : 4118 U/L : 319 U/L : >2.0

:138
: 26 mg/dl : 1.0 mg/dl

SGOT
SGPT

: 407 u/dl
: 87 u/ dl

Enzymes
CK CK-MB Trop T

Total Cholesterol : 236 u/dl

HDL
LDL Trigliseride

: 137 u/dl
: 44 u/dl : 209 u/dl

DIAGNOSIS
Anterolateral wall STEMI onset >12 hours, Killip II

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

ADVISE

Coronary Angiography

DISCUSSION

DEFINITION
Myocardial infarction (MI) rapid

development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium.
This usually results from plaque

rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.

PaTHOPHYSIOLOGY
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.

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.

Risk factors
Non- Modifiable
Gender and Age Men, increased risk after age 45

Modifiable
Smoking Hypertension Diabetis Mellitus Dyslipidemia Obesity Lack of physical activity

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

WHO DIAGNOSTIC CRITERIA

1. 2.

3.

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
Chest pain, >30 minutes Usually tight, crushing, and band

like Location in retrosternal May radiate to left arm, throat, and jaw Associated features including palpitation, sweating, breathlessness, and nausea.

ECS CHANGES IN AMI

ST segment elevation

over area of damage ST depression in leads opposite infarction Pathological Q waves Reduced R waves Inverted T waves

Leads with st elevation in mi

Cardiac biomarkers

Diagnose DIAGNOSIS
Signs of myocardial ischemia
ECG

Yes

ST segmen elevation ?
No Lab Biochemical cardiac markers ? No Yes

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

NSTEMI ( No ST-Segment Elevation Myocardial Infarction )

Unstable Angina

Therapy
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
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
Myocardiac reprofusion as soon as possible Thrombolitic - streptokinase and t-PA

Plaque stabilization Simvastatin

PROGNOSIS
KILLIP CLASSIFICATION

Class I II

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

III IV

30 - 40 60 80

COMPLICATION

Congestive heart failure Myocardial rupture Arrhythmia Pericarditis Cardiogenic shock

RISK SCORE FOR ACS

TIMI Risk Score for STEMI
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 Time to rx > 4 hrs Risk Score = Total 2 points 3 points 1 point

Risk Score 0 1 2 3 4 5 6 7 8 >8

Odds of death by 30D* 0.1 (0.1-0.2) 0.3 (0.2-0.3) 0.4 (0.3-0.5) 0.7 (0.6-0.9) 1.2 (1.0-1.5) 2.2 (1.9-2.6) 3.0 (2.5-3.6) 4.8 (3.8-6.1) 5.8 (4.2-7.8) 8.8 (6.3-12)

3 points 2 points 2 points 1 point 1 point 1 point (0-14)

* referenced to average mortality (95% confidence intervals)

RISK SCORE FOR ACS

TIMI 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 (<24 hours) severe angina Elevated serum cardiac biomarkers ST- segment deviation > 0.5mm
Calculated TIMI Risk Score Risk of >1 Primary End Point* in <14 Days Risk Status

0 or 1

5%

Low

2
3 4

8%
13 % 20 % Intermedi ate

5
6 or 7

26 %
41 %

High