STEMI INFEROPOSTERIOR ET RIGHT VENTRICULAR ONSET 2 HOURS KILLIP I

Presented by: Henry Liemer Wijaya

Supervisor : dr. Khalid Saleh, Sp.PD-KKV, FINASIM
Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

PATIENT IDENTITY
Medical Record Name Gender Age Address Date of admission

: 622664 : Mr. R : Male : 31 years old : Maros : 13 August 2013

HISTORY TAKING
Chief complaint:

Chest Pain

History of Present Illness:

The chest pain began since 2 hours ago before he was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was resting at home. The pain is described like dull heavy feeling on the left chest, radiated to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and tightness sensation. The patient felt nausea and not vomiting. The chest pain felt continuously more than 20 minutes duration, and not relieved by rest. The patient felt breathlessness while having chest pain, and it was accompanied by palpitation and cold sweat. He never wakes up from her sleep in the night because of breathlessness. He could sleep with 1 pillow only. There was no cought and fever. No history of epigastric pain. Urination and defecation were normal.

HISTORY TAKING
History of Past Illness:

History of chest pain before (-) History of smoking ( + ) 2 packs/day

History of hypertension : denied

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

No history of epigastric pain

RISK FACTOR

Non Modifiable Gender: Male

Modifiable
Smoking (+) Obesity (+)

PHYSICAL EXAMINATION
General Status Moderate illness/obesity 1/composmentis Vital Signs BP : 130/80 mmHg

HR RR T BW BMI

: 70 bpm, regular : 22 tpm : 36.7C : 82 kg H :170 cm : 28,3 kg/m2

PHYSICAL EXAMINATION
Head Examination
Eyes Lips Neck

: Anemic -/-, Icterus -/: Cyanosis (-) : Lymphadenopathy (-), JVP R+1 cmH2O

Thorax Examination

Insp. Palp. Perc. Ausc.

: Symmetrical R=L, normochest : Mass (-), tenderness (-), VF R=L : Sonor : Vesicular Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination
Insp. Palp. Perc. : IC wasnt visible : IC wasnt palpable : Dull, normal heart size

Right border : Right parasternalis line Left border : Left medioclavicularis line
Ausc. : Pure regular of I/II heart sound, murmur (-)

PHYSICAL EXAMINATION
Abdominal Examination Insp. : Flat and following breath movement Ausc. : Peristaltic sound (+), normal Palp. : Liver and spleen is unpalpable Perc. : Tympani (+), ascites (-)

Extremities Oedema : Pretibial -/-, Dorsum pedis -/-

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

Interpretation:

Rhythm : Sinus QRS-Rate : HR 75 bpm, reguler P-Wave : 0.08 sec PR-Interval : 0.16 sec QRS Complex : 0.08 sec Axis : 120 ST-Segment : ST-elevation on lead II, III, aVF, V3R, V4R, V5R, V6R, V8, and V9. T-Wave : Normal

Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardial infarction.

CHEST X-RAY
14 Augusts 2013

Normal

pulmonary CTI: Normal Result: Normal Pulmo

LABORATORY EXAMINATION

WBC HB PLT HCT GDS Ureum Creatinin

: 23,7 x 103/mm : 16,4 gr/dl : 312.000 : 49,7 % : 123 mg/dl : 15 mg/dl : 0,8 mg/d

PT APTT

: 21,7 (0,8) : 52,4 (26,6)

CK CKMB Trop. T Na K Cl SGOT SGPT Albumin

: 281 U/L : 22 U/L : 0,02 : 141 mmol/l : 4,2 mmol/l : 107 mmol/l : 31 U/L : 34 U/L : 4,0 gr/dl

DIAGNOSIS
- STEMI Inferioposterior + Right

Ventricular onset 2 hours KILLIP I

INITIAL MANAGEMENT

Bed rest O2 2-4 LPM (via nasal canule) IVFD NaCl 0,9% loading 500 cc/24 hours Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-0-0 Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg) maintenance 0-1-0 ACEI Captopril 3 x 6,25 mg Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) Trombolitik

Streptokinase (Streptase 1,5 million units were dissolved in 100 ml of Dextrose 5% in drips for 1 hour)

Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth

ELECTROCARDIOGRAPHY Post Trombolitik 1 hour

PLANNING
Echocardiography Coronary angiography

ACUTE CORONARY SYNDROME

DIAGNOSIS OF CHEST PAIN

1 point
Retrosternal or substernal chest pain

1 point

Increased by activity or emotion

1 point

Relieved by resting or nitrate SL

3 point typical chest pain

Tend to be Stable Angina Pectoris than Acute Coronary Syndrome

2 point atypical chest pain

Tend to be Acute Coronary Syndrome than Non Cardiac Chest Pain

1 point or none non cardiac chest pain

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).

CLASSIFICATION

ANATOMY

American Heart Association: http://watchlearnlive.heart.org

PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

PATHOGENESIS
Lipid transport disorder Inflamation Plaque deposition

Stable plaque
Thrombus

Erosion

Plaque rupture

Acute coronary syndrome: Unstable angina Myocardial infarction : - Non Q waves - Q waves

Stable angina pectoris

Thrombosis

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

DIAGNOSIS OF ACS
At least 2 of the following:
1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

1. ISCHEMIC SYMPTOMS
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

2. DIAGNOSTIC ECG CHANGES

ECG CHANGES
Timing of myocardial infarction based on ECG

3. SERUM CARDIAC MARKER ELEVATIONS

Troponin T CK-MB

CK

Myoglobin

CARDIAC BIOMARKER

DIAGNOSIS
Signs of myocardial ischemia ECG

Yes
ST segmen elevation ?

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

STEMI

No

Lab

Yes

Biochemical cardiac markers ?

NSTEMI (No ST-Segment Elevation Myocardial Infarction)

No

Unstable Angina

INITIAL TREATMENT
1. 2. 3. 4.

Bed Rest Diet Oxygen (2-4L/mnt) Anti platelet therapy :

Aspirin 160-325 mg chewed immediately and 81-162 mg

continued indefinitely. Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months

5. Nitroglycerin ISDN 10 mg or 20 mg, 2-3 a day. ISDN 5 mg SL when chest pain.

INITIAL TREATMENT
6. Morphine 2,5-5 mg or pethidin 12,5-25 mg iv 7. ACE I (Captopril 12,5-25 mg )

8. Fibrinolytic therapy:

a) Streptokinase 1.5million units iv b) Tenecteplase 0.5mg/kg body weight iv. 9. Anticoagulation therapy: a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI. 10. Statins Simvastatin 20 mg

THROMBOLYTIC AGENT
INDICATIONS
Age < 70 yo Typical chest pain, > 20 minutes, not

relieved by nitrat ST elevation > 0,1 mV, on 2 lead or more Onset < 12 hours

THROMBOLYTIC AGENT
CONTRAINDICATIONS

Absolute:

Relative:

Previous intracranial haemorrhage or stroke of unknown origin at any time Central nervous system damage or neoplasms Recent major trauma/surgery/head injury (within the preceding 3 weeks) Gastrointestinal bleeding within the past month Known bleeding disorder (excluding menses) Aortic dissection

Transient ischaemic attack in the preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 week postpartum Refractory hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg) Advanced liver disease Infective endocarditis Prolonged or traumatic resuscitation

PROGNOSIS KILLIP CLASSIFICATION

Class I II III 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 30 - 40

IV

60 80

PROGNOSIS TIMI SCORE

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 1 point 3 points 2 points 2 points 1 point 2 points 3 points 1 point

Total Score
0 1 2 3 4 5 6 7 8 9-14

Risk of Death in 30 days

0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

Time to treatment > 4 hrs

Risk Score = Total

1 point
(0-14)

RIGHT VENTRICEL INFARCTION

RVI is common complication of Inferior Myocard Infarct. CORE study 2001 explained that RVI has many

complication, such as shock, tachycardia or fibrilation ventricel and atrioventricular block. Inferior Myocardial Infarction + RVI has mortality rate until 25%-30%, and without RVI the rate is 6% only. Guidelines ACC/AHA for STEMI 2004 tells that we have to be careful by giving nitrat, because it can decreases preload and can cause moderate hypotension. RVI therapy: inhalation nitric oxide, work as pulmonary vasodilator, can recover hemodynamic condition for Shock RVI patient.

MANAGEMENT
Maintaining preload right ventricel by using

fluid Avoid nitrat, diuretik, or morfin. Hypotension & bradycardi atropin & fluid (50 cc/10 min) Nitric oxide inhalation